Southall East Junction Report and Recommendations

"The formal inquiry panel found the that the left leading wheel of the leading bogie of coach D struck a piece of broken fishplate that had lodged in the flangeway of the cast common crossing of points numbers 8175A. The two leading fishbolts in the joint at the country end of the cast crossing had unscrewed and fallen onto the ballast. Both fishplates at the joint had broken in half, and the leading right hand half fishplate had then moved foul of the crossing flangeway through vibration from wheelsets of vehicles in advance of coach D.

Other underlying causes were found to be the track component condition before installation. Forging flash on the fishplates and reduced vertical spacing of the crossing fishing surfaces were contributory causes of the bolts falling onto the ballast and the fishplates fracturing. There were a number of potentially unsafe maintenance conditions of the permanent way components in and around the crossing that were not identified by the basic and supervisor visual track inspection. The fishbolts in the failed joint had not been kept adequately tight. Failure to arrange simultaneous possession of the Up Main and Down Relief lines reduced the ability to maintain good top and line through the crossover."

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