The Health & Safety Executive investigation into the 1997 Bexley derailment identified 15 lessons to be learned from the incident when it was published last week.
The thrust of these is that safety management on the railways needs to be improved. Railway contractors need to resource jobs adequately and continuously monitor them to ensure work progresses safely. And Railtrack must supervise its contractors adequately.
As HSE deputy chief inspector of railways Bob Smallwood said when he presented the report's recommendations: 'These are not rocket science'.
In fact they are obvious. It is worrying that they need to be pointed out at all and it is even more worrying that there seems to be a string of incidents after which these lessons are highlighted yet again.
Last week SCOSS, the Standing Committee on Structural Safety, published its biannual review of trends involving structural safety (see News last week). It says: 'A good structural safety record will not be sustained in the future unless adequate resources are provided to enable vigilance and effort in the maintenance.'
The recent trial following the 1994 Heathrow Express tunnel collapse also focused on the failure of the project supervision and monitoring regime to ensure safety. The SCOSS report and the HEX trial make it clear that the drive to keep costs down compromised safety - the first duty of all engineers. It is time the industry actually acted on these lessons instead of paying lip service to the need to improve.
At Bexley faulty track made seven wagons derail when a freight train passed through a station. Four people working in arches underneath were injured and extensive damage was done to the viaduct and neighbouring buildings. South East Infrastructure Maintenance Company, Southern Track Renewals Company and Railtrack were fined a total of £150,000 for their parts in the accident.
The derailment happened because track fastenings worked loose from rotting longitudinal support timbers, allowing the tracks to spread. Coupled to this one of the train's wagons was overloaded, exerting higher loads than normal on the track.
The report says the underlying cause was the failure of South East Infrastructure Maintenance Company to provide enough resources to ensure that the Southern Zone railways were safely maintained. It said SEIMC had spotted that the rotten timbers needed repairs but failed to arrange for the work to be done.
The report also points out that Railtrack failed to monitor the performance of the contractor even though the unsafe condition of the track was known to the network manager.
The HSE claimed in the report that it had found 'very little evidence' that new safety standards adopted by Railtrack in 1995 were being implemented. It said the track manager had failed to produce an audit plan for the 12 months before the accident. The failure to provide resources to repair track at Bexley is yet another triumph of cost cutting over safety.
With publication of the report the HSE has called for railway companies to examine their businesses to ensure they are not repeating the same safety management failures. Everybody can learn from the Bexley accident, though sadly the evidence makes it doubtful whether they will.