Management failures underlying cause of Burntisland derailment - HSE
Health & Safety Executive : Saturday, July 10, 1999
The derailment of an English Scottish & Welsh Railway coal train was caused by track defects, but the underlying cause was the failure of management systems of Railtrack and its contractor First Engineering Limited according to a report by the Health & Safety Executive.
The EWSR train was travelling between Mossend and Longannet when 16 of its 27 wagons became derailed at Burntisland on the Firth of Forth, Scotland. The incident occurred on 8 July 1998 as the train traversed a section of track where the rails had spread.
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".
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.
Scene of the Bexley derailment on 4 February 1997
The "lessons to be learnt" are reiterated:
According to a HSE press statement Railtrack Scotland Zone have produced an action plan to address the issues by the end of October 1999 and HSE will review the plan then. HSE has decided that, in view of the investigation findings, there is not sufficient evidence of breaches of law to refer the matter to the Procurator Fiscal. HSE will continue to monitor progress with the plan and will take action if appropriate.
- 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.
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