Formal Inquiries

Hatfield report and recommendations

Railway Safety confirmed that it has issued its report of the formal inquiry into the Hatfield rail accident to the industry.

A panel of independent railway experts appointed by Railway Safety has looked at all aspects of the accident which sadly resulted in the death of four people in October 2000. Its remit included looking at the circumstances of the accident, condition of equipment including track, train, signalling and electrification system, maintenance work, safety cases, audit, rolling stock and human factors as well as the accident investigation and management.

The chairman of the panel John Mitchell said "We have looked at every aspect of this tragic incident and made a number of recommendations for improvements in future. Our report should not be seen as allocating blame but as our view of the circumstances leading to the accident and most importantly what lessons can be learnt. It is imperative that these lessons can be shared quickly and that those with a duty to provide a safe railway take appropriate action to restore public confidence."

The report found that the immediate cause of the accident was due to the fracture and subsequent fragmentation of the high rail over a 35 metre length due to substantial transverse fatigue defects in the rail head. It states that these defects had their origins in gauge corner cracks, a form of rolling contact fatigue, which had developed on the rail surface.

The report points to a number of underlying causes which led to the accident:

An incomplete appreciation of the risks presented by gauge corner cracking, and the consequent failure to develop and disseminate comprehensive instructions on its identification and the control measures required.
A failure to manage and execute a competent visual inspection regime, and to manage the ultrasonic inspections so as to identify the true condition of the high rail at the Welham Curve, and to take appropriate action to maintain the line.
An inadequate management of the contracts relating to the maintenance and renewal of the track asset.
The failure to ensure the completion of the urgent proposal to re-rail Welham Curve as a result of a lack of effective project management, and a failure to take account of the potential risks of delay.
The failure to act on the findings of audit reports relating to a lack of adequate knowledge of the track asset.

Sequence of events

The train left King’s Cross on time at 12.10. At 12.23 it was travelling around the Welham curve at approximately 115mph. After passing under Oxlease Avenue overbridge, the driving crew observed that the brake pipe pressure had fallen to zero, initiating a full brake application. They felt considerable buffeting of the locomotive from behind as the train came to a stand.

The locomotive and the first two mark 4 coaches remained on the track, but the remaining eight vehicles were derailed. Some coaches were leaning over or were on their sides. The train split into three portions with the two first class coaches and the DVT (driving van trailer) located some 250 metres to the rear of the front portion of the train. The two first class coaches were separated by a distance of about five metres.

The four fatalities were all located within the service coach. This had impacted two lineside electrification stanchions whilst on its side, and had lost a large section of its roof and bodyside structure as a result. About 30 people required hospital treatment for their injuries.

The high rail shattered into some 300 pieces over a length of about 35 metres.

Recommendations

The report makes recommendations for future improvements in a number of key areas. The primary ones include:

Establishing control and mitigation measures for gauge corner cracking.
Improving visual and ultrasonic track inspection methods.
Optimising the benefits of rail grinding.
The strategy for prolonging the life of track assets by means of deferred renewal should be reviewed and robust procedures put in place to deliver urgent re-railing proposals.
Contractors should review their procedures for the movement of managerial staff together with the recruitment and training programmes to ensure staff are competent.
A national database be prepared to record the state of all track including any flaws.
Consideration be given to making electrification stanchions less aggressive to reduce the effects of collisions with passenger coaches.
Any future system which replaces the National Radio Network should incorporate a facility for drivers to communicate directly with the signallers.
The audit system be re-evaluated.

The inquiry panel is made up of individuals who are retained by Railway Safety to independently investigate railway accidents. The panel first met together at the end of October 2000 and interviewed over 55 witnesses with observers present from other organisations to ensure due process was followed.

Railway Safety has responsibility for ensuring that, when such accidents occur, a thorough independent inquiry takes place and for ensuring that effective learning is obtained. All Railway Group members have a duty to co-operate with the inquiry process, covered by a Railway Group Standard.

The three man inquiry panel comprised experts in rolling stock, track and structures and railway operations. In the past each held senior positions within British Rail and have in total in excess of 115 years railway experience. They have each independently chaired a number of inquiries in the past two years.