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October 23, 2008

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Design flaw and inspection failure caused Grayrigg derailment

Infrastructure defects and a missed track inspection were key factors that caused the derailment of a train in February last year at Grayrigg, Cumbria.

Releasing its final report into the incident yesterday, the Rail Accident Investigation Branch (RAIB) made 29 safety recommendations — the majority of which relate to a review of the design, inspection and maintenance of points. Staff fatigue is also considered to be an issue in need of addressing.

The investigation body concluded that rail operator, Network Rail, had “an incomplete understanding of the design, maintenance and inspection” of stretcher bars used in points “due to the limited application of a risk-based assessment”. The operator has accepted responsibility for the incident and apologised.

The train travelling from London to Glasgow derailed on points while travelling at 95mph on 23 February 2007. Passenger Margaret Masson was killed, and 86 other people were injured.

The immediate cause of the derailment was the deterioration of points through a combination of failures of the three stretcher bars, the lock stretcher bar, and their fastenings. This allowed the left-hand switch rail to move into an unsafe position.

The RAIB said this came about as a result of:

€ᄁ the mechanical failure of a bolted joint;

€ᄁ the incorrect set up of the points; and

€ᄁ a missed track inspection five days earlier, caused by limited access times.

It also highlighted a report into the 2002 Potters Bar crash, which had recommended that Network Rail apply a risk-based approach to the management and maintenance of its points. However, this was not seen as a priority by Network Rail, the RAIB found.

The inquest for Potters Bar was adjourned last year pending the outcome of the Grayrigg inquiry. Transport secretary, Geoff Hoon, said he would consider the Grayrigg report in detail, and announce his decision early next year on the most appropriate way forward with regard to both incidents.

Network Rail says it is taking steps to improve the set-up and inspection of points similar to those involved in the Grayrigg derailment. New instructions have also been issued for standardised track inspection. It is now carrying out work to assess the design of this type of points to determine whether it should modify its design, maintenance and inspection regime.

The company’s chief executive, Iain Coucher, said: “The tragedy at Grayrigg was caused by the failure of our infrastructure, something we were devastated to discover. We immediately accepted responsibility for the accident and once again apologise to Mrs Masson’s family, and all those affected.”

The RMT union renewed its call for a joint public inquiry into Grayrigg and Potters Bar, and blasted Network Rail for “systematic management failings, lack of resources, and imposition of unrealistic workloads”.

General secretary, Bob Crow, said: “It is a total no-brainer that there is a link between funding cuts, unrealistic workloads, inappropriate work practices, and fragmentation on the one hand, and inadequate standards on the other.”

He concluded: “We need an end to the ‘contract culture’ and inappropriate practices brought in by private contractors, and to shift the emphasis from getting things done quickly and cheaply to doing them properly and safely.”

http://www.raib.gov.uk

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