POTTERS BAR INVESTIGATION: HSE ISSUES LATEST PROGRESS REPORT

HSE press release E087:03 - 29 May 2003

The Health and Safety Executive (HSE) has published a further progress report from the independent Board set up to oversee its investigation into the Potters Bar derailment on 10 May 2002, which claimed seven lives and injured over 70 people.

HSE's investigation, along with that of the British Transport Police, who remain in the lead, continues. The report describes technical, forensic and other work undertaken by the Health and Safety Laboratory (HSL) and HM Railway Inspectorate (HMRI). The Board has reviewed this and other information, makes observations on factors associated with the derailment and recommends action to improve further rail safety and its regulatory system.

The Board considers that the detailed evidence from the investigation to date indicates that the most likely underlying cause of the derailment was the poor condition of points 2182A at the time of the incident, and that this resulted from inappropriate adjustment and insufficient maintenance for their operating environment and safety functions, probably arising from failures of management systems. The Board is satisfied that no evidence has yet been established to support speculation about sabotage or deliberate unauthorised interference and that an explanation for the failure in points 2182A can be based on the evidence of their poor condition.

HSL has examined the technical causes of the derailment, and what happened during and after it. They examined points 2182A and their components, both at the scene and under laboratory conditions. The train was also examined, both internally and externally, and damage caused by the derailment to the surrounding rail infrastructure was carefully assessed. Most of this work is now complete.

HMRI has examined systems for managing the inspection and maintenance of points, and points 2182A particularly. Inspectors have reviewed, among other matters, the operation, testing and repair history of points 2182A and issues such as worker training, competence and supervision.

Key conclusions from the technical investigation include:

• four main factors contributed to the failure of points 2182A: components were in poor condition; nuts to secure the right-hand end of the rear stretcher bar and the left-hand end of the front stretcher bar were absent from the ends of the bars; and the lock stretcher bar failed by fatigue, broke and became disengaged from the bracket fixing it to the right-hand switch rail.
  
• the points had been poorly maintained and were out of adjustment;
  
• other sets in the Potters Bar area showed attempts had been made to improve the retention of nuts, indicating difficulties with nuts on the ends of stretcher bars loosening;
  
• the train was being driven normally and within the permissible speed.

HMRI's investigation so far has indicated:

• there were two separate systems for the inspection and maintenance applied to points 2182A , involving both permanent way and signalling personnel. This created the possibility that roles and responsibilities were not clear;
  
• there appears at this stage to have been no guidance or instructions for setting up, inspecting and maintaining points of this type, based on an understanding of the design and safety analysis of this item of safety critical equipment;
  
• there were deficiencies in the response to a 'rough ride' reported in the area south of Potters Bar station the night before the derailment.

HMRI conducted two sample inspections of points across the rail network, in May/June and October/November 2002. These inspections revealed examples of failure to apply good engineering practice and led HMRI to conclude that there may have been a wider problem. The deficiencies were, however, less serious than those at Potters Bar.

The Board makes a number of observations and 26 recommendations. The main ones are summarised below:

• Safety management and culture in the industry: an effective management system for safety critical equipment such as points was not evident in Railtrack. Recently, welcome signs of change have resulted from the creation of Network Rail, e.g. a move away from a fixed attitude, based on historic engineering and maintenance practices, to a philosophy founded on searching for solutions to safety-related problems using fundamental safety principles. The Board recommends accelerated progress in this area and urges the industry and those who influence it to work in partnership to accelerate progress in developing the safety culture.
  
• Rail industry response to the derailment and the Board's July 2002 report: Railtrack did not demonstrate a response to either of these matters that the Board expected against the principles of good risk management. Network Rail has been more positive over recent months, e.g. starting a design/safety review of points to assist in identifying a proper, risk-informed, strategy for improvement.
  
• HSE's role and the regulatory system: while there was no direct HMRI involvement in this part of the network, there may be lessons for better targeting of HSE's rail resources towards preventing catastrophic risks and for better aligning the safety case regulatory regime in a similar way. The Board recommends that HSE review its approach to see if lessons can be learned.
  
• Industry's approach to design, engineering and maintenance: the Board recommends that Network Rail builds on its developing approach to risk in these areas, recognising that safety goes hand in hand with good business, particularly on the railways where attention to inherently safe design and preventative maintenance can lead to improved reliability, less down time on the network and improved safety.

The Board has also reviewed its findings against recommendations from Lord Cullen's Part 2 report into the Ladbroke Grove Public Inquiry and the interim recommendations from HSE's investigation into the Hatfield derailment. It reinforces and adds to recommendations in respect of its observations on contractors, the management of safety critical work, safety leadership in the rail industry, the regulatory regime, track maintenance competence, managing safety critical maintenance, record keeping and infrastructure design.

Dr Mike Weightman, Chair of the Board, said: "We hope that the lessons from the derailment are learnt and that the industry moves forward. In making our recommendations, we are not saying the rail network is unsafe or that the regulatory regime is ineffectual, and we welcome the recent progress made, particularly since the advent of Network Rail.

"We are saying that there are important lessons and if these are taken forward with vigour the opportunity exists to develop a safer, more reliable cost-effective railway system that serves the public better."

Alan Osborne, HSE's Director of Rail Safety, said: "I welcome today's thorough and comprehensive progress report. It makes a number of sensible recommendations, eight for HMRI to implement. These range from the agreement with Network Rail for an enhanced preventive maintenance regime; through to assuring the process for the management of contractors; to focusing more of our resources on risks with the potential for catastrophic loss.

"We accept without reservation all of the recommendations and have begun implementation.
We will also be closely monitoring the implementation of the other recommendations aimed at the industry, as part of our independent inspection process."

The Board intends that this should be the last progress report on HSE's investigation. A final report on the HSE investigation will be published when any legal proceedings have been concluded or a decision has been taken not to take any action.

Copies of 'Train derailment at Potters Bar, 10 May 2002: A progress report by the HSE Investigation Board' are available on HSE's website at http://www.hse.gov.uk/railways/pottersbar.htm

Notes to editors

1. On 10 May 2002 a train travelling from London derailed at Potters Bar when passing over points 2182A, causing seven deaths and injuring over 70 people. Since then, two criminal investigations have been in progress: one by the British Transport Police (BTP) into possible manslaughter offences, and the other by HSE into possible offences under the Health and Safety at Work etc Act 1974. The former investigation takes primacy and HSE's work has largely been in support of the BTP investigation, but the investigations overlap.

2. The Health and Safety Commission (HSC) directed HSE to undertake its investigation under the oversight of this Investigation Board, which includes members independent of HSE. The Board has no role in relation to the BTP investigation. HSC required the Board to suggest ways to improve rail safety in the light its considerations. The report covers HSE's investigations up to the end of May 2003 and follows two earlier reports published in May and July 2002.

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