An 84-year-old woman was killed and 22 people injured when the London to Glasgow Virgin Pendolino plunged off the track at Grayrigg in February.

Three days later an interim investigation blamed faulty points.

A Network Rail report, released on Tuesday, found systematic failures in track patrolling and management.

The report identified a list of deficiencies in inspection and maintenance.

GRAYRIGG CRASH

Summary report of the investigation [366k]
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It revealed that a visual inspection of the points, scheduled for 18 February, was not carried out because the inspector decided "to finish early".

Network Rail said the inspector's records clearly showed that, but the inspector's supervisor then failed to pick up that the inspection had been missed.

The report makes 14 recommendations with a further 19 specific action plans to reduce the chance of anything similar happening again.

Margaret Masson, from Glasgow, died in the crash

After the accident, Network Rail accepted responsibility and offered apologies to everyone affected.

Important lessons

Iain Coucher, chief executive of Network Rail, said: "I renew that apology today.

"The report makes for difficult and sobering reading. Mistakes were made and there are important lessons for all of us at Network Rail.

"We have already made changes and more change will follow as we put in place all the actions and recommendations put forward by this report."

Tony Collins, chief executive of Virgin Rail Group, said: "This is a comprehensive report and clearly indicates some fundamental deficiencies at local level in Network Rail.

"It is crucial that we learn from the accident at Grayrigg and it is extremely positive that Network Rail has acknowledged the failings that led to the accident."

A Rail Accident Investigation Branch inquiry is still ongoing.

In July, British Transport Police arrested a 46-year-old Network Rail employee from the Preston area and questioned him on suspicion of manslaughter.

He was released on bail until 31 October.

GRAYRIGG POINTS: KEY FAILURES

Stretcher bars maintain the distance between the switch rails, which allow trains to change tracks at points

When the front wheelsets of the Virgin Pendolino train hit the defective points, the deformed switch rails caused them to derail

See also:

Fault was missed days before fatal crash

The Times: September 5, 2007
Ben Webster, Transport Correspondent

Network Rail staff “falsified” maintenance records and ignored basic safety rules in the weeks before a train derailment that killed one passenger and injured 22.

An investigation by the infrastructure company found that five days before the Virgin train crashed at 95mph in Cumbria on February 23, a track worker had failed to complete a weekly inspection of a set of points that would have showed that crucial parts were broken.

Previous inspections had been poorly executed, and managers had failed to take action despite clear indications that safety was being compromised in the area.

The speed of the line had been increased a year earlier, resulting in greater stress on the track and much less opportunity for inspections. Workers were encouraged to rush their checks, and ten different people had carried them out in the previous four months, meaning that there was no chance of a consistent approach or for staff to become familiar with the condition of the track.

Managers were so keen to meet performance targets that they failed to check whether inspections were being carried out properly. They operated “a management style where breaches were left unchecked and observance was unrewarded”.

The Network Rail report disclosed that loose bolts were found on the points at Grayrigg more than six weeks before the crash. They were replaced, but the cause of the problem was never investigated.

Peter Henderson, Network Rail’s group infrastructure director, said that he did not know why the check on February 18 had not been completed. He said that the inspector started at the right place, “but he came off at an access point just before [the points]”.