THE CUMBRIA DERAILMENT (and Potter's Bar)
SEPTEMBER 04 2007

The faulty points that caused a fatal crash in Cumbria should have been inspected five days earlier, a rail industry report has revealed.

It revealed a lot more than that.

Network Rail said the inspector's records clearly showed that, but the inspector's supervisor then failed to pick up that the inspection had been missed.

It revealed a lot more than that. Some time before, 2 nuts had worked their way off and nobody even bothered to ask why, and a photo taken automatically by an inspection train showed a bent rail immediately after a manual inspection had logged everything as in order.

The head of Network Rail stressed many times today that points all over the country had been inspected and nothing of the kind had occured or was about to occur elswhere. He described it again and again as a specifically local problem. What is he trying to say?

I suggest he is implying that in a very desolate and out-of-the-way if albeit beautiful part of the countryside it has been employing people with insufficient intelligence and dedication to take their job seriously or imagine the consequence of a less than rigorous approach. The only alternative is deliberate criminal negligence or sabotage. Can we have it straight out please? Or does the craze for political correctness prevent him from saying that track inspection in Cumbria was left in the hands of some local simpletons who happened to be available?

The answer to the above is now only too clear. The proper people people were on the job but so insufficient in number that the workload was such as to render its completion to satisfaction and on  time absolutely impossible. See the entry for January 13th 2012. It has taken 4 years for the truth to be faced.



NOVEMBER 16th 2007     

No further comment required from me for the moment. The union claim is that unrealistic workloads and lack of resources were the cause. If this is the case, we need to know if this is true and if it was properly communicated to management before the date of the accident.

Two held over Cumbria rail crash

Press Assoc. - Thursday, November 15 09:23 pm

Two rail workers have been arrested on suspicion of manslaughter following the Cumbrian train crash.

The men, aged 60 and 64, are both Network Rail employees and from the Tebay area of Cumbria, a few miles from February's crash site at Grayrigg.

They were arrested by detectives from British Transport Police (BTP).

A force spokesman said, "The 64-year-old man has been released on police bail pending further inquiries. The 60-year-old man is currently in custody."

One woman died and 89 injured when the London to Glasgow Pendolino express derailed in the Cumbrian countryside on the evening of February 23.

BTP has already arrested and bailed a 46-year-old man, also a Network Rail employee, from Preston.

The arrests relate to Margaret Masson, from Glasgow, who died in the crash.

The two track workers were members of the Rail Maritime and Transport Union which said it was "mystified" at the arrests.

The union claimed that systematic management failings, lack of resources and the imposition of unrealistic workloads were at the heart of the tragedy.

According to the RMT, the industry's own investigations have highlighted the need to tackle structural failings and to reverse spending cuts



FEBRUARY 10th 2008
The report just completed by Her Majesty's Railway Inspectorate for Network Rail says that there are systematic failings and the system of track inspections nationwide is 'not robust'.

Network Rail says they are dealing with it. But then their spokesman on the West Coast line upgrade fiasco over Christmas said that they were not aware that the total number of expert overhead electrical powerline installers to draw on at short notice was 'finite'. That means we cannot assume a basic level of intelligence in Network Rail management. I would have thought that the number of such experts available in the UK over the holiday, to be drawn on unexpectedly at short notice, was unimaginably small. Infinitely large? Not a chance.

We can all understand mistakes made under pressure. We have to accept occasional bad outcomes, but this looks like real overload at managerial as well as ground level. The maintenance budget has gone down at 8% over the last 3 years and more and more people travel by train.



OCTOBER 22nd 2008
At the end it turns out to be management failure and, reading between the lines, very likely a failure of the design engineers to give proper, clear instructions on the fitting and the critical maintenance of the railway parts and components they had approved and issued.

NR had an "incomplete understanding" of the design, maintenance and inspection of the stretcher bars used in the points, the RAIB said.

By NR we can take it that this understanding should have reached management and the men on the ground. So who was it who DID have the understanding and why did this understanding fail to be transmitted? Was it never committed to clear text on paper or electronic file? Was the clear text not given to management, or did management get it but not understand it? Did they pass it on? At what point did the critical knowledge fail to get to those fitting and those inspecting?  We are told nothing here. I guess I will have to read the whole sodding report.

Rail crash report blames checks

Track maintenance failures contributed to a train crash in Cumbria which left one person dead and dozens injured, a report has concluded.

Margaret Masson, 84, of Glasgow, died and 82 people were hurt when a Virgin West Coast Pendolino train derailed at 95mph near Grayrigg in February 2007.

A Rail Accident Investigation Branch (RAIB) report published on Thursday made 29 safety recommendations.

Three men were arrested after the crash. Two have since been cleared.

The 255-page report said rail infrastructure company Network Rail (NR) incorrectly set up points that failed and were the ultimate cause of the derailment.


The tragedy at Grayrigg was caused by the failure of our infrastructure, something we were devastated to discover.
Network Rail chief executive Iain Coucher

NR had an "incomplete understanding" of the design, maintenance and inspection of the stretcher bars used in the points, the RAIB said.

The organisation also failed to carry out a planned track inspection of the points five days before the fatal crash.

The RAIB said that the immediate cause of the derailment was the deterioration of the points at Lambrigg through a combination of failures of the points' three stretcher bars, the lock stretcher bar, and their fastening.

The report said that in the 35 years since the design of points used at Lambrigg was introduced there had been no previous catastrophic accident associated with the type of stretcher bars used in the design.

Network Rail 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 today to Mrs Masson's family and all those affected.

"Following a comprehensive and detailed industry investigation we made immediate changes to our maintenance regime.

"Travel by rail is the safest form of travel and despite Grayrigg, the railways are safer than ever before. It is important that the rail industry seeks ways to make it safer still and this report should help that process."

Local MP Tim Farron, Liberal Democrat member for Westmorland & Lonsdale, is calling for a public inquiry into wider rail safety.

He said: "Quite properly, this RAIB report only looked at the Grayrigg derailment.

"However, naturally, all of us will be drawing comparisons with other points-related tragedies, especially Potters Bar.

"The conclusions of this report only underline the need for a full public inquiry to look at wider safety issues."

Twenty-one of 29 RAIB safety recommendations are directed at Network Rail and include measures to tackle staff fatigue.

The RAIB said a report into the 2002 Potters Bar crash identified a need for NR to better understand the different designs of points used on the rail network.

The report said: "NR had accepted the value of such an approach but did not consider its application to existing points with non-adjustable stretcher bars to be a priority."

The report said Virgin's Pendolino train "performed" better than had been seen with earlier designs of trains in previous accidents.

'Systematic failings'

However, it went on to say safety could be improved by better designed seat mountings and overhead lighting panels.

Transport Secretary Geoff Hoon welcomed the report and said a decision on an inquest into the Potters Bar tragedy would be taken in the New Year.

The Rail Maritime and Transport (RMT) union renewed its call for a joint public inquiry into the Grayrigg and Potters Bar derailments.

RMT general secretary Bob Crow said: "It is now abundantly clear that systematic management failings, lack of resources and the fragmented contract culture still prevalent on the railway all played their part in the complex of causes of the Grayrigg derailment.

"For NR to attempt, as it did, to point the finger of blame at individuals it managed so poorly was outrageous, and for police to keep two of our members under suspicion of manslaughter for nearly a year without a shred of evidence demands an apology."




THE POTTERS BAR RAIL CRASH
JULY 30th 2010
http://www.bbc.co.uk/news/uk-10772410
I refrained from comment on the Potters Bar accident at the time on this web-site as I had quite a lot to say about it elsewhere. It may not have been sabotage but there is little difference between  a culture and systems that are totally irresponsible by their very design (or the state into which they have deteriorated) and deliberate criminal negligence. It is clear that no criminal prosecution is likely to succeed in such an environment where, when a serious problem is reported on a line, nobody is responsible for doing anything more than suggesting somebody take a look at it. The cause for the serious jolt reported by passengers the day before the accident required an inspector to find and identify the cause. If it was not found, it was clear they were not looking in the right place and further steps should have been taken to check with the originator of the report.

That the points were in the state they were in the first place, while unacceptable, is not to my mind as criminal as the failure to take action whe there was a warning. The union involved now says cuts in the workforce make it likely that there will be even less chance of keeping on top of proper inspection and maintenance; but it would appear it is not the number of employees that is the issue but how seriously they take the job.

Using more technology to replace manpower only makes sense if those in charge of the technology are of the right frame of mind. All too often technology can result in less human attention and unless the technology itself then benefits from its proper use by people who really know railways as well as the new toys they have been given, we can look forward to a new type of disaster rather than increased safety. Our motorway network is remotely patrolled by teams of people equipped with computers who manage to misinform motorists on every conceivable occasion of the state of the road ahead. A sign warning of fog will certainly mean the visibility is perfect, a sign saying it is clear ahead should be taken as a serious warning. The last 10 years of my experience has shown that the ignorance of the operators of the relation of their warnings of every sort to the reality is almost total, so the feedback from motorists must be zero. All temporary speed-limits warning of trouble ahead are routinely ignored by all motorists and I am not surprised, while the end of a speed limit may well indicate severe congestion just a few miles ahead - not as a result, I hasten to add.

The point I am trying to make is that in comparison to e.g. the French the modern British do not take well to technology at the industrial level where it is critical to the modernisation of a mobile society. They do not take well to it in the mines or in the nuclear industry at the level where care and technical expertise equals safety. How different this is from the past, when the reverse was the case. We took to the steam age like ducks to water and throughout WWII the men who ran the railways were the heroes of the day.

The survivors and relations of the Potters Bar crash victims want a public enquiry. I am normally against such things as being quite useless; however there needs to be a discussion and some decisions on how to move forward in the whole business of staffing our public transport systems and educating and training the people who are going to take responsibility for them. At the moment, we have unions engaged in an argument about staffing numbers and wages and in who wield the power in deciding thes things. This is utterly disgusting when what should be discussed, by people who understand it, is what technology will be used and what it will cost, who will use it and what tasks are better carried out by individuals, even if aided by technical devices, than delegated to programs and processors and automatons. Many people think we need more human involvement, not less, in quite a few areas of our modern routine systematic operations involving goods and services and transport.



MAY 13th 2011

Some years have passed and we have a judgement on the Potters Bar accident. The £3 Million fine does not punish those responsible though it may form part of a book-keeping exercise to fund the justice system. The judgement is the thing.

Judge Bright, presiding at St Albans Crown Court, said Railtrack's procedures and standards were "seriously inadequate" and that the serious faults with the points "could and should have been identified sooner".

The company's failures put the travelling public and train crews at the risk of serious injury, the judge said.

Considering how far within Railtrack the failings went, Judge Bright said that although there were very serious failings by Jarvis, "overall responsibility for the breach of duty lay with Railtrack at senior management level and their failures were significant and extensive".

http://www.bbc.co.uk/news/uk-13389147




NOVEMBER 1st 2011
MORE ON CUMBRIA
A Network Rail engineer broke down in tears as he told an inquest he forgot to inspect the points which caused the Grayrigg train crash in Cumbria.

It is clear these guys were under excessive pressure, understaffed and with unclear and bullying management.

http://www.bbc.co.uk/news/uk-england-cumbria-15544690



JANUARY 13th 2012

Network Rail to be prosecuted over Grayrigg crash

http://www.bbc.co.uk/news/uk-england-cumbria-16544694


nnnn