CAHIR RAIL ACCIDENT REPORT
Grimes & Company
GRIANAN HOUSE, TRAMORE ROAD, CORK, IRELAND
Tel. +353-21-431-4601 Fax +353-21-431-4602
e-mail : firstname.lastname@example.org
REPORT ON RAIL ACCIDENT
TUESDAY OCTOBER 7, 2003
Dr. Michael Grimes
OCTOBER 31, 2003
1. BRIEF DESCRIPTION
1.1 The 0335 Limerick to Waterford cement train derailed at Cahir Viaduct in or about 6 a.m. on October 7, 2003.
1.2 The train consisted of two locomotives, 134 and 186 of estimated weight 200 tons together plus twenty two cement “bubble” wagons in total weighing about 780 tons, being a total train weight of some 980 tons.
1.3 The locomotive had passed over the viaduct when the train derailed.
1.4 One wagon stayed upright behind the locomotive, the next eight wagons partially derailed and the final 13 completely derailed with five ending up in the river.
1.5 At the end of the incident the central and eastern spans of the bridge had collapsed.
1.6 The speed would have been about 40 m.p.h.
1.7 Two photos of the derailment location are on the cover of this report.
1.8 The train was travelling from bottom to top approaching Cahir in the right hand photo and from right to left in the left hand photo.
2. LOCOMOTIVES AND WAGONS
2.1 The locomotives did not cause the accident, had no pre-accident or post-accident defect, were capable of hauling the load, driven at a reasonable speed, were within the speed limit of the line and were in fit condition for the work being performed. All locomotives which crossed the bridge prior were recalled and checked and no defect was found.
2.2 The driver was within hours, in fit condition, and in no way contributed to the accident.
2.3 There is no evidence of any structural failure or structural defect of any of the wagons prior to the accident. In fact the damage shows that some wagons suffered over three times their maximum design stress.
2.4 It is interesting that the couplings, almost without exception, held and this can be clearly seen from photographs K, L, N and R and it is clear that they withstood stresses which had destroyed strong metal around them. The design and the maintenance of the couplings was blemish free.
2.5 It is safe to say that the couplings in no way contributed to the accident and neither was there any possibility of buffer locking as the track at the location of the incident was not curved.
2.6 The coupling that actually parted would have taken a load of over 2,000 tons.
2.7 It is quite clear from the other photographs that the wagons withstood stresses far beyond their design and in no way contributed to the accident.
3. THE VIADUCT
3.1 The viaduct had parts of it rebuilt in 1955 after the accident at that time. It was clear that the new structure withstood the damage far better.
3.2 Nevertheless there is absolutely no evidence of any defect in the design, construction or operation of the viaduct.
3.3 The severity of the stress and the way it is was withstood is clear from photographs G H I and J. The impact point of the wheels can also be seen.
3.4 The cross members collapsed like dominoes because the train was effectively a 900 ton guided missile doing 40 m.p.h., and with the derailment came to as near a sudden stop within seconds and no viaduct, no matter how designed, could have catered for this eventuality.
3.5 From the results of the cross members recovered it is clear that there was no structural failure of any kind that could be attributed to the viaduct steel.
3.6 Because the design withstood the impact so well it is recommended that the new viaduct be re-designed exactly as the old one.
3.7 The spacing of the beams in the new design could be the same as previously but an enhanced safety margin would be gained by reducing the spacing by up to 20%.
3.8 However it is recommended that the top of the cross beams be plated.
3.9 It should be borne in mind that with the 1955 accident and now this, it is unlikely that this accident will ever occur again and there is no point throwing money at a tank engineering approach as there was nothing wrong with the current design.
3.10 The current blame culture leads to waste of money. What happened was a once off freak which could not have been foreseen as happening in this location. Irish Rail is an easy target in a trial by media.
3.11 It is very difficult to pinpoint the exact sequence of events but the second upright girder from the right in photograph B suggest a certain sequence of events. C and D tend to support the theory.
3.12 It is quite clear from the photographs, that any disintegration of the viaduct was not caused by structural failure of the viaduct itself, but as a result of unforeseeable excessive loads applied to the cross members.
3.13 The load to bend the cross members as much as occurred in the accident and to rip them out of their side mountings was as much as five times the maximum design stress which in itself was about three times the maximum load that could be expected. There was no way any bridge cross members, no matter how designed, could have withstood the stresses applied. The only item which could have minimised the damage was adequate plating.
4. THE TRACK
4.1 The rail was of adequate weight for the purposes used and there is no evidence to suggest that a rail fracture in anyway caused the accident.
4.2 There is no evidence to suggest that in the time prior to the accident there was any gauge failure which could have led to a derailment ab initio.
4.3 It is unlikely that walking the track prior to the accident would have seen anything to lead him to the conclusion that a defect existed.
4.4 It is unlikely the ballast gave rise to any problem in that the line was adequately ballasted where ballast existed.
4.5 It is also unlikely that a chair fractured. It is more likely that it moved.
4.6 It was known that the sleepers were in a bad condition and photographs U, V, W, X, Y and AA give an idea as to how bad.
4.7 Inspection of a number of sleepers has indicated a condition where the sleeper could appear normal, yet underneath the chair, severe rot had set in and there was little or no holding power in the chair. Once one chair moved, adjacent chairs would not have been able to stay rigid and chairs would lift out, each one easier as the stress would increase to an excessive level on the next chair to move.
5. THE LIKELY CAUSE OF THE ACCIDENT
5.1 The most likely cause and sequence of the accident is as follows.
5.2 A sleeper had a severe case of rot under the chair.
5.3 With the passage of the locomotives and nine wagons some 500 tons had passed over.
5.4 The locomotives loosened the chair which lost its grip due to rot in the sleeper.
5.5 The chair spread outwards thereby widening the gauge.
5.6 Once the chair moved the rail tended to move outwards thereby increasing the stress on adjacent chairs. It is probably that the stress was transmitted in both directions simultaneously and rapidly.
5.7 This in turn probably led to a gauge widening ahead of the defective sleeper and this led to the derailment of wagons. This progressed forward to No. 2 wagon and No. 3 to No. 9 derailed but stayed upright.
5.8 Meanwhile back at the viaduct a wagon, possibly No. 10 or No. 11 started dropping its left hand wheel.
5.9 This in turn hit a sleeper which was rotated through ninety degrees and this sequence led to sleepers being stuffed up underneath wagons as seen in photos M N and O.
5.10 With the sleeper effectively removed, the wheel and axle then dropped down and hit the crossmember thereby causing a severe torque tending to stop the train.
5.11 The other wheel lifted off the rail and dropped but owing to the imbalance was probably high for a short period thus allowing it to ride over the cross member which the left wheel hit.
5.12 The crossmember once hit buckled severely and was wrenched loose.
5.13 The first crossmember to be hit probably got hit on the left side first, it is possible that the axle lifted over it and the axle behind came in with a wallop with both wheels simultaneously providing the vital hammer effect to dislodge and buckle the cross member.
5.14 Effectively the cross member wished to stop the train instantaneously but the kinetic energy of the train was much greater than the maximum energy the crossmember could absorb without buckling and something had to give and that was the cross member.
5.15 The train at that stage started derailing rapidly with some forward motion and as the members got hit they fell away like a domino heap.
5.16 The train stopped rapidly but the kinetic energy caused the axles to go either with the buckled cross members or in the case of later wagons down with the cross members.
5.17 It is more than likely that it was the wheels of the first wagon to derail and possibly the one behind it that took out the girders. It is very difficult to state which wagon caused the initial derailment as it could have been anywhere from No. 2 to No. 11 but in my view the evidence suggest it was No. 11 and the others just dropped into the hole was there seems no indication of those wheels hitting anything. The wagons have the appearance of just falling down.
5.18 I estimate that the forward motion of the train remaining on the viaduct after the initial impact of the wheel and the cross member was about two feet.
5.19 While I could not tell what wheels might have hit which member and while I cannot say with certainty that photograph DD is such a hit, it is a likely result of hitting.
5.20 The axlebox support fractures are consistent with the axle coming to a complete and sudden stop while the body absorbed the energy in a limited forward motion tearing them from the axle.
5.21 The fact that the first wagon on the viaduct which initiated the accident lost its bogies and the ones behind did not lends credence to this theory.
5.22 It is obviously impossible to identify the exact sleeper that caused the initial collapse owing to the damage.
5.23 It seems that the second derailing wagon took the brunt of these sleepers flying giving credence to the theory that the first rotated them and they then went under the second.
5.24 Further evidence of this theory of cause is the way the sleepers are embedded into the undercarriage of some wagons indicating that when the sleeper chair went, the sleeper got hit by that falling wheel, was turned through 90 degrees and rammed itself up under the body of either the rear axle of that wagon or the ensuing wagons. Photographs V, W, X and AA are evidence of this theory.
5.25 It is worth noting in photograph O, the mark on the axle, but it is difficult to tell if this was caused by the accident or the recovery. It is severe enough to indicate it could have been caused by the accident.
6.1 The accident was caused by the widening of the gauge due to a chair failing to maintain position due to rotten timber under it thereby causing the derailment of that wagon.
6.2 The most likely wagon for the initial derailment was number 11.
6.3 This was followed by a wheel hitting the crossmember, tearing it loose and leading to the subsequent removal of other cross members.
6.4 Subsequent derailment lead to the failure of the other crossmembers.
6.5 The derailed wagons and the remainder of the train fell into the void thereby caused.
6.6 It is unlikely that the permanent way staff could have taken any action prior to prevent the accident. Responsibility is another matter which has its own section.
6.7 No blame can be attached to the driver, the maintenance staff or the permanent way staff.
6.8 A considerable amount of the ensuing damage was due to the fact that the sleepers were in an unfit condition for the stress they were asked to withstand. They were pretty rotten.
7. PRIOR WARNING TO THE ACCIDENT – PREVIOUS REPORTS
7.1 The cause of the accident was a system failure due to senior management not accepting the responsibility for the safe running of the railway.
7.2 It was the grace of God this was not a passenger train. If it had been a passenger train there would have been a serious loss of life and the Chairman and Board of Directors would have faced criminal charges for corporate manslaughter. They individually and collectively ignored all the warning signs
7.3 In September and October 2002 he and all the members of the Board of Iarnrod Eireann were notified of this kind of defect, that the track was unsafe in this general area, and they choose to do nothing and thereby abrogated their responsibility and duty of care to those who travel and work on the railway.
7.4 I quote from my September 2002 report:
“I attach to this report some (track) photographs taken on the 19th. August 2002. I believe they are absolutely appalling. They should put the fear of God into anyone with any sense of responsibility on this railway. And this was on about a quarter of a mile which I inspected! What is the rest of the system like? Are we waiting for a Potters Bar? As of August 31, 12 DAYS LATER. nobody from safety has contacted me to enquire where the defects are and the trains are trundling over them, hour in, hour out. Management said I was to be ignored! He does not want to know and cares less. I inspected the tracks again on August 30, 2002 and all the defects are still there and one rail fracture is spreading its head. THAT IS CRIMINAL.
When the inevitable accident occurs, as the way things are going, it must, then the directors are now on notice of an unsafe situation and they can be held personally accountable when the accident occurs and liable to a fine or imprisonment. That will be the day when any of our lot go to jail! They are not responsible for anything! So dear Directors, decide now whether to continue with overcrowding or not and be it on your heads. At the Cherryville Enquiry everyone ran for cover as management always do. Nobody ever knows anything!
I would argue that in Cork, we have the worst approach to safety on the system. A train breaks in two in Cork tunnel and it is the grace of God 100 people are not killed. In Cork we had for weeks a railcar set with defective brakes trundling up and down to Cobh every day and despite repeatedly reporting it, nothing was done. Everyone knows and nobody does anything! Locomotives are run with oil leaks causing potential for fire and nobody does anything. Vans are in even worse condition and are filthy. Who runs Cork? Nobody.
I am hampered in checking safety violations and instead of dealing with the violations and curing the problem the management have consciously taken steps to stop me finding out what is going on, not that that would ever work! They should cooperate to make the railway safer not obstruct me. On August 29, the Station Inspector in Mallow told me that he had had instructions to prevent me checking any safety violations. That can only have come from the top. The question is who? If a guard grounds a train for safety reasons he will not be backed by management. Interestingly enough, the staff on the ground cooperate fully. Management is the obstruction.
7.5 We are now having regular derailments on the system. How long before it happens
at 100 m.p.h. and then think of the consequences? Wagons are found with one
bogie on one track and the second on the adjoining track! A passenger train even
comes off in Cork station. We are running a railway where the aim of every person is
to get the train out of his section so that if something happens, it is on someone
else's patch! ”
7.6 By October 4, 2002 I had become so concerned over the state of the track in or around this accident scene that I issued a second report again with photographs outlining what in my view were unsafe track practices.
7.7 I effectively repeated the warnings of the earlier report and accompanied the second report with further full colour photographs.
7.8 Both reports went to the Chairman, every Director, every senior management and to every station on the system as well as most staff.
7.9 The Chairman and his legal advisors took a decision that I was not to be communicated with as if they discussed the matter it would indicate there was a problem in the first place.
7.10 This accident like most accidents was not a one off event but the inevitable culmination of unsafe practices, incompetent Management and a totally incompetent Board of Directors headed by an Incompetent Chairman
7.11 There are practices current on Iarnrod Eireann which must lead to another accident. This time statistics say it will be a serious passenger accident.
7.12 There is no safety culture within the management of Irish Rail and they do not want to know. In recent times we have had derailments at Cork (2), Mallow, Sligo (2), Rosslare, Limerick and now Cahir. How many more do they think we are going to get away with without serious loss of life?
7.13 I am unable to accept that passenger trains should be allowed to travel on lines where there are either clips missing or timber clips being used. The use of timber clips in my view is criminal.
7.14 This was brought to The Chairmans attention last September yet not one of them has been replaced. He has done nothing. If someone gets killed then he and he alone will be to blame.
7.15 What is amazing is that missing clips and timber clips are clearly visible in the track photographs and nobody does anything about it. In my book missing clips are a no-no item and as for timber clips I would fire anyone who put them in. If clips were to be made of timber then Pandrol would make them!
7.16 I now turn to another problem which is quite prevalent, namely the lack of bolts or the insertion in the wrong direction. Plates do not have four holes for two bolts and there is a very good reason why there are two bolts on each side, namely to provide a safe haven in case a bolt goes.
7.17 In Potters Bar bolts were missing and look what happened. Admittedly they all fell out there but even half bolts in the first place must lead to an inevitable accident. It has now become accepted practice to use only two bolts and also to inert bolts in opposite directions on one plate and this is totally unacceptable.
7.18 But what is worrying about all this is that while there are rules for the correct maintenance of track, they are being broken daily and the answer is, “Oh, well it is unlikely to cause problems”. Rules are there to be obeyed!
7.19 We then turn to the problem of the CWR. There is an argument that the CWR that we are using is totally defective. The problem with rail is that you do not find out about the problems until it is too late. The rail we are using is in railway terms, new rail. The type of shelling fractures appearing on it is not visible in any older type rail. Nor for that matter have I seen the fractures on other railways and I have seen a few of them!
7.20 I have tried without success to have an intelligent discussion with the people involved but they have been banned by senior management from discussing it.
7.21 It is not clear yet if we have been sold a pup in the rail we have bought or that it will cost over one billion pounds to fix the problem. But if I am right it is an unsafe practice to allow trains at 90 m.p.h. on the CWR rail I have shown in photographs.
7.22 If, as it appears, the flanges are spreading then it is only a matter of time until a coach rides up the defect and over and if in the middle of a station like Mallow the death toll will be large. It will be far worse than Potters Bar.
7.23 In any normal business one admits that one has a problem and endeavours to find a solution. In Irish Rail one buries ones head in the sand and hopes that then problem will go away and that one will not be blamed for it and that one will be retired by the time the accident happens.
7.24 For a legal department to advise management that to acknowledge a problem would indicate there was a problem in the first place thereby causing a potential liability is a frightening approach. It is very, very, wrong advice.
7.25 The most bizarre response to my warnings was the reaction of one Manager, in that he actually had me banned from travelling on the railway – it only lasted seven hours before wiser counsel prevailed – because his ego was pricked and he lost his rag.
7.26 In my professional view some of the rail problems are due to the rail becoming plasticized and therefore welding will only transfer the liability to fracture to a different area but this second time the failure can and probably will be catastrophic as the original strength will not be restored. There is a parallel in aircraft repairs and to the best of my knowledge no research has been done on our railway into the effect of this type of repair. The situation has to be controlled immediately by grinding but as far as I can see none has taken place. In my view we are facing a situation where we may face a complete shutdown of the system.
7.28 In my view any rail that has become fluid should have an immediate 60 m.p.h. limit placed on it. 90 m.p.h. is grossly unsafe. But I would rather not be in the Chief Civil Engineers shoes trying to explain why he is imposing a 60 m.p.h. limit on the entire railway or alternatively why he did not, at the accident enquiry!
7.29 There are two other problems giving rise to the failures namely the 201 class locomotives pounding the rails and concrete sleepers. The first we can do nothing about except contain the failures but the second has cures available. I feel we are laying the rail incorrectly on the sleepers in such a manner as to compound the hammer blow. It is inevitable that the condition of sleepers such as they were on the accident line must have an increased chance of failure from these two causes.
7.32 I have yet to receive one letter from the Department telling me what actions they have taken as a result of my reports. They do not want to know.
7.33 What has to be equally worrying is the deliberate policy of the management not to report serious incidents to the Department and to hide them.
7.34 I obviously have a different set of values on safety whether it be track or equipment. The attitude of the railway safety department is best illustrated by a typical event.
7.35 An air hose broke in the morning of 9th. January, 2003. It was repaired en route, the train went to Dublin, was passed by the train examiner, sent out, and the hose broke a second time on the way to Cork. The reason from what I could see was that somebody had stuck a Dart airhose on the coach instead of a Mk III. If that had happened that evening when the train was doing 100 m.p.h. the cost to the Company would have been astronomical and I am sure a whole trainset would have been out of service for some time for reprofiling.
7.36 The problem with Irish Rail is the attitude that as long as the train gets out of “my” area it is OK. The culture “Not 100% - No go!” does not exist.
7.37 If a staff member does spot a potentially lethal problem instead of begin complimented he is castigated. The Chairman has to bear a lot of the blame for this as has the Board. They do not want to know.
7.38 Everybody on the ground knew that the Cahir accident was going to happen as everyone knew that corners on maintenance were being cut but nobody did anything. The dogs in the street were barking but the management were deaf.
7.39 I was the only person who spoke out, put it in writing and promptly got banned from the railway. I even got assaulted thrice. Management approved such assaults and refused to take any action against the offenders.
7.40 A spokesperson for Irish Rail said on the radio that safety was paramount. But, day in, day out, trains are sent out in a condition where they should be grounded. A railway must have everything 100% correct or the train does not go. If you institute that culture then it may cause mayhem for a short while but once it settles down we have a safe railway.
7.41 As of February 8, 388 DAYS LATER, nobody from safety has contacted me to enquire where the defects are and the trains are trundling over them, hour in, hour out. It is absolutely criminal and shows a frightening degree of incompetence in our management and this accident is frightening proof.
7.42 But what is now worse is that the accident line is not going to be re-laid. The decision was taken to lower maintenance to an unsafe level and the accident was the result and still they are not going to do anything. How many people have to die first?
7.43 Unless senior management acts fast, a passenger accident is now inevitable. This accident is a warning. They must take heed.
8. RESPONSIBILITY FOR THE ACCIDENT
8.1 This accident will cost the taxpayer some three million euro. Nobody has been or will be fired. In any private business heads would roll and should roll here.
8.2 It was caused by the failure of the senior management to recognise the potential problems in the track on this section and their recklessly negligent incompetent decision to reduce maintenance of the track on the line from Limerick Junction to Waterford to an unsafe level.
8.3 The Department Railway Inspectorate failed in their responsibility to adequately supervise the safe running of the railway and if they did not know the possible potential of this type of accident then they should have known.
8.4 The Board of Irish Rail failed in their duty and it ahs cost the taxpayer three million euro. Nobody has resigned. of the taxpayers money and not one of them has the honour to resign. Being a Board Member of Irish Rail is a political perk for the railway ignorant.
8.5 The worker directors cannot be blamed either, as if any of them were that good they would now be Managers in the railway. But they have also gone native. They more than anyone should understand the situation that led to Cahir but none of them at any meeting have complained or done anything. They are headless chickens.
8.6 It is worth noting that none of the Board other than the worker directors have any railway experience on Irish Rail or any other railway for that matter and that none at all of the board have any experience on any railway other than Ireland. It takes talent lose €590 million in one year, but they did it in 2002. This year they will lose another €600 million of the taxpayers money.
9.1 That Cahir Viaduct be rebuilt immediately as previously designed.
9.2 That the track be relayed, where not recently done, between Limerick Junction and Waterford and for 60 m.p.h. railcar limit.
9.3 All timber clips be replaced immediately, missing clips and bolts on plates be replaced and all bridges be checked for sleeper condition
9.4 That shelling be ground within seven days of appearance.
9.5 That a review be made of all temporary speed limits and that a schedule be drawn up for their elimination on a system wide basis.
9.6 That staff be urged to report safety defects and be supported when they do and trains be failed when not 100% right.
9.7 Finally, why did we have to get foreigners to do this accident report at exorbitant expense and for whose results we are still waiting? Our own people are more than competent themselves.