Formal Inquiries

Kings Cross report and recommendations

Rail Safety and Standards Board has issued its formal inquiry report into the derailment of a passenger train at Kings Cross on 16 September 2003. 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 accident and make recommendations to prevent or reduce the risk of recurrence.

Sequence of events

Work to overcome a defective cast crossing, (a track component associated with a set of points), was carried out under a possession at Kings Cross Station. The planned possession was due to end at 0545hrs but overran until 0657hrs.

At this stage, the defective crossing had been removed and replaced with plain rail, making several of the normally available routes from platform 4 unavailable. Correct procedures were not followed that should have ensured that the unavailable route could not be set by the signaller.

At the departure time for the 0700hrs Kings Cross to Glasgow Central train, the signaller was able to set a route and clear the signal for a route where a section of rail was missing. The driver approached 15mph (24km/h) when he noticed the new rail in place of the crossing and the gap in the left hand rail, and he applied the emergency brake. The locomotive derailed, there were no injuries to passengers or crew.

Conclusions

The panel found a number of underlying and immediate causes surrounding the derailment, these were:

The absence of clips, scotches and padlocks on the switch ends of appropriate points.
The status of the signalling system that allowed the signaller to set and signal a train over a route with incomplete track.
The decision taken to carry out the permanent way work near one set of points and on another set points without preparation and use of a method statement.
Insufficient time allowance before the possession to plan the work.
Failure to order and have available a suitable crossing as a replacement for a track component known to have a long standing and worsening unrepairable defect.
Communication failures between person in charge of possession, signaller and signal engineering staff.

Recommendations

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

Order request tracking procedures should be reviewed.
When a short notice possession has been planned, requests to undertake additional work within the same possession should only be accepted after the full implications have been discussed.
When any part of a switch or crossing is replaced, resulting in a single route over the switch and crossing, the switch blades must be clipped, scotched and padlocked.
Method statements are prepared for all tasks and used to brief the staff involved.
Proposals to restrict routes by removing signal links must be documented and checked by an independent competent person.
In all situations when the signalling is to be handed back after completion of work with restrictions, the appropriate form (RT3187) must be used.
Shift handover practices and documentation should be reviewed in Kings Cross signal box.
Targeted audits and surveillance assessments of new safety critical procedures should be introduced.
The testing and inspection frequency established to monitor track component defects should be related to the severity of the defect and its rate of propagation.
Track Engineering standards should be revised to make clear under what circumstances allowances and dispensations are open to engineers.
The Rule Book should have clear unambiguous instructions on the situations in which points must be clipped.
Possession requirements shown in Weekly Operating Notices and Late Notices should always give an indication of work to be carried out when this will result in restrictions to signalling equipment on hand back.
Discussions should be held with the HSE to agree the processes to be used to obtain information from vehicle based data recorders.

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.