The Rail Accident Investigation Branch has released its report into the rail crash which took place near Stonehaven rail crash in which three people died.
At around 09:37, 1T08, the ScotRail 06:38 Aberdeen to Glasgow service was returning to Aberdeen due to a blockage on the line ahead.
It was travelling at 73mph as it hit debris on the track and derailed. The train then deviated to the left and struck a bridge parapet and caused the vehicles to scatter.
Tragically, three people died in the accident – the conductor, Donald Dinnie, the train driver, Brett McCullogh and a passenger, Christopher Stuchbury. The remaining six passengers onboard were all injured.
On the 12th August 2020, there was near-continuous heavy rain at the site of the accident which totalled 51.5mm
1T08 struck debris that had been washed out of a drainage trench. The trench had been constructed between 2011 and 2012 made up of a perforated pipe. However, the drainage system and earthworks had not been constructed to the original design so were not able to accommodate the water flow on that fatal morning.
Investigators found that a low earth bank, or bund, had been constructed that ran across the slope.
The presence of this bund altered the water flow that would cause a concentrated flow into the steep slope of the trench. Evidence from the RAIB has shown that the water flow was such that there was enough intensity to wash away the gravel fill surrounding the trench.
No instructions were given by route controller or signaller that 1T08 should run at a lower speed. At the time, there was no written process that required such precaution.
Normal railway rules were applied to the train movement and the investigation found that the route controllers had not been given information or training that they needed to manage situations like those found on the morning of the crash.
The RAIB has also found that Network Rail's management processes had not identified any weaknesses in the way it minimised the consequences of the rainfall events.
Despite an awareness of the risk, the RAIB says that Network Rail had not completed the implementation of control measures following previous extreme weather events.
Moving onto the train, which was a ScotRail Inter7City train made up of Class 43 power cars and mk3s, the RAIB says that a train built to modern standards would have had new features that would have minimised the damage to the train in the event of a collision or derailment.
However, the refurbished HST was designed before these standards came into force. Whilst the RAIB hasnt said what may have happened in a hypothetical situation, it considers it more than likely that the outcome would have been better if the train had been compliant with modern crashworthiness standards.
20 recommendations have been made by the RAIB, with areas covered including:
- better management of civil engineering construction activities by Network Rail and its contractors
- additional standards and guidance on the safe design of drainage systems
- improved operational response to extreme rainfall events, exploiting the full capability of modern technology, and based on a detailed understanding of the risk associated with extreme rainfall
- enhancing the capability of route control offices to effectively manage complex events
- extending Network Rail's assurance regime to encompass route control offices
- addressing the obstacles to effective implementation of lessons learnt from the investigation of accidents and incidents
- measures to prevent derailed trains from deviating too far from the track (equipment fitted to track and/or trains)
- addressing train design issues identified by the investigation and better understanding the additional risk associated with the operation of older trains.
You can read the full 300-page report on the RAIB website.
Simon French, the Chief Inspector of Rail Accidents, said: “This was a tragedy that devastated the lives of the three families who lost their loved ones and brought terror and injury to six other people on the morning of 12 August 2020. Our thoughts are with them all. Nothing can undo this event, but we owe it to everybody who was affected by it to strive to learn safety lessons for the future.
“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.
“No one wants to shut down the railway every time it rains. 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.
“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. Is there more that could be done to keep trains in line and closer to the track, to minimise the risk of jack-knifing and to keep bogies attached to rail vehicles? RAIB doesn't have all of the answers but is urging the railway industry to think about ways of guiding derailed trains, and to think about the longer-term implications of continuing to operate rolling stock that pre-dates modern standards.”
Commenting on the publication of the Rail Accident Investigation Branch (RAIB) Carmont report, 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 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.”
HM Chief Inspector of Railways, Ian Prosser CBE said: “Our thoughts remain with the families of Donald Dinnie, Brett McCullough and Christopher Stuchbury at this time.
“We welcome RAIB's recommendations today and will work with industry to ensure these are addressed quickly and effectively.
“Our own joint investigation with Police Scotland and British Transport Police is making good progress and we anticipate handing over the final report to the Crown Office and Procurator Fiscal Service in the coming months.”
This is an indictment on the culture of the civil engineering contractor Carillion. The formation drainage had been renewed by that company, the work not in accordance with the drawings, not meeting the specification, and with poor workmanship. How many people with good training and who were professionally endorsed by their institution, set those standards aside in order to climb the career ladder ? How much of the Carillion work elsewhere should now be fully inspected to determine the extent of its defects ?