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It is tempting to conflate the fatal derailments at Grayrigg and Potters Bar. But the temptation should be resisted. As Network Rail Chief Engineer Andrew McNaughton put it when the results of the Formal Inquiry into Grayrigg was published ‘we don't share the view that this (Grayrigg) is remarkably similar to Potters Bar, other than that it was a derailment on a set of points'.
For a start the design of the points mechanisms were different. Potters Bar has the relatively recent adjustable stretcher bars while at Grayrigg the Lambrigg Groundframe 2B featured fixed stretchers of a design which has been in use for around 60 years.
More significantly, at Potters Bar, a set of points in a stable condition was put into a dangerous state, using the adjustable stretcher bars, and failed within hours. In contrast Lambrigg 2B points fell apart over a long period, during which, at any time, the progressive deterioration could, and should, have been detected during routine inspections and then rectified.
That the points could fall apart to the point where the only connection between the switch rails was one back-drive and detached nuts and bolts were jammed between switch blades and their stock rails is surely infinitely more frightening than the tampering at Potters Bar, disturbing though that was.
And while it is, once again, easy for lay observers to blame the design of the points, or even, as happened after Porters Bar, for engineers from other disciplines to criticise the primitive nature of their engineering. But everyday life demonstrates that if you neglect to clean and oil your bicycle chain regularly it will stretch or jam your gears.
Thus points are simple, robust assemblies of steel, concrete and timber. But they are simple robust assemblies which must be maintained to millimetric precision if the wheels racing through at up to 125mile/h, resting on a contact patch the size of a finger-nail supporting a weight of up to 10 tonnes, are to not just run smoothly but avoid putting high frequency loads into a structure held together with rods, bars, nuts and bolts, all of which are vulnerable to vibration.
But in transport vibration is a fact of life. Helicopters are excellent vibration testing rigs, their passengers suspended on the ‘Jesus' nut which couples the rotor to its drive shaft. What matters is how vulnerable equipment is maintained and monitored.
And in the case of Lambrigg 2B ‘management structure' is an oxymoron on a par with military intelligence. To read the sections in the Formal Inquiry summary released by Network Rail, with special dispensation from the Rail Accident Investigation Branch, dealing with the ‘soft' human issues is to enter a bizarre world where nearly three years after Network Rail took maintenance back in house a Carillion organisation chart was still being used ‘to support the Carillion job description that are currently in place because certain employees have chosen not to sign new job descriptions'.
Was there ever a more resounding justification of the much derided quasi-military ‘command and control' system which the railway network developed from its earliest days. Remember that back in the early 19 th Century only military officers had the experience of managing large, dispersed real time wet-ware-based organisations.
Today, so much of the railway can be run from a screen and a key board in head office that it is easy to forget that primary safety depends on the integrity of 42,000 miles of rail and 14,000 sets of points. And while the scurrying yellow New Maintenance Trains have automated plain line inspection, switch and crossing work inspection depends crucially on the human eye and the calibrated safety boot, backed by experience of what a correctly functioning set of points should look like and the doggedness to put things right despite severe time pressures from above.
Responsibility for this vital activity rests on some of the least regarded of the railway workforce, who have been treated especially badly since privatisation. Formed into artificial companies for sale, TUPED from pillar to post, subjected to the rigours of the private sector in the drive to reduce costs and then brought back into Railtrack.
Perhaps not surprisingly the chain of command has broken down over this ten years of turbulence. The report paints a picture of harassed local management struggling to keep up with demands from above. The new patrolling method required by the introduction of tilting trains was dumped on them. Yet like some malign fractal Lancs & Cumbria was a microcosm of the whole with a ‘them and us' culture between local and area management.
Within this beleaguered group patrolling seems to have been organised as a Sunday morning workers collective. Infractions of rules and standards led to the gap in the lengths covered by two patrols, in the middle of which lay the disintegrating Lambrigg 2B.
It is a shocking report. But it is not unique. On 13 September the Rail Accident Investigation Branch published a report on a derailment on points at Epsom station on 12 September 2006 . It makes familiar reading.
Poor track geometry created by a combination of lateral and vertical misalignment, local rail damage and sidewear were the proximate cause. These were exacerbated by lack of rail lubrication following removal of the local lubrication and the failure of the remote lubricator. Once again, there was ‘lack of proper maintenance attention' and ‘lack of effective follow-up to inspections which had identified various faults at these points ‘over a period of two years'.
Once again we have harassed maintenance management which had not been allowed to recruit staff to fill the vacancies in the Wimbledon section and had thus concentrated resources on the main lines. A Track Recording Car run over the derailment site in August generated such a large volume of rectification work that it ‘overwhelmed' the resources available to the section manager'.
Not surprisingly Network Rail's recently appointed Chief Executive Iain Coucher was in sombre mood when he introduced the presentation on the Formal Inquiry report, confessing to a failure of the inspection regime, the supervision regime and the assurance regime'. He was right to be concerned because there are those who would like to see a charge of corporate manslaughter attached to such failures.
And yet the solution is straightforward. Above all, the men in the hi-viz jackets, out on the track in all weathers and on whom primary safety depends must be recognised and cherished. ‘Office-engineers' must get away from their meetings and computer screens and get out and about visiting maintenance depots and joining the work gangs. The chain of command must be reinstated and it must command and control. And unrealistic demands must not be made on local management, so that they run the railway rather than chase ‘green KPIs'
George Orwell once said that people sleep peaceably in their beds at night only because rough men stand ready to do violence on their behalf. On the railway, people ride serenely in their seats because those same unregarded men diligently maintain the track. And it is the job of management to foster and monitor that diligence. Taking maintenance back in house was a start, but as Lambrigg and Epsom show, for it to be effective a culture change is essential in middle and senior engineering management.