ORR publishes Hatfield derailment report

24 July 2006
ORR/21/06

The Office of Rail Regulation has today published the final report by the Independent Investigation Board set up by HSE to oversee their investigation into the Hatfield train derailment that occurred on 17 October 2000.

Four people were killed and more than 70 people injured, four seriously, when a Leeds-bound GNER train carrying 170 passengers derailed south of Hatfield station.

This final report from the Independent Investigation Board is published by ORR which since April 2006 has been the combined safety and economic regulator. The Independent Investigation Board was chaired by Sandra Caldwell – currently HSE’s Director of Field Operations Directorate. It is published now that all legal proceedings and appeals have been concluded.

The immediate cause of the derailment was the fracture and subsequent fragmentation of the rail near to Hatfield.  The rail failure was due to the presence of multiple and pre-existing fatigue cracks in the rail. The underlying causes identified by the HSE investigation were that the maintenance contractor at the time, Balfour Beatty Rail Maintenance Ltd (BBRML) failed to manage effectively the inspection and maintenance of the rail at the site of the accident. The investigation also found that Railtrack PLC, the infrastructure controller at the time, failed to manage effectively the work of BBRML.

Sandra Caldwell said: “The board was impressed with the thorough and professional manner in which the HSE investigation was carried out into this tragic incident, which has had an impact on so many lives, concluding in the successful prosecution of Railtrack and Balfour Beatty Rail for health and safety offences. These prosecutions resulted in the largest fine imposed in the English courts for health and safety offences on the railway and reflected the severity of the case.

“The rail industry must guard against complacency and continue to seek reasonably practicable improvements to health and safety using effective risk assessment as an essential element of decision making.”

Bill Emery, Chief Executive of the Office of Rail Regulation, said: “This report makes salutary reading for all those in the railway industry, though a great deal has happened since Hatfield to reduce the risk of such an accident happening again. We endorse the closing observations of the Independent Investigation Board that provide clear requirements and expectations on Network Rail to ensure there is no let-up in building its health and safety leadership role.”

Notes for editors

  1. The report is available from the ORR website at http://www.rail-reg.gov.uk/upload/pdf/297.pdf.
  2. The derailment of the 12.10 Kings Cross to Leeds passenger express train took place on 17 October 2000 near Hatfield. Four people were killed and over 70 people were injured. The investigation into the cause of the derailment has been undertaken jointly by HSE and the British Transport Police (BTP), with the latter in the lead because the offences under consideration included manslaughter.
  3. Shortly after the derailment the HSC directed the HSE under Section 14(2)(a) of the Health and Safety at Work etc Act 1974 to undertake an investigation into the derailment.  HSE’s investigation was carried out under the supervision of an Independant Investigation Board, chaired by Sandra Caldwell, who was at the time a Director of HSE’s Policy Group and a former member of the Channel Tunnel Safety Authority. The Board included independent members, namely Consulting Engineer Stuart Mustow, CBE, FR Eng, FICE; Richard Profit, OBE, Group Director Safety Regulation, Civil Aviation Authority; and Prof. Ernest Shannon CBE, FR Eng, FIAE, formerly Director of Engineering Research, British Gas. The Board's terms of reference were:

    - To ensure the thorough investigation of the Hatfield derailment by HSE and thereby establish its causation, including root causes;

    - To identify and transmit to the appropriate recipients any information requiring immediate attention;

    - To examine HSE's role in regulating safety on the railways with regard to this incident, both prior to and in the investigation of the incident, within the context of the existing regulatory framework applicable to railway safety, and in securing compliance with regulatory requirements by the infrastructure controller and other duty holders involved;

    - To report findings to the Executive and Commission as soon as possible.
  4. The publication of this report follows two interim reports by HSE into the Hatfield derailment. They are 'Train Derailment at Hatfield, 17 October 2000, First HSE Interim Report' published 20 October 2000;'Train Derailment at Hatfield, 17 October 2000, Second HSE Interim Report', published 23 January 2001; and ‘Train Derailment at Hatfield – Interim recommendations of the Investigation Board’, published August 2002 (please see related links).
  5. The closing recommendations of the Independent Investigation Board’s report are as follows:

    - Network Rail needs to continue to build its health and safety leadership role;

    - The industry should develop a culture that accepts the importance and significance of risk assessment as an essential element of decision making (especially when the decision is not to take action);

    - A robust audit regime needs to be recognised and valued by all for what it adds to achieving quality and compliance;

    - Communication between all parties is essential, as is the testing of understanding of the information being shared; and

    - The industry needs to guard against complacency and continue to seek reasonably practicable improvements to health and safety.

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