Hatfield Report and Recommendations

"The report found that the immediate cause of the accident was due to the fracture and subsequent fragmentation of the high rail over a 35 metre length due to substantial transverse fatigue defects in the rail head. It states that these defects had their origins in gauge corner cracks, a form of rolling contact fatigue, which had developed on the rail surface.

The report points to a number of underlying causes which led to the accident:

An incomplete appreciation of the risks presented by gauge corner cracking, and the consequent failure to develop and disseminate comprehensive instructions on its identification and the control measures required.

A failure to manage and execute a competent visual inspection regime, and to manage the ultrasonic inspections so as to identify the true condition of the high rail at the Welham Curve, and to take appropriate action to maintain the line.

An inadequate management of the contracts relating to the maintenance and renewal of the track asset.

The failure to ensure the completion of the urgent proposal to rerail Welham Curve as a result of a lack of effective project management, and a failure to take account of the potential risks of delay.

The failure to act on the findings of audit reports relating to a lack of adequate knowledge of the track asset. "

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