A summary of Network Rail's investigation into the Virgin rail crash that killed one person 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.
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Andy,
Do you think it might be a problem that we do not seem to have agreed definitions of these classes of "cause"? I mean "immediate" and "underlying" which are used in this report. Other reports use other adjectives, but nobody defines them.
The developer of the Apollo Root Cause method, Dean Gano, surprisingly says we don't seek causes, we seek solutions. I like that - it makes us focus on the reasons for investigation and what we should do with the report.
Do you think identifying inadequate inspection as an underlying cause is falling in line with the current trend of de-emphasising technical or operator failure in favour of organisational failure?
Questioning the design of the points is valid. This is what we should do with investigation reports - question, test, discuss.
John.
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