During a JGA rail tanker move using a capstan, the injured person (IP) placed the strap over the buffer-stop with the rope and hook and attached to the strap. Upon the tension being taken up on the capstan rope the strap snapped and recoiled and struck the IP on the ankle, (this is assumed as the IP did not remember much prior to the incident and to getting to hospital).

Image shows  broken strap attached to buffer.

Images show broken strap and rope

Rope and capstan

The operator sustained the following injuries, bruising to the ankle, pain to right leg and knee, cut to ear and a graze to head.

Key Factors:

• The primary reason the IP was hurt was that he was stood in an unsafe position as per training.

• The person in charge did not clear the area before using the capstan as per training.

• Unauthorised un-serviced equipment (the strap) used for the task.

• Task HIRA and SSoW did not identify the risk or manage the risk.

• There was no management of change , HAZOP or STOP conducted for the new process in 2020.

• Site stopped using JGA wagons at the location where incident occurred


• Safety brief to be conducted to all personnel including any contractors regarding the safe zone.


• A visual safe zone to be painted on the floor to make personnel aware of the safe zone area.


• HIRA and SSoW to be updated to include more detail and communicated to all person involved in the task, include contractors via induction.


• Identify any lifting and other equipment which has not registered to the site and inspect/service remove/dispose.


• A management of change to be conducted if the use of JGA wagons is decided to restart.