Management failures underlying cause of Burntisland derailment - HSE

Faulty installation work in the 1960's was to blame, when a particular combination of fastening was used - a two hole base plate and a concrete sleeper. This defect was hidden by the fastenings which secure the rail to the sleeper. The HSE's HM Railway Inspectorate investigation faulted the management systems of both companies. They "did not analyse information they had on the condition of the track, and so did not spot and act on the worsening track spread".

Scene of the Bexley derailment on 4 February 1997

The HSE also pointed out that the management failings are similar to those found in HSE's investigation of the accident at Bexley, Kent on 4 February 1997, when a ballast train derailed due to poor track condition.

The "lessons to be learnt" are reiterated:

• Each infrastructure maintenance company (IMC) should ensure that staff are competent to carry out tasks required of them without undue risk to themselves or others.
• Each IMC should undertake ongoing monitoring and reassessment to confirm the adequacy of the systems and resource provided. Modifications to systems or resources should be made as necessary.
• Each Railtrack zone should ensure that they undertake ongoing monitoring and reassessment of their contractors' performance in accordance with the Contract Performance Monitoring Strategy.
• Railtrack Zones and Railtrack HQ should monitor and review the effectiveness of the systems they have in place to ensure that the infrastructure is maintained in a safe condition. They should monitor and review the adequacy of the resource to do this.