Stonehaven rail crash: Series of deadly management failings revealed

A final report into the derailment has found that Network Rail, which runs the infrastructure, and railway managers were not properly prepared to deal with issues of heavy rain and had not adequately handled drainage issues that caused the landslip.

The train drivers' union Aslef said Alex Hynes, managing director of Scotland’s Railway, a group of government and rail industry organisations should resign, saying the crash findings were “damning” and must be “a watershed moment for rail safety".

Neil Davidson, partner at Digby Brown Solicitors, which acts for injured passengers and relatives of one of those who died said it was the "very definition of negligence".

“It should come as no surprise that many now hope further action will be taken against Network Rail," he said.

Transport Secretary Grant Shapps said it would be a “disservice” to the men who died if lessons were not learned.

READ MORE: Stonehaven train crash: Union demands that Network Rail 'examine every mile" of Scots track to stop any repeat

The Rail Accident Investigation Branch (RAIB) said that the railway industry’s risk assessments had clearly signalled that earthwork and drainage failure due to extreme rainfall was a "significant threat" to the safety of the railway but they had not clearly identified potential areas of weakness in the existing operational mitigation measures.

The RAIB found that the train derailed because it struck debris that had been washed out of a faulty drainage system constructed between 2011 and 2012 by failed outsourcing giant Carillion.

Both Network Rail, which owns the infrastructure, and the designers of the drain were unaware that Carillion did not build it to specification and so were not able to safely accommodate the water flows that morning.

Investigators found that the drainage works were not entered into Network Rail’s infrastructure maintenance database so it was never inspected or maintained after installation.

After the drain was built, the landowner complained to Network Rail and Carillion that the land next to it was affected by surface water but neither followed this up.

In 2015 Network Rail acquired a computer tool – the Network Rail Weather Service (NRWS) – to accurately capture weather data to help assess appropriateness of train speeds or service cancellations. But it was not properly configured and staff were not properly trained in how to use it.

The RAIB’s investigation also found that the route controllers, who were responsible for the operational management of Scotland’s railway network, had not been given the information, procedures or training that they needed to effectively manage complex situations of the type encountered on the morning.

The found the control team was under severe workload pressure around time of the crash due to volume of weather-related events. But no additional staff were called in to help - even though plans existed to help with such issues through the senior management ‘gold command’ structure.

The train had turned back due to another landslip when it hit the landslip at Carmont near Stonehaven in Aberdeenshire after heavy rain. It was travelling at 73mph, which was just below the normal permitted speed for that line.

The driver was only four seconds from impact before the debris could be seen and the emergency braking was too late.

The RAIB found that no instruction was given by route control or the signaller that the train should be run at a lower speed on its journey between Carmont and Stonehaven during near-continuous heavy rain.

Investigators say that at that time there was no written process that required any such precaution in these circumstances so "normal railway rules" were applied to the train movement.

They said that the management processes of Network Rail had not identified or addressed weaknesses in the way it dealt with the consequences of extreme rainfall events.

The railway industry's own risk assessments had "clearly signalled" that earthworks and drainage failure due to extreme rainfall was a "significant threat" to safety.

Despite an awareness of the risk, the RAIB said Network Rail had not completed the implementation of additional control measures following previous events or clearly identified potential areas of weakness Network Rail and RAIB concerns were heightened by a landslip just outside the portal of tunnel in Watford, Hertfordshire, in September 2016 that caused the derailment of a train.

The investigators made 20 recommendations for the improvement of rail safety in the wake of the Stonehaven crash.

Among them is a call for improved operational response to extreme rainfall events, exploiting the full capability of modern technology.

Simon French, the chief inspector of rail accidents said: "Although railway safety in the UK has been steadily improving over recent decades, the tragedy at Carmont is a reminder of just how disruptive and potentially dangerous Britain’s volatile weather can be.

"The railway industry needs to get even smarter about the way it counters this threat, and to better exploit remarkable modern technology that enables the prediction and tracking of extreme weather events such as summer convective storms. There’s also an urgent need for the railway to provide real-time decision-makers with the information, procedures and training they need to manage complex and widespread weather-related events across the rail network.

“It’s important for all of us in the rail industry not to dismiss this truly harrowing accident as a one-off event. The railway industry needs to think through the implications of severe weather on its infrastructure, whilst also looking to the behaviour of trains should they derail after striking obstructions such as washouts and landslips.”

The refurbished high speed train was designed before modern standards were brought in with design features intended to minimise the damage to the train in case of collision or derailment. The RAIB said that it was more likely than not that the outcome would have been better if the train had been compliant with modern ‘crashworthiness’ standards.

The investigators called for better management of civil engineering construction activities by Network Rail and its contractors and additional standards and guidance on the safe design of drainage systems.

They said railway managers should address the "obstacles" to effective implementation of lessons learnt from the investigation of accidents and incidents And it said there needed to be better undertanding of the "additional risk" associated with the operation of older trains.

Mr French added: “Railways need to operate safely and reliably in most weather conditions. If they’re not able to achieve this, potential passengers will be forced onto the roads, which are undoubtedly much more dangerous in bad weather conditions. So, there’s a balance to be struck and technology can help to get this balance right.

"Modern weather forecasting and monitoring systems can spot the truly exceptional events before they occur and as they happen, so allowing railway operators to implement precautionary measures when it’s prudent to do so. This would benefit the safety of the line - by restricting train speeds, or suspending operations, when necessary - while reducing the need for imposing blanket speed restrictions over areas that are not at significant risk.

“This investigation highlights the risk of uncontrolled changes to railway infrastructure during construction. It is so sad that a project that was designed for the protection of the travelling public became unsuitable for its intended use and posed a hazard to trains because of such uncontrolled changes to the design. When anything is built in difficult conditions, such as on the side of a steeply sloped cutting, changes will often be needed for practical reasons.

"Although such changes are normal and can be highly beneficial in terms of saved time and cost, they need to be made with care. In each case, the original designer needs to understand the change that’s proposed and review the implications of a change that may appear inconsequential to the team on site. I hope this example will resonate throughout the UK’s construction industry."

Aslef general secretary, Mick Whelan, said: “This report is damning and makes for difficult reading, not least for the families of those who died and were injured.

“The failures identified in this report are so bad that we believe this must be a watershed moment in the way we ensure the safety of passengers and staff on our railway network.

“Network Rail and Abellio ScotRail failed the passengers and staff who were on the train that crashed at Carmont and must be held to account. This should start with Alex Hynes given his involvement with Network Rail and Abellio ScotRail. His position is untenable, and he must resign with immediate effect."

Andrew Haines, Network Rail chief executive, said: "This report makes clear that there are fundamental lessons to be learnt by Network Rail and the wider industry. As well as expressing our deep sorrow and regret at the loss of the lives of Christopher Stuchbury, Donald Dinnie and Brett McCullough, it’s important that we acknowledge it should not have taken this tragic accident to highlight those lessons. We must do better and we are utterly committed to that.

“In the 18 months since the accident, we have inspected similar locations and drainage systems across the length and breadth of the country and the added insight the RAIB has provided today will help us in our efforts. We also commissioned two independent taskforces led by world class experts to help us better understand extreme rainfall events and how to better manage our cuttings, embankments and their drainage systems.

"We have invested tens of millions of pounds towards improving the general resilience of our railway and how we predict and respond to such events. But this remains a multi-generational challenge and there is still much to do.”

Ian McConnell, ScotRail chief operating officer said: “The majority of the RAIB recommendations relate to other parties but ScotRail will play its part fully in ensuring that safety lessons are learned. We are working closely with Network Rail and the wider industry to do everything possible to reduce the risk of something like this ever happening again.

“The way the industry responds to extreme weather incidents has already changed following the events of 12 August 2020 and a number of the report’s recommendations have already been implemented.”

A joint investigation involving the Office of Rail and Road regulator, Police Scotland and British Transport Police is expected to hand over a final report to the Crown Office and Procurator Fiscal Service in the coming months.