Crash report: points not checked
Updated on 04 September 2007
A report into February's Cumbria rail crash criticises Network Rail's inspection and management systems.
A track inspector abandoned his checks - just yards from faulty points. Five days later a high-speed train derailed at Grayrigg in Cumbria, leaving one woman dead and twenty two people injured.
In a highly critical report into its own systems of inspection and management, Network Rail has admitted a series of failings in its Cumbrian track maintenance department, leading up to February's crash. It said there had been a breakdown in relations between track patrollers and supervisers - which managers failed to rectify.
Network Rail report
The catalogue of failings that led up to the derailment makes grim reading for Network Rail:
- Failings in the way routine track inspections were carried out and managed.
- Failings in relationships between local managers, supervisors and track workers.
- And failings in higher management who were unaware of any problems.
"There's talk of a 'them and us' culture between some of the guys on the ground and the supervisors, and between the patrollers and the control. People not talking to each other properly in safety critical areas. That is always the most terrible news and leads to terrible things" - Nigel Harris, editor of Rail magazine.
'There's talk of a 'them and us' culture between some of the guys on the ground and the supervisors, and between the patrollers and the control.'Nigel Harris, editor of Rail magazine
The report confirms the crash was caused by a set of damaged points and reveals that a crucial inspection the Sunday before, when the points were already broken, wasn't done.
And worse: supervisers knew, and did nothing about it. And worse still: the points had been broken for six days already.
Network Rail believes the points first went slightly out of alignment in December last year - and the subsequent pounding by trains at 90 miles an hour led to vibrations that caused the nuts and bolts to come undone and the stretcher bars to break.
Timetable of inspection
January 7 - inspection: missing nuts and bolts replaced
January 9 to February 4 - 7 - visual inspections: no defects reported
February 11 - inspection "...difficult to reconcile with the evidence..."
February 12 - Gauge train video reveals broken stretcher bar .
February 18 - inspection scheduled: not carried out, supervisor failed to take action.
February 23 - train derailed.
None of which was spotted in a series of inspections, despite an alarm in early January, when two missing nuts were found and replaced. From then to 4 February, seven visual inspections reported no problems.
An inspection on the 11th found no defects too - but the report says that is difficult to reconcile with the subsequent evidence of video from a special train that filmed the first broken stretcher the next day.
The next inspection was due on 18 February - but it never happened. The patrolman told his supervisor he'd not done it, but no action was taken. Five days later, the accident happened.
Network Rail says it accepts all of the report's 14 recommendations - including retraining, management restructuring and changing procedures. Staff have been moved in the area's track maintenance department - some have left the company. One man has been arrested, but not charged, in the ongoing British Transport Police investigation.
Where Network Rail is silent, though, is on the failure to spot something was wrong when the nuts and bolts first fell off in the January.
After the Potters Bar crash, Network Rail brought track maintenance back in house from private contractors to prevent similar accidents. Today's report suggests that wasn't the complete answer to their problems.
