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Select Committee on Environment, Transport and Regional Affairs First Report

FIRST REPORT

The Environment, Transport and Regional Affairs Committee has agreed to the following Report:—

RECENT EVENTS ON THE RAILWAY

Introduction

1. On Tuesday 17 October 2000, a Great North Eastern Railway (GNER) train from London King's Cross to Leeds derailed near Hatfield station in Hertfordshire whilst travelling at approximately 115 miles per hour.[9] Although the locomotive and the front two carriages remained on the track, the train's eight rear carriages were derailed. Four passengers were killed, and a further 34 were injured.[10] In the aftermath of the accident it rapidly became clear that a major contributory factor to it was likely to prove to have been a broken rail.[11] Within hours Railtrack engineers had "identified some significant deterioration in the condition of the rail" at Hatfield.[12] Later Railtrack admitted that the condition of the track at the site of the crash was "wholly unacceptable",[13] and the then Chief Executive of Railtrack, Mr Gerald Corbett, told us that "the condition of the track at Hatfield was appalling".[14] Mr Corbett offered his resignation on the day after the accident,[15] an offer later turned down by Railtrack's board.[16] When, on 17 November, Mr Corbett again offered his resignation, it was accepted. He was replaced by Mr Steven Marshall, formerly the Finance Director of the company. At the same time, Mr Jonson Cox, the Director of Operations, became Chief Operating Officer, and it was announced that Sir Philip Beck, the company's Chairman, would step down following Railtrack's Annual General Meeting in 2001.[17]

2. Of particular concern following the Hatfield crash has been a form of metal fatigue known as 'gauge corner cracking', which is believed to be caused by stresses imposed on the rail by wheels particularly where there are highly canted curves and vertical switch and crossing work.[18] Fears that the problem might be replicated elsewhere led Railtrack, by 10.00 pm on the day of the Hatfield crash, to impose emergency speed restrictions at 80 sites on the network whilst the track was checked and made safe. The number of speed restrictions grew thereafter: a week after the accident, speed restrictions were in place at 150 sites,[19] and within three weeks approximately 450 speed restrictions were either in place, or had been and had since been lifted.[20] Within a month of the Hatfield crash Railtrack had inspected 3,000 sites on the network for gauge corner cracking.[21]

3. Inspections of the track have meant that in addition to imposing speed restrictions Railtrack has been obliged to close some sections of track in order to check and repair it. Such closures have caused significant disruption: for example, on the evening of Tuesday 24 October Railtrack gave train operators fifteen hours notice that it would close a section of the West Coast Main Line for three days to allow rails to be inspected. [22] Although the route was in fact re-opened more quickly than expected, the closure caused considerable inconvenience and disruption to passengers and freight users.[23] Re-railing has occurred at many sites across the rail network, in recent weeks,[24] and is scheduled to continue in future: in all, Railtrack says that it plans to replace 250 miles of rail.[25] Users of the rail network have faced considerable delays, and Railtrack has warned that problems may continue for many months.[26] Railtrack has also set aside £250 million to compensate train operating companies for the disruption, and to pay for the re-railing programme.[27]

4. In addition to the Hatfield crash, there have been a number of more minor accidents on the railway in recent weeks. A few hours prior to the accident at Hatfield, a South West Trains service between Staines and Virginia Water was derailed after it struck a minibus trapped on a level crossing in Egham.[28] On 19 October the locomotive and the first two carriages of a Virgin Cross-country train travelling between Birmingham New Street and Manchester Piccadilly left the track outside Stafford station because of a broken rail.[29] On 26 October, the South West Trains Weybridge to Staines service derailed close to Virginia Water station after passing a signal set at danger, apparently because wet leaves prevented the train from braking normally.[30] Finally, on 1 November, two freight trains collided at Lawrence Hill in Bristol after one suffered brake failure.[31] Each incident also contributed to the disruption. In addition the weather has played a major part in causing further chaos.[32]

5. In light of these developments, we decided at our meeting on Wednesday 25 October to take evidence from Mr Corbett, along with other Railtrack officials, to examine recent events on the railway, and Railtrack's reaction to them. Railtrack agreed to appear at short notice, on Wednesday 1 November, for which we are grateful. The oral evidence given on that day has since been supplemented by written material the company has provided, and by oral evidence taken from the company's Chairman, new Chief Executive and Technical Director for our inquiry into Rail Investment on 22 November 2000.[33]

6. The scope of our inquiry was narrow, and that is reflected in the brevity of this Report. We sought only to question Railtrack about recent events, and the role and ability of its management team in coping with them. Wider issues relating to the stewardship of the rail network, investment in it, and the regulation of Railtrack had already been addressed in July 2000, when we had taken evidence from Railtrack, amongst others, as part of our inquiry into Rail Investment: Renewal, Maintenance and Development of the National Rail Network.[34] That inquiry had been scheduled to continue in the Autumn in any event, and further oral evidence sessions were held in late November and December.[35]

7. We are also constrained by the fact that an investigation into the Hatfield accident has been instigated by the Health and Safety Executive, which will draw on independent and expert advice,[36] and that, following the serious train crash at Ladbroke Grove on 5 October 1999, Lord Cullen has been conducting an inquiry which will consider the "management, culture and regulation of safety on the railways".[37] We do not intend to second-guess the detailed work of either inquiry. Nevertheless, the evidence we have received will be of interest to the Health and Safety Executive, the Cullen Inquiry, the Government and the railway industry, and for that reason we have sought to put it in the public domain as soon as possible. Moreover, some of the evidence given cannot pass without comment, and it is to those matters we now turn.

Railtrack's response to events on the railway

8. Responsibility for safety on the railway is governed by provisions of the Health and Safety at Work, Etc Act 1974, the Railways (Safety Case) Regulations 1994 and the Railways (Safety Critical Work) Regulations 1994,[38] and certain aspects of Railtrack's network licence,[39] as well as by the contracts agreed between Railtrack and the companies which maintain and repair the rail infrastructure on its behalf.[40] All make clear that although Railtrack does not itself carry out maintenance and repair work, it remains responsible for such work, and thus for the state of the track: Mr Corbett told us simply that "the company, Railtrack, is responsible",[41] a statement echoed by Railtrack's new Technical Director on 22 November.[42]

9. Consequently, when selecting contractors to carry out work on its behalf, Railtrack is required to ensure that they are competent, and capable of maintaining a safe railway infrastructure,[43] and that they will in turn ensure that their own sub-contractors and suppliers are competent and safe.[44] Railtrack verifies the quality and safety of its contractors through 'end product' checks, random and periodic site visits and safety management system reviews, as well as undertaking safety audits.[45] In its evidence to our inquiry into Railway Safety in 1998, Railtrack argued that the structure of contracts and safety cases, coupled with Railtrack's checking and auditing systems, together with the work of the Health and Safety Executive, provided "an open and effective framework within which it is not necessary to 'second guess' those who are mutually committed to achieve safe operation".[46] In short, it claimed that the structure was adequate to ensure that the network would be maintained to the standard required by law of Railtrack.

The state of the track at Hatfield

10. The contractor responsible for maintenance on the East Coast Main Line, including the track in the Hatfield area, is Balfour Beatty. The details of the relationship between Railtrack and Balfour Beatty will no doubt be examined by the Health and Safety Executive during its inquiry. It would be helpful, though, for us to report what Mr Corbett told us. He said that Balfour Beatty apparently inspected the section of track in January 2000, and decided then that it should be re-railed.[47] No speed restriction was placed on the line, which Mr Corbett told us was "not acceptable".[48] Part of the site was re-railed in May, but no speed restriction was then placed on the rest: Mr Corbett said that a "speed restriction should have been put on the rest of it".[49] In June the site was tested by Balfour Beatty using ultrasound equipment which either "did not work",[50] or did not give a signal because of the state of the rail:[51] in any event, the correct procedure was not then followed.[52] Again, Mr Corbett told us, a speed restriction was not imposed, a decision which "[Railtrack] do not understand".[53] Finally, the rail was ground in early September, "a standard approach for gauge corner cracking".[54] The accident finally took place in October. Mr Corbett said that this sequence of events resulted from "either incompetence or a systems failure, or ... there might be a cultural aspect to it",[55] but conceded that it represented a "massive local failure",[56] for which Railtrack has quite properly accepted responsibility.[57] The Rail Regulator has concluded that at Hatfield there was "almost certainly a failure in the chain of command, a simple relationship between Railtrack and the organisation engaged to carry out maintenance on that piece of network",[58] and Railtrack's new Technical Director told us on 22 November that "there was a management failure in relation to the accident at Hatfield".[59] Whatever else is revealed during the investigation of the Hatfield accident, it is clear that Railtrack's management of Balfour Beatty on the East Coast Main Line prior to 17 October was totally inadequate.

Railtrack's relationship with contractors

11. Since the Hatfield accident, concerns have been expressed that contractors have proved either unwilling or unable to adopt best practice in maintaining the railway. One reason which has been given is that contractors have been obliged to cut costs, prompting the Chairman of the Association of Consulting Engineers to say that "Railtrack bosses need to radically alter their approach and accept that more money needs to be spent on track and line-side maintenance to ensure the highest possible safety standards".[60] Mr Corbett conceded that the maintenance contracts put in place at the time of privatisation included financial pressures which might affect "the safety culture at the front line ... this is something that does need some serious consideration".[61] Other allegations have been made by the National Union of Rail, Maritime and Transport Workers (RMT). The first is that contractors have routinely employed unqualified and poorly trained staff to work on the railway,[62] a matter which Railtrack has now undertaken to address.[63] It is worth noting, in this context, that four track workers have died on the railway in the last twelve months.[64] The RMT is also concerned about the fact that up to 84,000 people, working for more than 2,000 companies and other organisations, now hold the Personal Track Safety Certificate, indicating, the Union claims, that there has been an enormous increase in the use of casual labour.[65] At the same time, the RMT claims, the number of permanently-employed maintenance workers has fallen from 31,000 in 1994 to between 15,000 and 19,000 today.[66]

12. There are also difficulties with the structure of the maintenance contract regime. Mr Corbett suggested that Railtrack dealt with too many contractors, each of which maintained too small an area of the network. He told us that Railtrack intended "to reduce the number of contractors ... [to] four to six ... we do want to increase the average size of the area, because there is a critical mass issue in terms of the right size of a contract area".[67] Finally, Mr Corbett told us that the "whole issue of culture at the front line is going to have to come out of this [Health and Safety Executive] inquiry".[68] We are concerned that Railtrack has failed to ensure that the culture of safety now espoused by its senior management is not always shared by its contractors, sub-contractors and the front line workers on the railway.

The importance of engineering and railway experience

13. During his evidence to us Mr Corbett conceded that of the seven Executive Directors of Railtrack only the then Commercial Director and the Director, Safety and Environment, had significant experience of working in the railway industry.[69] Only Mr Middleton, the then Commercial Director, and now the Technical Director, is an engineer.[70] Mr Corbett argued that the lack of knowledge or experience of the railways or of engineering was not "an omission that needs to be addressed".[71] Others have disagreed: the Chairman of the Association of Train Operating Companies, for example, has told us that "they [Railtrack] need to substantially strengthen their engineering and technical resource. We believe that they should have an engineering director on their Board, somebody who really understands how the track and signalling out there work ... The fact that they have not is a major weakness".[72] He also said that "their technical experts are fairly low down the organisation. That is a fundamental flaw".[73]

14. Railtrack now seems to share that view. As we have said, on 21 November Railtrack announced that it had made "new Board and senior appointments to strengthen the role of engineering at the Board level".[74] Mr Middleton, the sole engineer on Railtrack's Board, has become Technical Director, an appointment intended to "ensure that engineering is given proper priority by the company".[75] In addition another engineer, Mr Andrew McNaughton, has been appointed as Chief Engineer. These two appointments are, Railtrack has said, intended to "signal our intention to review and enhance the level of Railtrack's engineering resource".[76] Such a review will be affected by the company's decision to take a "hard look at our maintenance and renewal contractual arrangements",[77] assessing whether to bring maintenance back 'in house', or to leave the arrangements largely unchanged, subject to better oversight of the contracts, or to opt for "somewhere inbetween ... [looking] at areas such as inspection and maybe [taking] direct control of that".[78] Whatever is decided, Railtrack will clearly require additional engineering expertise: Mr Middleton guessed that "hundreds" of additional engineers would be employed, particularly if management of maintenance on the railway was brought back 'in house'.[79] He also told us that Railtrack intended to address the shortage of appropriately qualified staff by measures including the sponsorship of graduate training programmes.[80]

15. Although Railtrack's decision to place a greater priority on engineering is welcome, it raises two points. First, it suggests that the company had previously lost sight of the fact that its core responsibility is to run a safe and efficient railway, and that to do so requires Directors and managers with appropriate experience and knowledge. Second, the changes are hardly radical: the new Technical Director remains as before the only Executive Director with an engineering background, and also remains one of only two members of the Board with significant experience of operating a railway. Railtrack should look again at its senior management, and appoint to its Board and to other senior positions people with knowledge and experience appropriate for running the railway.

The programme of track inspections

16. The weeks since the Hatfield accident have seen an extensive programme of track inspections: 3,000 sites in all have been checked for gauge corner cracking. Railtrack has said that such inspections were "necessary ... to restore public confidence in the network",[81] and it is indeed reassuring that the company has decided to take decisive action. However, the fact that Railtrack has been forced to undertake so many checks suggests that it is not confident that its contractors have adequately maintained the network. Moreover, it also suggests that its oversight of their work, using a system "within which it is not necessary to 'second guess' those who are mutually committed to achieve safe operation",[82] has in fact been fundamentally flawed.

17. If Railtrack's management of its contractors prior to 17 October was effective, it is difficult to understand why the programme of inspections, track closures and re-railing has proved so urgent since that date: as one newspaper has put it, "if the work really is so urgent that it cannot wait for a few hours, then we are, at the very least, entitled to ask why Railtrack allowed such a lethal state of affairs to persist for weeks or months before taking action".[83] Railtrack itself appears uncertain, reportedly saying, for example, about its decision to close the West Coast Main Line, both that "the West Coast line is safe", and that "the tests were necessary sooner rather than later".[84] We are concerned about the effect on passengers and rail freight of the programme of track checks and re-railing that is currently underway, but at least its implementation shows welcome decisiveness on the part of Railtrack. Nevertheless, we conclude that the instigation of the programme reflects the fact that Railtrack is not confident that its management of maintenance contractors prior to 17 October had been adequate or effective, or that the infrastructure for which it is responsible had previously been properly maintained.

The closure of the West Coast Main Line

18. Train operators were apparently told of the decision to close the West Coast Main Line between Carlisle and Glasgow from eight o'clock on the morning of 25 October at five o'clock on the previous evening.[85] Mr Corbett told us that the managers had concluded that "it was going to be easier to close the line and do the checking and the necessary work and then re-open, rather than having days of temporary speed restrictions ... at Railtrack we tend to think about the infrastructure, because that is our responsibility, and the reaction on the ground was to think about the infrastructure and the particular problems they had, rather than the impact on passengers".[86] As we have said, the impact on passengers and freight users was severe. Some passengers who arrived ready to travel on sleeper services to and from Scotland were forced to spend the night in sleeper carriages at Euston, Glasgow Central and Edinburgh Waverley stations.[87] ScotRail was particularly critical of Railtrack's decision,[88] and the Royal Mail, the single largest freight user of the railway, was reported to be "bitterly" critical.[89] Railtrack was forced to apologise for closing the line without adequate warning,[90] and Mr Corbett repeated to us that "we have apologised for the West Coast Main Line, it was not handled well".[91]

19. The decision to close the West Coast Main Line was taken by local managers.[92] Mr Corbett told us that it "was not a decision that they should have taken by themselves".[93] Moreover, they not only failed to consult higher management before taking the decision,[94] but then did not inform them for some time afterwards: Mr Corbett found out "a few hours" later.[95] He told us that he "went ballistic when [he] found out".[96] Disciplinary action following the closure had, at the time of our inquiry, extended only to the instigation of a review, and "people have been spoken to".[97] The decision to close the West Coast Main Line on 25 October, and the way in which that decision was reached, are indicative of poor communication between layers of management in Railtrack, an inability on the part of the company to see its activities and responsibilities in a wider context, and shows scant regard for the public interest.

Railtrack's record

20. During our inquiry twelve months ago into the Railways Bill, Mr Corbett said that "the [Ladbroke Grove] crash was ... a watershed event".[98] It is now clearly accepted that, as the Deputy Prime Minister has said, "there must be no priority higher than safety".[99] A number of very positive steps have been taken to address that priority: for example, the number of signals passed at danger has fallen from 771 in 1994-95 to 596 in 1999-2000,[100] and seems set to fall sharply this year.[101] Mr Corbett told us that the number of broken rails on the network has also fallen, by 4 per cent in 1999-2000, and, he said, by 32 per cent this year,[102] although the impact of the recent inspection programme on the figures has yet to be ascertained. Moreover, the recent fall in the number of broken rails is from a peak of 988 in 1998-99, up from 656 in 1994-95.[103] Incidences of buckled track, having fallen to a very low level in 1998-99, have since risen sharply.[104] Nevertheless, Mr Corbett told us, in recent years Railtrack has "been able to improve the quality of the track".[105]

21. It has been suggested that there may be conflict between passenger and freight growth, demands for better train performance and requirements for a greater emphasis on safety.[106] Mr Corbett told us that fragmentation of the rail industry at privatisation has made it more difficult to resolve that conflict.[107] Conversely, the Rail Regulator has argued that "a safer railway is where trains are well-maintained and run on time on a reliable infrastructure; good management of performance and safety are entirely consistent and inseparable".[108] Whatever the merits of each side of that argument, there is, as the Deputy Prime Minister has said, "universal acknowledgement that the rail industry has suffered from fragmentation, a lack of leadership and decades of under-investment".[109] We do not consider such longer term matters here: they will, in part, be considered during our inquiry into Rail Investment. Railtrack appears also, four years after first being alerted by the Health and Safety Executive of the problems it faced managing its maintenance contractors,[110] to be persuaded that radical measures may now be required: it is, as we have said, reviewing whether or not to take maintenance of the rail network or parts of the inspection process back 'in house' in due course.[111]

22. By accepting Mr Corbett's resignation, Railtrack's Board has accepted that its stewardship of the railway has not been adequate. As Mr Corbett told us, however, "this is bigger than [him]".[112] Railtrack's problems extend far beyond the personality of its Chief Executive, to the structure and style of management in the company. Mr Corbett told us that he did not enjoy being involved in crisis management.[113] Yet Railtrack has, it seems, staggered from one crisis to another in recent years. The issue of how the public interest in these matters of such profound importance is to be protected and promoted is rightly a matter of direct Government interest. As a private company, Railtrack, and ultimately its shareholders, should acknowledge that crises are not simply the result of unforeseen outside events such as accidents or "local failures", but are indicative of systematic, often-repeated failings in the company's management systems and leadership which the resignation of the Chief Executive and a cosmetic re-shuffling of the Board will not resolve. Mr Corbett's successor should now institute radical changes to the way the company is managed, and to the personnel involved, to ensure that Railtrack once again takes control of events on the railway.

9 See Train Derailment at Hatfield, 17 October 2000, First HSE Interim Report, 20 October 2000. Back

10 See HC Deb, 24 October 2000, col.136. Back

11 See HC Deb, 24 October 2000, col.136. Back

12 First HSE Interim Report, 20 October 2000, para.22. Back

13 Railtrack boss told to stay, The Guardian, 19 October 2000. Back

14 Q.5. Back

15 See Q.16. Back

16 Railtrack boss told to stay, The Guardian, 19 October 2000. Back

17 See Board changes at Railtrack, Railtrack Press Release, 17 November 2000. Back

18 See First HSE Interim Report, 20 October 2000, para.31. Back

19 See HC Deb, 24 October 2000, col.137. Back

20 See Railtrack works to restore network, Railtrack Press Release, 3 November 2000. Back