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Shoddy maintenance led to Grayrigg crash

A jury last week ruled that a poorly maintained set of points caused the 2007 Grayrigg train crash which killed 84-year-old grandmother Margaret Masson.

After a two week inquest at Kendal County Hall, the jury returned a unanimous verdict in which they said Masson died on 23 February 2007, after the Virgin Pendolino train she was travelling in derailed at the set of 2B railway points at Lambrigg, in Cumbria.

Points failure

It ruled that the derailment was caused by the failure of those points, that they had not been adequately maintained and that no inspection took place between 12 February and the date of
the crash, even though it should have done.

Thirty witnesses testified at the inquest, which heard damning evidence about maintenance procedures, over-stretched staff, missed inspections and fabricated paperwork.

Coroner Ian Smith said the Network Rail track section engineer David Lewis, who should have inspected the points five days before the accident but had not, had given his evidence with “dignity and a great deal of honour”.

Last Tuesday a tearful Lewis told the jury of the huge pressures he was under, and how he repeatedly raised safety worries with his Network Rail bosses.

Limited track access

Lewis’s solicitor John Sleightholme said Lewis - who has since left Network Rail - was still concerned about public safety because of worker fatigue and limited access to track.

The inquest was read two hard-hitting emails sent by Lewis to his Network Rail bosses a year before the accident, calling the company’s maintenance procedures a “shambles” that made it “impossible” to keep the railway safe.

One read: “It’s time for the ­hierarchy to stop ducking the issue and sort out this shambles once and for all.

“Ensuring the infrastructure is safe and fit for purpose is now virtually impossible.”

A separate email read: “Whilst I understand the need to remain within budget, I am at a loss to understand how I am expected to maintain a safe and compliant railway.

“In time we’ll see a steady decline in infrastructure.”

Essential inspections

The inquest jury heard how limited access time to the railway made it almost impossible for engineers to carry out essential track inspections.

The jury heard that rail engineers did a weekly inspection of an 8km stretch of line every Sunday, which included the points responsible for the derailment.

Jurors heard how engineers work in teams of around four to carry out the work, which can only be done during daylight hours and before 10am, when trains start running.

The introduction of higher speed limits and faster trains, like the Pendolino, mean inspections no longer take place after this time.

Restricted daylight

But Rail Accident Investigation Branch inspector Chris Hall told the inquest that workers would find it difficult to carry out a full inspection, particularly in winter months, when daylight is more restricted.

“It would be a challenge for a team to patrol that stretch of track at that time of year,” he said.

He explained that Network Rail guidance suggested 1.6km of track takes around half an hour to inspect, plus an extra 30 minutes for a set of points.

The inquest heard that there would be as little as two hours of daylight at some times of the winter.

Hall also confirmed that Network Rail submitted paperwork stating it had carried out maintenance work to fit points blades to a switch rail in December 2006 but that the work had not taken place.

Nicholas Hilliard QC, representing the Office of Rail Regulation, said: “There’s no warrant for behaviour like
that, is there?” to which Hall replied: “No”.

Further lapses in Network Rail’s maintenance regime were revealed by Network Rail track chargeman Geoffrey Ruddick.

He told the hearing that he had completed forms stating he had conducted safety tests on four railway points near the crash site on 17 December 2006 when he was in fact 80km away working in Gretna.

Ticked paperwork

He told the inquest that he ticked paperwork to say checks had been done before submitting the documents on 18 December, two months before the derailment. He said he was under “constant pressure” from supervisors to meet deadlines and sent off the paperwork because he was due to take a break from work and did not know when the checks would be done.

“You’re answering to different supervisors at times,” he told the inquest. “You’re put under pressure to keep to different timescales.”

Hilliard said the tests that were not carried out were “absolutely vital” and designed to prevent trains from derailing.

“It was a test concerned with reducing the risk of a derailment?” asked Hilliard, to which Ruddick replied: “Yes, that’s true.”

Ruddick added: “I said I had carried out tests at Lambrigg (near Grayrigg) when I hadn’t.”

Track engineers told the inquest that subsequent checks which did take place - on 9 January and 31 January 2007 - showed the points were in “perfect working order”.

The inquest jury also heard how changes to maintenance procedures in April 2006 could have contributed to the derailment.

Torque spanners

The changes removed a requirement for engineers to use “torque spanners”, specialist tools which help fasten bolts to stretcher bars to the correct tightness.

Instead, the guidance said, workers could use an open-ended spanner but Hilliard said there was no guarantee that bolts would be tight enough as a result.

“This is safety-critical ­equipment,” he said. “This isn’t a ticket machine or a coffee dispenser; this is really important material.”

 

Threat of prosecution for Network Rail

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File photo dated 9/5/03 of the scene at Potters Bar Station, London after a train de-railed, killing seven people. Experts concluded that the

The Office of Rail Regulation (ORR) will now decide whether to pursue a criminal case against Network Rail for breaches of health and safety regulations connected to the Grayrigg crash.

It said that it “welcomed” the conclusion of the inquest and that it would complete its investigation before deciding in “accordance with prosecution protocol” whether to bring criminal proceedings for health and safety offences.

It is unlikely that the rail operator or its engineers will face manslaughter charges as the derailment took place before the new Corporate Manslaughter Act took force.

Any charges would have to be brought using previous legislation, which was notorious for failing to bring about convictions.

Abandoned manslaughter charges

Last year the ORR abandoned attempts to bring manslaughter charges against Network Rail and Jarvis for the 2002 Potters Bar derailment, despite an inquest ruling that seven people died in the crash because of an unsafe set of points (NCE 18 November).

Its decision came after the Crown Prosecution Service (CPS) said that there was “no realistic prospect of a conviction” for gross negligence manslaughter against people or companies involved.

Attempts by the CPS to bring similar charges against individuals and companies, including Network Rail predecessor Railtrack, held responsible for the 2000 Hatfield rail crash also failed.

Rail unions immediately called for Network Rail to be held to account through a public inquiry into the disaster.

“There remain systemic problems which have failed to be addressed since this derailment,” said RMT general secretary Bob Crow.

The RMT added that failure of the ORR to enforce safe maintenance systems for high speed track was risking further derailments and that its performance also needed examination.

Network Rail managing director of network operations Robin Gisby said after the inquest verdict was reached that the firm has not hidden from its responsibilities.

Infrastructure fault

“The company quickly accepted that it was a fault with the infrastructure that caused the accident,” he said. “We again apologise to Mrs Masson’s family.

“Since the derailment Network Rail has worked closely with the authorities, conducted comprehensive and detailed investigations and made substantial changes to its maintenance regime. Today there is no safer form of travel than rail and it is important that the rail industry seeks ways to make it safer still.”

Crash timeline

Accident data from the train’s onboard recorder showed the exact time that the train - carrying 109 people - derailed at 152km/h over faulty points as 8.11pm and 49 seconds on 23 February 2007.

Just 1.63 seconds later, the first and second carriages began to jack-knife at 147km/h. The other carriages derailed further up the track, which had been damaged by the initial derailment.

At 3.15 seconds after first reaching the faulty points, the first carriage came off the track, ploughing into line-side signalling equipment at 130km/h.

The carriage, carrying 84-year-old Margaret Masson who died, then struck two overhead electrical line masts in three seconds, slowing down during the impacts, from 106km/h to 43km/h.

The carriage began to tip over and slide down an embankment, spinning 190° and turning onto its side before stopping in a field.

The Rail Accident Investigation Branch’s November 2007 report into the crash says that the immediate cause of the derailment was the deterioration of 2B 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 close to its stock rail.

This came about as a result of a combination of three factors, which were:

  • the mechanical failure of a bolted joint
  • the incorrect set up of the points
  • a track inspection that was missed on 18 February 2007.

All three factors were necessary for the accident to occur.

Contributory factors to the missed inspection included limited access times for maintenance of the West Coast Main Line at Grayrigg.

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