The day a lifeguard failed to do its job…
GREG MORSE looks back at a fatal accident in 1988 that highlighted issues around track condition and rolling stock maintenance procedures
Lifeguards. To most people in 1988, lifeguards were all about the beach. Soon, they’d become synonymous with bronzed adonises clad in red, with names like Mitch, Shauni, and probably Bruce.
Out on the railway, the lifeguard was (and is) something quite different: something with a much longer lineage; something designed to keep small objects away from the wheels of a train; something, indeed, to save lives.
On the morning of November 11 1988, one such lifeguard would play a part in the death of John Gerald Murray, who had spent 37 of his 58 years in the service of British Rail.
As with most accidents on the railway (if not all accidents everywhere), the causal chain had started some time beforehand. In fact, it was back on September 8 1988, when ‘Sprinter’ 150209 worked the 1709 Manchester Piccadilly-New Mills Central. Its guard noticed a noise, and later discovered the leading left-hand lifeguard on vehicle 52209 to be slightly loose.
He reported it at Manchester Piccadilly, where a rolling stock maintenance supervisor took a look and saw that all the bolts were present but not fully fastened. He tightened them with a ring spanner and short ratchet tool. A routine examination of the unit at Newton Heath Depot during the night of November 8 revealed nothing amiss.
Back in service, ‘209’ would travel some 1,600 miles over the next two days. On November 11, it was working the 2210 from Blackpool North to Liverpool Lime Street. When it pulled in to St Helens Central, a number of passengers got off, several more got on, and the train departed on time at 2315.
As he collected tickets at the station, Senior Railman Bates noticed sparks flying from beneath the underframe. Soon after, he heard a bang. As the train reached the point where the Up Goods line met the Down Main, the leading bogie derailed, sending the driving cab into a bridge abutment.
Guard Nugent immediately protected the rear of the train and went forward to protect the Up line. He then contacted the signalman at St Helens, by which time the emergency services had already arrived, Bates having already raised the alarm. On board, several passengers had tried to help the driver, but they were too late. John Murray had been crushed by the impact.
The inquest confirmed that 18 passengers had been injured, and that Murray’s death had been accidental. But it was left to J H Taylor, of the Health & Safety Executive, to consider the causes, and to consider what could be done to stop an accident like this from happening again.
Taylor soon determined that the left leading lifeguard had come into contact with the diverging check rail of the obtuse crossing at the junction. This caused the flange of the left-hand wheelset to climb over the running rail immediately beyond the crossing nose. The derailed wheelset then straddled the Up Goods and Down Main lines until, a short distance further on, the left-hand wheel was dragged over the rail of the former. At the same time, the rear bogie of the leading vehicle came off to the right.
An inspection of the lifeguard revealed it to be severely deformed. The securing bolts had been burned off to facilitate re-railing, but a rolling stock inspector found that of the four, the two inner ones had been missing.
At the same time, the trackwork was found to have been distorted by heavy wagons coming off the Sutton Oak branch. There was also one broken chair, but although all the lines were considerably worn, they were within the limits allowed.
At the point where the Up Sutton Oak Goods line passed through the Down Main en route to the Up, wear had resulted in the check rail being higher than the running rail. Heavy side pressure had also distorted the check rail, thus increasing the difference in height relative to the running rail.
However, despite the shortcomings of the
trackwork, the junction was deemed safe for operation at the low speeds permitted. Indeed, many trains had successfully traversed it before the accident. Clearly, then, another element was in play.
When the Down line was inspected three days after the accident, a smashed concrete block that would have weighed 53kg when complete was found about a mile and a half in rear of the junction. It hadn’t been there when the line was inspected the previous week, and the remnants and reinforcements of the block were lying as if it had been placed on the line and struck by a train.
But had it been Murray’s train? Taylor talked to passengers J F Tulley and J Smith, who had been in the leading carriage. They had heard no noises, nor felt any bumps to suggest the vehicle had struck an object.
The British Transport Police conducted “extensive enquiries”, but found nothing to suggest whether anyone had placed a concrete block on the line, nor any evidence from any other driver of striking an object at that location.
Further tests indicated that the noise of the train striking a concrete block may not have been heard by the passengers anyway, although it would have been apparent to Driver Murray. If such occurred, it would be normal practice to stop and report the event. Murray made no such report at St Helens Central.
The train had worked ten other services during the day, and there was no indication of damage to the lifeguard during that time, and no concrete particles evident after the accident. Seemingly stymied, Taylor’s attention then turned to the maintenance regime.
Traditionally, lifeguards were held by bolts fitted with ‘castellated’ nuts locked in place by split pins. “The drawback to this arrangement is that the holes and castellations must be in line and, therefore, the nuts may not be tightened fully, reducing somewhat the strength and [...] effectiveness of the lifeguard,” wrote Taylor.
The specification for the type fitted to Class 150s (and a number of other unit classes) was for a clearance above rail of 90mm to 100mm, with said lifeguard able to withstand an impact load of 50 kilonewtons (five tonnes) without damaging the bogie frame. To meet this specification, four 20mm diameter bolts were used, although to be effective a considerable torque had to be applied.
The design drawing for Class 150 bogies specified 476 newton metres. To apply that, a normal person would need a three-foot torque wrench - equipment not normally carried by artisan staff, but available at main depots. The drawing also showed the bolts with the head upwards and the thread downwards, but the bolts fitted to 52209 were the reverse, so that if the nuts were missing the bolts would fall out.
The rolling stock maintenance supervisor who tightened them on September 8 used a ring spanner and ratchet. When Taylor interviewed him, he said he was “unaware of the considerable torque required to secure the nuts for, as an out-stationed supervisor, drawings and similar information were not available to him”.
When Taylor talked to the three fitters recorded as having examined 150209 at Newton Heath on the night of November 8, they told him it was the practice at the depot to allocate several units to a group for such inspections and for the work to be shared out and booked accordingly. As a result, they were unable to identify who had inspected the bogies. But had a lifeguard been loose or damaged, “it would have been noticed and attended to”.
An inspection of the lifeguard revealed it to be severely deformed. The securing bolts had been burned off to facilitate re-railing, but a rolling stock inspector found that of the four, the two inner ones had been missing.
Tests suggested that the train could have reached 23mph from the stop at St Helens to the point of derailment. If it had struck the concrete block, its speed at that point would have been about 45mph.
Examination of the lifeguard, together with tests to simulate various possible nut and bolt arrangements, led to the conclusion that the two inner bolts had probably been missing for several hundred miles before the derailment occurred. The outer bolts had also probably been loose for several hundred miles.
This meant the lifeguard was slack enough to be hanging down towards the rail, at an angle of about 8°. If it had struck the concrete block, this would have been enough to bend the bolts, elongate the holes and cause embedding damage of the lower surface under the bolt heads. The lifeguard may not have sustained any other significant damage, but would have then been hanging closer to rail level - close enough to make contact with the check rail just outside St Helens.
Taylor’s enquiries into why the nuts became loose led him to Derby Works, where he learned that after manufacture
It is beyond doubt that the derailment leading to the death of Mr Murray was caused when a lifeguard that was improperly secured by only two bolts that were loose struck the check rail of the Up Sutton Branch. J H Taylor, Health & Safety Executive, St Helens accident report author
and assembly, the bogie had been sent complete to York, where the coach bodies were made and fitted to the bogies.
At Derby, the correct equipment was available to apply the necessary high torque to the lifeguard bolts, but at the time of manufacture no detailed record of the checking procedure was made.
At York, the vehicles were moved by traverser, and components likely to foul it (including the lifeguards) had to be removed temporarily. This is probably the point when - on reassembly - inadequate torque was applied.
Taylor wrote: “It is beyond doubt that the derailment leading to the death of Mr Murray was caused when a lifeguard that was improperly secured by only two bolts that were loose struck the check rail of the Up Sutton Branch.”
It seemed that the lifeguard ‘“had already been distorted by striking an object after being loosened”. Whether it had struck the concrete block was “open to conjecture”, although the investigation indicated that “an undamaged lifeguard, even in its loosened state, could not have made contact with the check rail”.
After the accident, BR took prompt action. An immediate check of its Class 150s revealed one lifeguard missing, one lifeguard bent, two bolts missing (on separate units), and 14 bolts on various units that needed tightening to the prescribed torque. A further survey carried out after improved procedures had been implemented revealed no lifeguards missing, one lifeguard bent and only six bolts requiring renewal. BR also changed its procedures to ensure that any loose nut or bolt would be replaced immediately.
In addition, Taylor recommended that the practice for replacing nuts and bolts be applied to all other rolling stock fitted with lifeguards, including on-track plant.
He noted that it was “not practicable for any individual who may be called upon to attend any defect on rolling stock to be in possession of, or even be aware of, details of special instructions with regard to torque settings”. He therefore also recommended that BR consider some “distinctive colour marking to ‘seal’ components that require special attention so that artisans are immediately aware of the existence of particular requirements even though they [might] not necessarily have the details to hand”.
Finally, he noted that “the practice of permitting communal responsibility for such an important task as inspection of a train” should cease, “by making people who do a job clearly responsible for it”.
Responsibility and chains of command would soon come up again. Just 16 days after the accident at St Helens, an overtired, undertrained technician would leave a bare live wire dangling in a relay room some 200 miles south.
Within another fortnight would come another rail disaster, the like of which had not been seen for more than 20 years…
That crash (at Clapham Junction) would claim the lives of 35 people. Thirty years on, RAIL 867 revisits that fateful day and examines how safety procedures have changed.