THE North York Moors Railway (NYMR) has been ordered to review safety procedures after a volunteer guard was crushed to death while carrying out a routine process.
Guard Bob Lund was fatally injured while uncoupling two carriages at Grosmont station in May after a steam locomotive unexpectedly changed direction.
A series of investigations took place following the incident and the findings of the Rail Accident Investigation Branch (RAIB) revealed a latch had not been put in place to prevent the movement of the train.
In the run up to the tragic incident Mr Lund (65) had manually uncoupled the carriages and given a hand signal to the fireman indicating the locomotive should reverse away but after three to five metres it changed direction.
It moved back and trapped Mr Lund, from Beverley, between the ends of the coaches, causing fatal injuries.
The report said: “The driver had already realised what had happened and made an emergency brake application...The locomotive was put into reverse gear and moved backwards to release the trapped guard. Unfortunately, his injuries were fatal.”
The train involved, an S15 class built in 1927, was fitted with a screw reverser, operated by the driver, in this case vastly experienced, to alter the setting of the valve gear which in turn can alter the direction of the train.
Movement of this reverser can be prevented with a mechanical latch but the RAIB say the latch had not been used and has been unable to determine why.
It says: “The reverser was able to move because the driver had not used the mechanical latch to prevent it, even though the evidence was that he fully understood the purpose of the latch and when it should be used. This almost certainly resulted from a lapse, the reasons for which the RAIB has been unable to determine.”
However, the report also says that in accordance with the NYMR rule book persons shouldn’t go in between vehicles unless they are stationary but Mr Lund would have thought it was safe because the locomotive and the coach was moving away.
The RAIB has told NYMR to review and improve safety management arrangements relating to shunting. In particular it should update the NYMR rulebook, improve the method of training so it is more formal, assessment should cover all the necessary areas of competence relating to shunting and the system of management checks should be reviewed.
The investigation had also revealed Mr Lund was supposed to have a two-yearly medical in July 2011 but this never happened because of the NYMR administrative process didn’t identify it was due.
However, RAIB said there was no evidence that this was a factor in the accident.
The North Yorkshire Moors Railway was unavailable for comment.