Case study: unsafe handling of sleepers
31 March 2026
Concern over inadequately risk-assessed change to work method leads to a new approach.
Overnight work to replace concrete railway sleepers could have led to manual handling injuries. There wasn’t the right equipment and procedures, said a reporter to CIRAS.
Unsafe practices included operatives standing on a pickup truck trying to push sleepers off with no barriers below. They also used slings to try to pull sleepers off a trolley, and straps and bars to line them up on the track.
The reporter said the safety briefing instructed operatives to use the correct equipment, which wasn’t available. There was also significant time pressure. The new sleepers arrived hours after the operatives.
Aureos Rail (previously Keltbray) postponed the following weeks’ work after the report to review the work. The project team was already reviewing some of the issues as part of its Plan/Do/Review process. A change to the planned methodology and a lack of effective change management had prompted the concerns.
There were enough cable management sleeper (CMS) lifters, but no one was accountable for issuing them, so one of the teams didn’t have enough. Using slings was a changed method that wasn’t adequately risk-assessed. Someone is now accountable for managing tools and equipment on site.
A telehandler was planned to unload the sleepers from a flatbed lorry at each access point. Moving the telehandler between them was too slow, so the site team changed to manual unloading. The risks of manual handling, establishing exclusion zones, and working from height weren’t adequately assessed, so there weren’t suitable and sufficient control measures.
The on-site supervisors knew of concerns with the changes but focused on completing some work on the night and didn’t address them positively. Although there was a chance to raise the issues with the on-call manager, they didn’t.
Aureos Rail derisked the work further by mechanising most of the operation. Road transport delivers the sleepers to the access points, where a road-rail vehicle loads them onto trailers, transports the sleepers, and unloads them.