Devastated is the word used by John Armitt, Network Rail's chief executive, to describe how he felt following publication of the initial report into last Friday's Grayrigg train crash.
Any engineer can perhaps understand why. For while it is still too early to be sure, all the evidence so far points to a repetition of the Potters Bar crash nearly five years ago.
Despite a massive effort to radically reform safety on the railways - effort that has, without doubt, delivered huge improvements - we are faced with the realisation that once again broken or defective points lie at the heart of a crash.
It is easy to understand why the general public might be upset. Painstaking investigations revealed the precise mechanical failures that caused Potters Bar. Yet ve years on and despite the components in question being identied as super safety-critical, problems appear to have not been ironed out. Taken in isolation, the lessons of Potters Bar have not been learned.
And it is hard to blame underinvestment by government. For while we are still recovering from decades of underinvestment, record amounts of cash have been poured into the network over the past five years.
So the question is why, given all we know and given what is technically possible, are we still relying on nuts, bolts, washers and the human eye to keep our trains safe?
While it's a fair question, and one that will be examined over the coming weeks and months, we also know from an engineering perspective that it is not unusual to face situations in which the failure of one relatively small but critical component can bring down the whole system.
And in Armitt's defence, during his ve years at the helm of Network Rail he has been relatively successful at changing the organisation's culture and revamping the way that risk is assessed. He was certainly motivated by his experience of Potters Bar, which came just four months after he was named chief executive of the not-forpro replacement for the tarnished Railtrack. Since that baptism of e he has grasped many nettles.
Most notable were his decisions to first refocus the organisation on engineering excellence and then to bring all rail maintenance back in house in 2004. Overall, the industry is in better shape as a result. The Rail Safety & Standards Board con rms that rail is now the safest form of transport in the UK.
But equally no one at Network Rail, or indeed in the wider rail industry, would ever accept that the job was done. With the best will in the world there are still a myriad of human interfaces, decisions, mechanical devices and electrical components that every day threaten to trample over this record.
Armitt is aware of this.
Speaking to NCE just a few weeks ago after cold weather and defective points heaters brought the network to a grinding halt, he said that the challenge was his to meet.
'To what extent can we get our infrastructure, or parts of our infrastructure, to virtually never, ever fail is the challenge we face, ' he said. 'But it is one we are prepared to take on as part of Network Rail's goal towards becoming a worldclass company.' five years after joining Network Rail and just four months from his retirement as chief executive, Armitt was this week reminded just how difcult this challenge remains.
Antony Oliver is NCE's editor