Grayrigg train crash: Faulty points caused woman's death

<a href="http://www.bbc.co.uk/news/uk-england-cumbria-15593840">BBC website</a> 4 November 2011

The inquest into the death of Margaret Masson, 84, from Glasgow, who died after the Virgin train derailed on the West Coast Main Line in February, 2007 has concluded that badly-maintained points were to blame.



The train went over a "degraded" set of points at 92 mph and careered down an embankment, leaving 88 people injured. Network Rail engineer David Lewis told the hearing he had forgotten to inspect the points near where the crash happened. He said he was "under pressure" when he failed to check a section of the rail line five days before the derailment. His team were under-staffed, with workers not given the right tools or enough time to carry out checks. He had warned his boss about the "shambles."

His colleague Paul Wills, an assistant track section manager, told the hearing staff had to put up with "bully-boy" management.

The 11 jurors had heard how a subsequent Rail Accident Investigation Branch (RAIB) inquiry ruled the "immediate cause" of the crash was that the train had gone over a "degraded and unsafe" set of points, known as Lambrigg 2B.
One of three stretcher bars, which keep moving rails a set distance apart, was missing while the other two were fractured and bolts were missing.

Network Rail investigation report

A summary of Network Rail's investigation was released 4 September 2007. It is available from here

The report uses a lot of railway jargon that I am not familiar with.

The conclusions identify the immediate cause as the deterioration of components in the stretcher bar system on the points. Underlying cause was a failure to carry out an inspection that would have identified the fault.
* Deficiencies in the asset inspection and maintenance regime employed on Lancs & Cumbria maintenance area resulted in the deterioration of 2B points not being identified. These deficiencies included:
* A breakdown in the local management/supervisory structure that leads, monitors and regulates asset inspection and maintenance activities;
* A systematic failure in the track patrolling regime employed on the local area;
* The issue and subsequent briefing of mandated standards not being carried out in a robust and auditable manner;
* A lack of sample verification to test the quality and arrangements for inspections undertaken.

I find this quite bizarre. Failure to inspect something does not cause it to fail. Yes, it may allow a hazard to be discovered before an accident occurs, but that is not the same thing. It sounds to me like Network rail are trying to distract us from more fundamental problems with the design of points. Especially given the fact we still do not know what caused the Potter's Bar train crash, which also involved a failure of points.

In fact, reading more of the report into this crash it seems design issues were raised, and most of the action items are focussed on these types of issue. This makes it even more strange in my opinion that the conclusions in the report (which are probably all that most people will read) are so focussed on inspection.

Driver's actions

This is London website on 3 March 2007

The driver who survived the Cumbria rail crash has revealed for the first time how he desperately tried to stop the train after coming round from being knocked unconscious.

Iain Black, 46, told friends how he was catapulted out of his seat and hit his head on the roof when the Virgin Pendolino 'tilting' train hit faulty points at 93mph before being derailed and plunging down an embankment at Grayrigg, near Kendal.

With blood pouring down his face, Mr Black - a former policeman - came round, crawled back on to his seat and applied the emergency brakes in an attempt to avert the accident, in which Margaret Masson, 84, from Glasgow, died and 100 people were injured.

He told friends visiting him in the Royal Preston Hospital: "I am so sorry somebody died. I did my best to stop but there was nothing I could do."

In fact, the brave driver was unaware that as he tried to apply the brakes to the packed train, its automatic braking system had activated after a brake pipe was severed by the rogue points, which had nuts and bolts missing from track stretcher bars connecting sections of rail.

Repair backlog

Telegraph online 4 March 2007

Only weeks before the fatal Cumbrian rail crash, Network Rail was struggling to cope with a backlog of repairs, the largest rail union said last night.

Virgin rail crash in Cumbria: Network rail resources Network Rail denies there was a reduction in maintenance personnel.

The Rail, Maritime and Transport union blames the crisis on a failure by Network Rail to fill vacancies over two years - resulting in a 10 per cent cut in "front-line" technicians and track workers.

With numbers down on the 400 staff the RMT believes are needed, it says the backlog of essential maintenance work in the North-West mounted.

An RMT spokesman, John Tilley, said: "Network Rail are running at what they call deficit manning levels as the norm. The result is that the maintenance people are so stretched, and a backlog has been created."

Network Rail denied that there had been any reduction in the number of maintenance personnel or that a significant backlog had developed.
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A spokesman said: "We are making efficiency savings of 31 per cent between 2004 and 2009. There may be a couple of vacancies in the North-West, but this is not a picture I recognise. I am not aware of any particular staffing issues and there is no national policy of natural wastage. We have a to-do list, but nothing I would recognise as a backlog."

Worker short-cut

This sounds like pure speculation to me, but was reported in the Independent online on 28 February 2007

Track workers may have deliberately dismantled the points which caused the rail crash in Cumbria last Friday.

Staff working on the line - possibly for a private contractor - may have removed vital components as a short cut to complete the work quickly, according to industry sources.

The industry sources argued that workers may have taken the points apart in order to switch a vehicle from one track to another. Under normal circumstances the special crossover can only be operated by line-side personnel if it has been "released" by a signaller. The points are only used for engineering work and during emergencies.

The industry insider said the evidence pointed to maintenance staff taking the points apart so that they could switch a vehicle from one track to another without the involvement or authorisation of the signaller. Clearly the staff then failed to reassemble the equipment.

Video evidence

According to the Independent online on 28 February 2007


Network Rail confirmed that video footage taken by special engineering equipment found that a critical piece of equipment, which stabilises the points, was missing from the crossover two days before the accident. The film showed that the front stretcher bar, which keeps the rails apart, was missing from the points last Wednesday.

A spokesman for the infrastructure company however said that, as a matter of routine, the video footage was not inspected until after the crash.

At least 200 trains carrying tens of thousands of passengers passed over the faulty points before the accident in which a Virgin Pendolino train left the track, killing an elderly woman and seriously injuring five other people.

Similar news also reported in the Daily Record on 28 February 2007, but with a slightly different spin.

RAIL chiefs had video evidence that could have prevented the Cumbria death crash - but failed to look at it.

Footage recorded two days before Friday's accident could have revealed the fatal flaws in the set of points where the Virgin express train derailed.

But Network Rail admitted last night that nobody viewed the footage until after the accident at Grayrigg in which one person died and 22 were hurt.

It has emerged the film, taken by a hi-tech safety inspection train, showed one of four crucial "stretcher bars" was missing.

It also picked up the fact that bolts were missing from two of the remaining bars, which play a critical part in keeping the rails a precise distance apart.

Had the faults been spotted, a 20mph speed restriction would have been put in place right away.

A company spokesman said the £5million train, which checks the state of the track, had initially flagged up no problems.

But he added: "The train also has a video recorder which films the track. It did pick up the fact that one of the stretcher bars and some bolts were missing.

"But the video footage is not used on a day-to-day basis. It has to be run in super-slow motion to pick up any faults."

Network Rail looked at the film after the disaster then passed it to accident investigators. RMT leader Bob Crow branded the failure to look at the footage earlier "pure negligence".

Crow said it showed the "madness" of relying on technology.

Calling for an inquiry, he said: "Inspectors who walk the track are the eyes and ears of the railway."

Network Rail press release - after RAIB initial report

Responding to the initial finding of the Rail Accident Investigation Branch, Chief Executive, John Armitt said: ”Network Rail is devastated to conclude that the condition of the set of points at Grayrigg caused this terrible accident. We accept the RAIB report in all respects. We would like to apologise to all the people affected by the failure of the infrastructure.

“We now need to understand how the points came to be in this condition – and we will leave no stone unturned in our search for the facts behind this derailment. We will continue to co-operate fully with the investigators as they work towards more detailed conclusions.

“When more detailed findings are available, we will consider them carefully, and learn any lessons that need to be learned. We will also, at that time, consider any action that might need to be taken as a result.

“Passengers should be reassured that we have carried out extensive checks of similar points across the rail network. Over the weekend, more than 700 special inspections took place, and nothing out of the ordinary was found.

“Our key priority is to run a safe railway. Despite this terrible tragedy, it is worth remembering that the railway is safer than it has ever been before, and remains the safest form of transport in the UK .

“We again extend our sympathies to the family and friends of Margaret Masson, who died as a result of the incident, and to those who were injured and shaken. We would also like, again, to thank the emergency services who worked heroically on that difficult evening.”