Passing trains had shaken loose the nuts and bolts holding three stretcher bars in place at the Lambrigg 2b points. Stretcher bars are used to keep the points a fixed distance apart.
None of the three stretcher bars were correctly in place, allowing the ‘switch’ rail to move freely. By the time the 17:15 Euston to Glasgow train passed, the switch rail had moved, and the train’s wheels hit the loose rail. You can see in Network Rail’s pictures the mark where the wheels of the Pendolino hit the free rail.
The train derailed immediately, leaving the train sprawled on an embankment, like the train-set of a spoiled child. Those at the scene of the accident agreed that the death-toll could have been far higher.
An efficient inspection regime would, Network Rail claim, have discovered that the stretcher bars were loose – in one case missing entirely as it had been hit by a previous train and bumped into the undergrowth - and prevented the accident.
Unfortunately, an efficient inspection regime was not in place. Neither had it the chance to take root, plagued by animosity between patrollers and supervisors, leading to a lax approach to patrol regimes, which ought be rigidly policed.
On the day of the last inspection, on the morning of Sunday 18 February, the patroller had completed a little over half of the area he should have covered. The damaged points were left unchecked.
Without question, Network Rail should be applauded for pulling no punches in their raw appraisal.
Subsequent reports by the Office of Rail Regulation and British Transport Police will reveal respectively whether there should be a fine to pay, or whether specific Network Rail staff will have to answer to the law.
But, the sequence of failure Network Rail have revealed is extremely troubling. Perhaps doubly so in that chief executive Iain Coucher could be at best ‘fairly certain’ that such failures were not at work elsewhere on the rail network.
Most damaging is the notion that animosity between the patrollers and supervisors was a key obstruction to safe inspection procedure. The ‘us and them’ culture shows a total breakdown in working relations, harking back to industrial disputes of the 1950s, parodied by Peter Sellers in the film ‘I’m Alright Jack’ where he portrayed a blinkered union boss.
In that film, both workers and management strived for their own self-interest at the expense of the company, bringing it to its knees.
NCE spoke to Mott MacDonald transportation director, Richard Williams. He said that, “Ownership of this accident is not as simple as one worker missing his beat. Poor relations between patrollers and supervisors is more likely to occur in a nationalised businesses, where unionisation can take deeper root. The London Underground is a good example of this.
“But, it is disgraceful that a person was allowed to leave early and not complete his inspection. But this is not to just knock the worker – he is also a victim. Network Rail allowed the poor industrial relations to develop. Someone has failed, but so has the system to catch that failure,” he says.
Williams has first hand experience of investigating systemic failures, as he was involved in the aftermath of the Clapham rail disaster in 1988. He says that there is simply no room for an ‘us and them’ culture in a safety system, and who can argue? Safety must be a top priority for all staff.
That Coucher is only ‘fairly certain’ that such work practices are not at work elsewhere in the country is as much because of the complexity of the system. There has to be a degree of trust, and we all have to hope that that this dreadful accident awoken both sides to realise this.
In May, the RMT were quick to condemn Network Rail when bonuses were suspended for inspection workers in Cumbria, while the Grayrigg debacle is picked-through. What better way to preserve an ‘us and them’ culture than to deprive one side of their Christmas bonuses?
Both sides need to start again, and put safety and excellence of the railway first. While Network Rail has come light years from the dismal days of Railtrack, they still have plenty of work to do.
The ideas set out in the Government’s rail white paper show a vision of a world-class network. Let us hope they can convince their own workforce to get behind them and give us the world-class railway we all deserve.