Formal Inquiries

Southall East Junction report and recommendations

Rail Safety and Standards Board has issued its formal inquiry report into the circumstances that led to the derailment of a passenger train at Southall East Junction on 24 November 2002.

The formal inquiry was convened under independent chairmanship and included representatives on the panel from the involved parties. As with all such inquiries the panel's task was to establish the immediate and underlying causes of the incident and make recommendations to prevent or reduce the risk of recurrence.

Sequence of events

The points, numbers 8175, are facing crossover between the Up Main and Down Relief lines, and is one of a ladder of crossovers known as Southall Junction. The crossover was set normal for the passage of train 1L79 along the Up Main line through this junction.

The passenger train was running close to its maximum speed of 125mph (201km/h) when it arrived at points 8175A. The leading bogie of the fifth coach derailed to the right as it reached the common crossing. A full break application was made a short time after due to the operation of the passcom equipment by a passenger, and the train came to a rest about two miles beyond the derailment point, close to West Ealing Station.

Conclusions

The formal inquiry panel found the that the left leading wheel of the leading bogie of coach D struck a piece of broken fishplate that had lodged in the flangeway of the cast common crossing of points numbers 8175A. The two leading fishbolts in the joint at the country end of the cast crossing had unscrewed and fallen onto the ballast. Both fishplates at the joint had broken in half, and the leading right hand half fishplate had then moved foul of the crossing flangeway through vibration from wheelsets of vehicles in advance of coach D.

Other underlying causes were found to be the track component condition before installation. Forging flash on the fishplates and reduced vertical spacing of the crossing fishing surfaces were contributory causes of the bolts falling onto the ballast and the fishplates fracturing. There were a number of potentially unsafe maintenance conditions of the permanent way components in and around the crossing that were not identified by the basic and supervisor visual track inspection. The fishbolts in the failed joint had not been kept adequately tight. Failure to arrange simultaneous possession of the Up Main and Down Relief lines reduced the ability to maintain good top and line through the crossover.

Recommendations

The report makes recommendations for improvements in a number of key areas and these are summarised as follows.

• Produce component specification and standards with regard to fishplates.
• Review the standards and specification of the visual track inspection.
• Review track maintenance standards.
• Review in detail management monitoring.
• IMC organisation.
• Inspection of cast crossing.
• Contract management.
• Post accident management.

Rail Safety and Standards Board has issued a full copy of the report to each member of the Railway Group and the other organisations involved in the accident. All recipients of the report need to review the findings and recommendations and take actions where appropriate to address identified deficiencies within their own systems. Rail Safety and Standards Board will track the industry's response to this report.