RECOMMENDATIONS BY THE HATFIELD INVESTIGATION BOARD
22 Aug 2002 11:16 AM
The Health and Safety Commission (HSC) has today published
recommendations prepared by the independent Investigation Board
established following the Hatfield derailment. Four people were
killed and 70 injured in the derailment on 17 October 2000.
The immediate cause of the derailment was the fracture and subsequent
fragmentation of the track at Hatfield. The recommendations derive
from the investigation into why this happened, and focus on improving
the management of health and safety and maintenance, track design and
inspection, and rolling stock and infrastructure design.
While the Investigation Board will not be able to produce a final
report into the derailment until any legal proceedings are concluded,
it is keen to put its recommendations into the public domain in the
interests of openness. The Board has also forwarded a dossier of
papers to the Crown Prosecution Service.
Bill Callaghan, Chair of the Commission, said:
"I am pleased that it is now possible to make these recommendations
public. While the Board has passed relevant safety critical
information to both the Health and Safety Executive (HSE) and the
rail industry's own inquiry board, I believe that it is important
that the public sees its work to date."
"The Board notes that action already taken by the industry, including
that to implement recommendations made by Lord Cullen in his Inquiry
Reports, will have addressed many aspects of its own recommendations.
In the light of that, I have asked the industry to endorse the
Board's work, to let me know how much work has been done so far to
meet the recommendations, and what more needs to be done to fully
implement them. I have also sought views on an appropriate timetable
for completing this work."
'Hatfield Derailment Investigation: Interim Recommendations of the
Investigation Board' is available on the HSE's website at
http://www.hse.gov.uk/railway/hatfield/investigationb1.pdf
Notes to Editors
1. The derailment of the 12.10 Kings Cross to Leeds passenger express
train took place on 17 October 2000 near Hatfield. Four people were
killed and 70 injured. The investigation into the cause of the
derailment has been undertaken jointly by HSE and the British
Transport Policy (BTP), with the latter in the lead.
2. The HSC requested that the derailment be investigated under
Section 14(2)(a) of the Health and Safety at Work etc Act 1974. The
investigation was overseen by a Board, chaired by Sandra Caldwell,
head of HSE's Health Directorate and a former member of the Channel
Tunnel Safety Authority. The Board included independent members,
namely Consulting Engineer Stuart Mustow, CBE, FR Eng, FICE; Richard
Profit, OBE, Group Director Safety Regulation, Civil Aviation
Authority; and Prof. Ernest Shannon CBE, FR Eng, FIAE, formerly
Director of Engineering Research, British Gas.
The Board's terms of reference are:
- To ensure the thorough investigation of the Hatfield derailment by
HSE and thereby establish its causation, including root causes;
- To identify and transmit to the appropriate recipients any
information requiring immediate attention;
- To examine HSE's role in regulating safety on the railways with
regard to this incident, both prior to and in the investigation of
the incident, within the context of the existing regulatory
framework applicable to railway safety, and in securing compliance
with regulatory requirements by the infrastructure controller and
other duty holders involved;
- To report findings to the Executive and Commission as soon as
possible.
3. The Board asked the HSC to publish its interim recommendations,
and it has also passed a dossier of papers to the Crown Prosecution
Service. The BTP component of the investigation is continuing. The
Board will prepare its final report into the derailment when any
legal proceedings are concluded.
The publication of the recommendations follows two interim reports by
HSE into the Hatfield derailment. They are 'Train Derailment at
Hatfield, 17 October 2000, First HSE Interim Report' published
20 October 2000, and available on
http://www.hse.gov.uk/railway/hatfield/interim1.htm and
'Train Derailment at Hatfield, 17 October 2000, Second HSE Interim
Report, published 23 January 2001 and available on
http://www.hse.gov.uk/railway/hatfield/interim2.htm
4. Lord Cullen made 89 recommendations in Part 1 of his Report (HSE
Books, ISBN 0 7176 2056 5) on the Ladbroke Grove Rail Inquiry and 74
recommendations in his Part 2 Report (HSE Books, ISBN 0 7176 2107 3).
The latter Report dealt with the management of safety on the
railways, and the regulatory regime.
PUBLIC ENQUIRIES: Call HSE's InfoLine, tel: 08701 545500, or write
to: HSE Information Services, Caerphilly Business Park, Caerphilly
CF83 3GG.
PRESS ENQUIRIES: Journalists only: Mark Wheeler 020 7717 6905/
Jacqueline Noble 020 7717 6903, out of hours 020 7928 8382.
HSE information and press releases can be accessed on the Internet:
http://www.hse.gov.uk
Ends
INTERIM RECOMMENDATIONS OF THE INVESTIGATION BOARD
Introduction
On 17 October 2000 four people were killed and 70 injured as a result
of a derailment near Hatfield. The Health and Safety Executive (HSE)
has published two interim reports on the derailment. The
investigation into the causes of the derailment has been undertaken
jointly by HSE and British Transport Police (BTP), with the latter in
the lead.
The immediate cause of the derailment was fracture and subsequent
fragmentation of a rail. The HSE investigation examined a number of
systems and process issues. These related to the root causes of the
derailment and included responsibility for the management and
maintenance of the line. The HSE Investigation Board (the Board) has
already shared all technical findings with the independent panel
chair appointed by Railway Safety to carry out the industry's own
investigation into the derailment. Other safety critical information
was shared with those responsible for assessing the current version
of Railtrack's Safety Case and during the operational contact with
the relevant Railtrack zone. Information has also been shared with
the Potters Bar Investigation Board.
The Board is not able to produce a final report until the position on
possible legal proceedings is clear. However, in these circumstances,
the Board wishes to put its interim recommendations into the public
domain for the record and in the interests of openness. We are now at
a point when making such recommendations public will not prejudice
either the ongoing BTP component of the investigation or any possible
legal proceedings.
The interim recommendations should be read in the context of those
arising from:
- the second part of Lord Cullen's Ladbroke Grove Rail Inquiry held
during 2000, which considered in detail the management of safety
and the operation of the regulatory regime on British railways;
- the report issued by Railway Safety following the industry's own
inquiry into the Hatfield derailment entitled "Derailment of
Passenger Train ID38 1210 Kings Cross to Leeds between Welham Green
and Hatfield on 17 October 2000";
- a review of maintenance and renewal processes conducted by
Railtrack in response to the lessons learned from Hatfield and its
experience of the early maintenance and renewal contracts; and
- the Health and Safety Commission's report on "The use of
contractors in the maintenance of the mainline railway
infrastructure" published on 10 June 2002.
The Board is aware that in the period since the Hatfield derailment
much work has been undertaken by the rail industry and others to
address the factors which caused the derailment. The examples given
above are illustrative of this. The Board also recognises that action
already taken to implement Lord Cullen's recommendations will have
addressed many aspects of these interim recommendations flowing from
Hatfield.
The interim recommendations are derived from the investigation of the
Hatfield derailment and as such focus specifically on track
maintenance. However, the recommendations have wider currency and
application to any circumstances where safety critical maintenance is
being undertaken. Also there are lessons to be learned from the
interim recommendations by all large organisations that rely on
effective monitoring of contractors to deliver essential safety
critical maintenance work.
The causes of the derailment
The Hatfield derailment happened because a rail, in which there were
multiple cracks and fractures due to rolling contact fatigue,
fragmented when a high-speed train passed over it. The Board has
identified, under the heading 'Direct causes', a number of interim
recommendations intended to prevent this type of catastrophic rail
fracture occurring again.
In addition, there were a number of contributory factors which made
it more likely that this derailment would occur, and a range of
aggravating factors which, in the Board's opinion, made the
consequences of the derailment worse than they might otherwise have
been. There are interim recommendations which target these issues
also.
Finally, the Board has made recommendations based on observations of
other matters pertinent to this type of derailment, and which it
identified from information obtained during the investigation.
Direct causes
The incident happened because a train travelled at the permitted
speed over a rail that had been identified as in poor condition, and
which should have either been replaced or a temporary speed
restriction applied.
The following recommendations relate to the management systems which
should have prevented these circumstances.
Future role of the Board
The Board will continue to monitor the progress of the investigation,
and the sharing of safety related information, and may make further
recommendations as appropriate. However, its most pressing task will
be to prepare the final report into the derailment at Hatfield. This
work will begin when any potential legal proceedings arising from the
investigation have been completed.
The Board's Interim Recommendations
1. Health and safety management
Recommendation
1.1 All employees with responsibility for any aspect of track
maintenance should attain the necessary levels of both technical and
managerial competence. In particular, the following areas should be
addressed.
(a) Additional training should be given to senior and middle rank
managers. This should include training in risk based safety systems;
management of conflicting priorities; monitoring staff performance
and auditing skills.
(b) Engineers' training should be improved to ensure they are kept up
to date on any changes to standards and procedures.
(c) A national accreditation scheme for rail examiners, analogous to
the Personnel Certificate in Non-destructive testing (PCN) system,
should be developed.
(d) Existing legal requirements for competence, within the Management
of Health and Safety at Work Regulations 1999, and the Railways
(Safety Critical Work) Regulations 1994 should be reviewed, and
associated guidance revised where necessary, to ensure they are
sufficiently robust in so far as they relate to all employees whose
decisions have a direct impact on public safety on the railways.
(e) The arrangements for assuring the standard of competence of all
those with responsibility for track maintenance should be assessed by
HSE as part of the assessment of Railtrack's safety case, and their
effectiveness considered as part of the subsequent inspection
process.
Lead responsibility
(a) - (c) Railtrack and Infrastructure Maintenance Contractors (IMCs)
and Track Removal Contractors (TRCs)
(d) HSE, as part of its planned work in response to Lord Cullen's
Ladbroke Grove Rail Inquiry
(e) HSE
1.2 Quicker and more responsive mechanisms should be established by
which employees can bring safety critical matters to the attention of
senior managers.
(a) HSE to consider whether their intervention strategies should
include an assessment of these improved mechanisms.
Lead responsibility
1.2 Railtrack, IMCs and TRCs
(a) HSE
1.3 The performance of IMCs, and other track-related contractors,
must be managed to ensure their activities achieve the required
standard of track quality and integrity. This will require the
following.
(a) A review of existing contracts to ensure there remains no
perverse incentive which may tend to jeopardise the effective
maintenance of track integrity.
(b) All staff, including those responsible for monitoring contracts,
understand the importance of, and their role in, ensuring track
integrity.
(c) Commence the installation of systems which enable Railtrack to
access basic information on track maintenance e.g. numbers of track
defects; performance against the track- walking plan etc., and to
retain and transfer information on track maintenance in the event of
a change of contractor.
(d) Procedures to increase the level of evaluation of contractors
based on observation of activities and end products aimed at assuring
the quality of work done.
(e) Improved mechanisms for ensuring safety critical information, and
alterations to standards, are communicated to contractors rapidly and
effectively, without requiring lengthy contract amendment procedures.
Lead responsibility
Railtrack
2. Management of maintenance
Recommendation
2.1 Railtrack should make a clear statement of the importance of
track maintenance and implement an effective maintenance programme to
ensure that the probability of a safety critical rail fracture is as
low as is reasonably practicable. This should include the following.
(a) The development of performance based maintenance standards.
(b) Arrangements for ensuring that safety maintenance requirements
are met.
(c) A database which defines the condition of the rail throughout the
network and which identifies clearly all sites with significant
deterioration, sets priorities and latest dates for rectification,
and registers dates of completion of all necessary work.
(d) A revised strategy, developed in conjunction with rail
manufacturers, train operating companies (TOCs), rolling stock
companies (ROSCOs), and IMCs for proactively managing all aspects of
identification and rectification of rail deterioration. Any changes
to existing practice should be incorporated into relevant contracts
with manufacturers and IMCs.
(e) Ensuring sufficient track access time is available for
maintenance.
(f) Specification of responsibilities for imposing speed restrictions
for track with safety significant deterioration.
(g) A revised strategy for rail grinding, developed in conjunction
with rail manufacturers and IMCs and taking into account lessons
learned from the strategies employed by DBAG (Deutsche Bahn AG) and
SNCF (Société National de Chemin de Fer).
(h) Revised procedures for ensuring urgent maintenance, including
re-railing, are completed to schedule, and risks associated with
failure to achieve the schedules are recognised and managed.
Lead responsibility
Railtrack
2.2 IMCs and TRCs should ensure that any contractor engaged in safety
critical work on the railway infrastructure should;
(a) review their arrangements for ensuring that safety critical work
is performed to meet the standards established by Railtrack and
Railway Safety;
(b) ensure adequate arrangements are in place for;
(i) reporting and recording safety critical information, e.g.
defects; and
(ii) reviewing and acting appropriately on such information (e.g.
seeking possessions, imposing speed restrictions, liasing with
Railtrack).
(c) improve systems to ensure that communications from Railtrack
relating to safety critical information (e.g. alterations to
standards) are acted upon and procedures are amended accordingly.
Lead responsibility
IMCs and TRCs
3. Inspection of track
Recommendation
3.1 Current best practice in detecting rolling contact fatigue should
be implemented. Automated (i.e. train borne) techniques should be
investigated and techniques capable of detecting defects in a wider
range of orientations should be developed. This work should include
the evaluation of other methods for the non-destructive examination
of rail (e.g. Eddy current, Alternating Current Field Measurement).
Lead responsibility
Railtrack
3.2 Procedures for rail inspection, both visual and using non-
destructive testing techniques; the reporting and categorising of
rail defects; and the identification of the relevant actions to be
taken should be improved. Revised procedures should take into account
the human factors aspects of rail inspection.
Lead responsibility
Railtrack
Contributory factors
This set of interim recommendations is concerned primarily with
matters that are directly relevant to the incident but which arose
only because of the failure to address the management issues
identified above.
4. Rolling contact fatigue (RCF)
Recommendation
4.1 Work should be set in hand to improve understanding of the RCF
mechanism in rails. This work should consider the effects of
wheel/rail geometry and loading to develop an understanding of crack
behaviour, looking in particular at predicting when fatigue cracks
'turn down' to become transverse. The work should also consider the
effects of rail lubricants; grinding; ferrites in the microstructure;
and residual stresses, on the initiation and propagation of RCF
cracks. It should compare the occurrence of RCF between mill heat
treated and other types of rail, and should assess the value of
alternative steel types in providing improved fatigue resistance.
Lead responsibility
Railtrack and TOCs
5. Track design and wheel/rail interface
Recommendation
5.1 Track and rolling stock design should be reviewed to consider the
stresses on rails, the materials used, and in particular to identify
whether they reduce the risk of RCF so far as is reasonably
practicable. This review should take account of the likely traffic
mix encountered on GB railways at typical axle loading, and the
impact of tilting trains running at higher speeds.
The review process should consider the stresses on rails, and in
particular the impact of cant deficiency at levels currently
permitted, on high-speed curves, on RCF. It should identify any
necessary improvements in the design of track fixing, bedding, or
support mechanisms on these curves. The review process should take
account of standards of track design, and levels of cant deficiency,
approved in other countries.
Lead responsibility
Railtrack and TOCs
6. Economic regulation
Recommendation
6.1 HSE, the Office of the Rail Regulator (ORR) and the Strategic
Rail Authority (SRA) should continue to review the regulatory regime
to eliminate any potential conflict of priorities between meeting
service delivery targets and the development of the safety culture
cited in Lord Cullen's recommendations.
Lead responsibility
HSE, ORR and SRA
Aggravating factors
These interim recommendations address matters which, in the opinion
of the Board, may have made the outcome of the derailment worse than
it might have been.
7. Rolling stock and infrastructure design
Recommendation
7.1 Train sets should be designed, built and maintained to maximise
the chance of their remaining upright and intact during high speed
derailment. Particular aspects of rolling stock design which should
be reviewed are:
(a) bogie and suspension component retention. Strengthening of the
attachment systems should be considered;
(b) 'Tightlock' couplers; their propensity to open when rotated
should be assessed and the design loads reviewed. In addition,
'Tightlock' couplers from vehicles involved in accidents should not
be reused unless their integrity can be assured;
(c) strength of vehicle roofs and walls;
(d) passengers seats; the risks to passengers as a consequence of
seat damage or failure should be reassessed; and
(e) the design of catering facilities should be reviewed to minimise
the risk to staff in the event of an accident.
Lead responsibility
ROSCOs
7.2 The design of overhead line equipment stanchions should be
reviewed with a view to making them less likely to penetrate
passenger space in the event of a collision. In addition, the risks
associated with trains striking any trackside equipment in a
derailment should be assessed.
Lead responsibility
Railtrack
Observations
The following interim recommendations arise from information obtained
during the investigation while they did not necessarily have a direct
bearing on the cause or consequences of the Hatfield derailment, they
are relevant to general improvements in health and safety.
8. Interim recommendations arising from data and voice tape analysis
Recommendation
8.1 The provision of communications equipment for drivers should be
reassessed to permit direct contact to be established between loco
drivers and signalling staff (as via the cab secure radio system).
Lead responsibility
TOCs
8.2 Procedures relating to the reporting and handling of non-
described alarms issued by Train Describer systems should be reviewed
to identify whether these alarms provide any relevant safety
information on track integrity
Lead responsibility
Railtrack
8.3 The new railway industry safety body should take responsibility
for "horizon scanning" to ensure that it is aware of developments in
best practice worldwide as regards the management of safety on the
railways.
Lead responsbility
New railway industry safety body
8.4 Education of engineers should deliver professionals who
understand their professional responsibilities for the safety of the
public, including the need to act on safety critical defects, and who
can apply the principles of risk management
Lead responsibility
The rail industry and the professional bodies
9. Emergency evacuation
We note that Lord Cullen, in his Part 1 report on the Ladbroke Grove
Rail Inquiry, made a number of recommendations on emergency
arrangements, which we endorse.
10. Safety Culture
We note and fully support Lord Cullen's recommendations as regards
the need for improved health and safety culture in the railway
industry.
The Hatfield Investigation Board
August 2002
References
The Ladbroke Grove Rail Inquiry Report Part 1
HSE Books ISBN 0 7176 2056 5
The Ladbroke Grove Rail Inquiry Report Part 2
HSE Books ISBN 0 7176 2107 3
Railway Safety Formal Inquiry: Provisional Report 'Derailment of
Passenger Train 1D38 1210 Kings Cross to Leeds between Welham Green
and Hatfield on 17 October 2000' RS/2001/HAT/03
Train Derailment at Hatfield 17 October 2000 -
First HSE Interim Report
www.hse.gov.uk/railway/hatfield/interim1.htm
Train Derailment at Hatfield 17 October 2000 -
Second HSE Interim Report
www.hse.gov.uk/railway/hatfield/interim2.htm
Health and Safety Commission: 'The use of contractors in the
maintenance of the mainline railway infrastructure'
www.hse.gov.uk/hsc/contrail.pdf
Railway (Safety Critical Work) Regulations 1994,
Railway Safety Critical Work Approved Code of Practice and Guidance
HSE Books ISBN 0 7176 1260 0
Management of Health and Safety at Work Regulations 1999
Approved Code of Practice and Guidance
HSE Books ISBN 0 7176 2488 9