Families of the seven people who died in the Potters Bar train derailment have highlighted weaknesses in the railway industry’s safety management system, as part of a range of safety proposals they want the inquest coroner to back.
The nine-week inquest concluded on 30 July, with the jury determining that the crash resulted from a points failure caused by their unsafe condition. Various factors were identified as contributing to the incident, including failures of inspection and/or maintenance of the points.
Judge Baker informed the court that he would be issuing a Rule 43 report in line with the 1984 Coroners’ Rules, which would “necessarily range more widely into the systems which lay behind the immediate causes, some of which still give rise to concern today”.
Delivering a wish-list of recommendations to be included in that report, John Hendy QC, on behalf of the victims’ families, said conformity with a safety management system, as prescribed in BS OHSAS 18001, “should be applied to the railway”.
Under the Railways and Other Guided Transport Systems (Safety) Regulations 2006, most railway operators are required to maintain a safety management system. However, during the hearing, the Regulations were criticised by rail-safety expert Dr Anthony Boyle for not setting the standards for such systems widely enough.
Dr Boyle pointed out that there isn’t a requirement for recording defects and other non-compliances, so the system fails to look at root causes.
Mr Hendy stressed that this should be a key purpose of a safety management system, adding: “It requires of management that they have processes and sub-systems, of their own design, dealing with the particular features and characteristics of their industry, but dealing with the broad requirements of risk assessment, audit, and so forth.”
He further explained: “It’s the root cause, rather than the immediate cause, that a safety management system would catch.”
Representing Network Rail, Prashant Popat QC replied: “[T]he companies within the railway industries develop their safety management systems, based on inputs from a wide range of sources, and adapt them to meet their own needs. There isn’t a ‘one-size-fits-all’ safety management system that can be applied in the way suggested.”
The operator also argued against a number of other recommendations put forward by the families, including an industry-wide licensing scheme, a national register of licence-holders, and training and assessment to be approved by “somebody in authority and with the power to be definitive about what is required”.
On these issues, Mr Popat claimed that all employees who work on the railway, including contractors and subcontractors, must hold a Sentinel card, which “requires them to have suitable and appropriate qualifications in personal track safety and COSS duties”. Furthermore, he stressed that preparation of training schemes and assessment should be for the duty-holders to discharge as it is they who “are best placed to understand what the training requirements are, and what level of competence is required to be achieved, and how that is to be measured”.
Mr Popat also dismissed Mr Hendy’s proposal that recommendations made by the Rail Accident Investigation Branch should be binding, arguing that such a measure “would impose upon and provide RAIB with enforcement powers which go far beyond the role of an investigator”.
Responding to Mr Hendy’s call for minimum staffing levels in relation to maintenance and inspection activities, Mr Popat suggested that such a recommendation would go “far beyond what is appropriate for a Rule 43 report,” and highlighted that “requisite consideration is given to the appropriateness of the staffing levels”.
Following the hearing, a Network Rail spokesperson further underlined the improvements that have been made in maintenance, saying: “The railways are almost unrecognisable since the days of Railtrack and the Potters Bar tragedy of 2002. Private contractors are no longer involved in the day-to-day maintenance of the nation’s rail infrastructure, as Network Rail took this entire operation, involving some 15,000 people, in-house in 2004.”
But unions insisted that maintenance cuts present a real danger of a repeat disaster. Said RMT general secretary, Bob Crow: “Nobody should be under any illusions that the cuts to maintenance and renewals being imposed on our railways today are dragging us back to exactly the same poisonous cocktail of conditions that led to Potters Bar.”
His counterpart at train drivers’ union ASLEF, Keith Norman, added: “This terrible incident makes it imperative that we continuously examine the relationship between cuts to maintenance routines that jeopardise safety standards and the vast sums of money taken out of our industry by privatisation. ASLEF members rely on proper maintenance not only for our livelihoods but for our lives.”
The conclusion of the inquest now puts the ball in the court of the Office of Rail Regulation. In 2005, the HSE, which was then responsible for regulating rail safety, said it would delay a decision on whether to prosecute for health and safety offences until a coroner’s inquest had been held. That followed the Crown Prosecution Service’s announcement that, on the basis of the evidence, there was no realistic prospect of conviction for an offence of gross negligence manslaughter.
An ORR spokesperson said it would discuss the inquest verdict with other relevant parties, including the HSE and the CPS, before making a decision on any prosecution, which it would lead, if health and safety-based.
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