Irish Railway Record Society
Journal 173 Accident Reports
Malahide
Viaduct Accident Report
RAIL ACCIDENT INVESTIGATION UNIT
The
RAIU is a functionally independent investigation unit of the Railway Safety
Commission (RSC) and on 16 August it issued its report into the collapse of
Malahide Viaduct (See JOURNAL xxxx). “The purpose of an investigation by the
RAIU is to improve railway safety by establishing, in so far as possible, the
cause or causes of an accident with a view to making recommendations for the
avoidance of accidents in the future. It is not the purpose of the RAIU to
attribute blame or liability.”
The “Executive Summary” is substantially re-printed here:
On 21 August 2009 as an Iarnród Éireann (IÉ) passenger service, travelling from Balbriggan to Pearse, passed over the Malahide Viaduct the driver witnessed a section of the viaduct beginning to collapse into Broadmeadow Estuary. The driver reported this to the controlling signalman who immediately set all relevant signals to danger ensuring no trains travelled over the viaduct. Within minutes of the report of the accident, by the driver, Pier 4 of the Malahide Viaduct had collapsed into the Broadmeadow Estuary. All post accident emergency procedures were properly employed by the operating staff resulting in no fatalities or injuries to any members of the public or staff.
At the time of the accident, the Malahide Viaduct piers were formed on a grouted rock armour weir, with stones intermittently discharged along this weir to maintain its profile.
The immediate cause of the collapse of Pier 4 was as a result of the undermining of the weir that surrounds and supports Pier 4 through the action of scouring. This was as a result of a combination of factors:
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An inspection carried out on the Malahide Viaduct three days before the accident did not identify the scouring defects visible at the time; |
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A scour inspection undertaken in 2006 did not identify the Malahide Viaduct as a high-risk structure to the effects of scouring; |
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IÉs likely failure to take any action after an independent inspection carried out on the Malahide Viaduct in 1997 identified that scouring had started at the base of Pier 4 and that the rock armour weir was “too light for the job”; |
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The historic maintenance regime for the discharge of stones along the Malahide Viaduct appears to have ceased in 1996, resulting in the deterioration of the weir which was protecting the structure against scouring |
The above factors were necessary for the accident to happen. Contributory to the accident happening were the following factors:
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IÉ had not developed a flood/scour management plan at the time of the accident, despite the IRMS Implementation Review (2001) and the AD Little Review (2006) recommending that this plan be developed. Contributory to IÉ not developing this flood/scour management plan was the fact that the RSC closed this recommendation in 2008; |
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Engineers were not appropriately trained for inspection duties, in that the inspections training course they completed was an abridged version of the intended format, and there no formal mentoring programme, for Engineers on completion of this course; |
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There was a shortfall in IÉs suite of structural inspection standards in that a standard which provided guidance for inspectors in carrying out inspections was not formalised; |
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There existed an unrealistic requirement for patrol gangers to carry out annual checks for scour, as they do not have access under the structure and in addition, they did not have the required specialist training/ skills to identify defects caused by scouring; |
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A formal programme for Special Inspections for structures vulnerable to scour was not adopted, as per IÉs Structural Inspections Standard, I-STR-6510, at the time of the accident. |
Underlying factors to the accident were:
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There was a loss of corporate memory when former IÉ staff left the Division, which resulted in valuable information in the relation to the historic scouring and maintenance not being available to the staff in place at the time of the accident; |
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There was a dearth of information in relation to the Malahide Viaduct due to IÉs failure to properly introduce their information asset management system; |
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IÉs inadequate resourcing of Engineers for structural inspections to be carried out at the Malahide Viaduct; |
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IÉs failure to meet all the requirements of their Structural Inspections Standard, I-STR-6510, in that: |
Visual inspections were not carried out for all visible elements of structures;
Bridge Inspection Cards, for recording findings of inspections, were not completed to standard or approved by the relevant personnel;
A formal programme for systematic visual inspections of all elements of a structure, including hidden or submerged elements, despite an independent review recommending that IÉ implement this programme in 2006.
Immediately after the accident, IÉ carried out inspections on over a hundred viaducts on the network. IÉ have now reinstating the Malahide Viaduct, ensuring that the overall structure has been significantly strengthened, that the weir profile has been restored and improved.
IÉ are currently reviewing all the Civil Engineering technical standards in order to improve the content, readability and practicable implementation of these standards. Improved control mechanisms are being introduced to ensure compliance with these standards. A competency management system is also being implemented to ensure the appropriate training is received by Engineers.
In relation to tracking recommendations made by independent organisation, the RSC has formalised their system for closing recommendations, and is now, in conjunction with IÉ developing an action plan to close all outstanding recommendations.
As a result of the findings of this RAIU investigation, the RAIU have made fifteen safety recommendations. Thirteen safety recommendations have been made to IÉ, one safety recommendation has been made to the RSC, and one joint recommendation has been made to IÉ and the RSC.
Recommendation 1 IÉ should put appropriate interface processes in place to ensure that when designated track patrolling staff (who report to two or more divisional areas) are absent from their patrolling duties, that appropriate relief track patrolling staff are assigned to perform these patrolling duties.
Recommendation 2 IÉ should amend the Track Patrolling Standard, I-PWY-1307, to remove the requirement for track patrollers to carry out annual checks for scour.
Recommendation 3 IÉ should formalise their „Civil Engineering and Earthworks Structures: Guidance Notes on Inspections Standard‟, I-STR-6515, which should include guidance for inspectors on conducting inspections and identifying structural defects. On formalising this document IÉ should re-issue, in the appropriate format, to all relevant personnel.
Recommendation 4 IÉ should introduce a verification process to ensure that all requirements of their Structural Inspections Standard, I-STR-6510 are carried out in full.
Recommendation 5 IÉ should ensure that a system is put in place for effective implementation of existing standards and to manage the timely introduction of new and revised standards.
Recommendation 6 IÉ should ensure that a programme of structural inspections is started immediately in accordance with their Standard for Structural Inspection, I-STR-6510, and ensure that adequate resources are available to undertake these inspections.
Recommendation 7 IÉ should carry out inspections for all bridges subject to the passage of water for their vulnerability to scour, and where possible identify the bridge foundations. A risk-based management system should then be adopted for the routine examination of these vulnerable structures.
Recommendation 8 IÉ should develop a documented risk-based approach for flood and scour risk to railway structures through:
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Monitoring of scour risk at sites through scour depth estimation, debris and hydraulic loading checks, and visual and underwater examination; |
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Provision of physical scour / flood protection for structures at high risk; |
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Imposing of line closures during periods of high water levels where effective physical protection is not in place. |
Recommendation 9 IÉ should adopt a formal process for conducting structural inspections in the case of a report of a structural defect from a member of the public.
Recommendation 10 IÉ should introduce a training, assessment and competency management system in relation to the training of structural inspectors, which includes a mentoring scheme for engineers to gain the appropriate training and experience required to carry out inspections.
Recommendation 11 IÉ should review their network for historic maintenance regimes and record this information in their information asset management system. For any future maintenance regimes introduced on the network, IÉ should also record this information in their information asset management system.
Recommendation 12 IÉ should incorporate into their existing standards the requirement for the input of asset information into the technical database system upon completion of structural inspections.
Recommendation 13 IÉ should carry out an audit of their filed and archived documents, in relation to structural assets, and input this information into their information asset management system.
Recommendation 14 The RSC should review their process for the closing of recommendations made to IÉ by independent bodies, ensuring that they have the required evidence to close these recommendations. Based on this process the RSC should also confirm that all previously closed recommendations satisfy this new process.
Recommendation 15 The RSC, in conjunction with IÉ, should develop an action plan in order to close all outstanding recommendations in the AD Little Review (2006) and the IRMS Reviews (1998, 2000, 2001). This action plan should include defined timescales for the implementation and closure of all these recommendations.
RAILWAY SAFETY COMMISSION
Also
on 16 August 2010, the RSC published its compliance audit into the Viaduct
collapse. This audit is separate and independent of the RAIU investigation. It
was completed in March 2010, but under section 57(1) of the Railway Safety Act
2005, the RSC could not make its findings public before the RAIU had published
its investigation report.
“The
compliance audit examined whether correct safety management systems were in
place and whether key safety checks were being undertaken by the railway
operator, IÉ, prior to the collapse of the viaduct ...”
The
RSC found four non-compliances by IÉ:
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Front line inspection staff failed to carry out monthly and yearly inspections of the viaduct, as laid out in IÉ standard I-PWY-1307 |
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There was a failure by Engineering grade staff to undertake the required number of inspections/ checks as set out in IÉ standard I-SMS-9021 |
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There was a failure to carry out structural inspections and keep proper records using the correct forms, as set out in IÉ standard I-STR-6510 |
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IÉ had failed to implement a competence assessment for all personnel engaged in safety critical roles in accordance with IÉ Railway Safety Standard 67. |
The
RSC made 16 recommendations, including that IÉ:
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Review the need for a Coastal Defence Inspector or inspection team Review the Structural Inspections Standard I-STR-6510, to include all relevant elements, including scour |
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Develop a procedure to manage reports of safety related events, e.g. information from the public |
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Review patrol ganger (frontline inspection team) competence requirements |
“IÉ
was requested and has provided an improvement plan and the RSC will monitor the
implementation of this plan closely.”
“The
purpose of an investigation by the RAIU is to investigate for cause – why an
incident occurred. The purpose of the RSC audit is to check for compliance with
agreed safety standards and legislation. As the regulator, the RSC has the power
to bring sanctions under s.76-78 of the Railway Safety Act 2005. Based on the
evidence in the RAIU report, the RSC will now consider what sanctions, if any,
are appropriate or possible under the legislation.”
The
RSC said: “In relation to Recommendations 14 and 15 made by the RAIU about the
RSC’s own role, we have already implemented Recommendation 14 and are
currently planning to implement Recommendation 15, as detailed in p110/1 of the
RAIU report.”
MINISTER FOR TRANSPORT
Mr
Noel Dempsey, TD, Minister for Transport issued a statement saying: “This is
an important report into a very serious event. Thankfully due to the speedy
actions of the train driver on that day and the effective operation of all post
accident procedures, there were no fatalities or injuries to any members of the
public or staff. However, this report gives a detailed and worrying account of
the inadequate maintenance and inspection regime in IÉ of recent years which
failed to safeguard the viaduct structure from the impact of scour and erosion
in Broadmeadow Estuary... I understand from the report and from updates by IÉ
that significant changes have now taken place to meet the short-comings
identified and to ensure that there is no repetition of this event.”
IARNRÓD ÉIREANN
IÉ
issued a statement saying: “At the outset, IÉ accepts the findings of the
RAIU and RSC, and together with the findings of our internal investigation, we
sincerely regret those issues – which have been highlighted in the reports -
which led to this accident on 21 August 2009, and apologise to customers, who
experienced significant disruption to services as a result.”
“Following the accident, IÉ commenced a programme of major reform across all aspects of the safety management of infrastructure...” “Following receipt of the compliance audit, IÉ agreed an action programme with the RSC to address the findings, and excellent progress has been made to this end.”
“These actions, which address the issues arising from the RAIU accident report and RSC audit, are part of a much wider review undertaken by IÉ since the accident of the Civil Engineering Department, and the approach towards the management of IÉ’s infrastructure.”
“Therefore, the actions to address the non-compliances and recommendations have been undertaken in the context of fundamental change implemented since January 2010 in the Civil Engineering area, including:
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A new Safety Management System for Civil Engineering |
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A re-organisation and re-staffing of the Civil Engineering area, with new management and structures |
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A thorough review of all the Civil Engineering technical standards is being conducted in order to improve the content, readability and practicable implementation of these standards. |
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A “compliance verification” process to regularly audit and check that the new processes are continuously followed in practice |
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The Civil Engineering Department have now implemented a competency management process that is resourced with a Competency Manager supported by Assessors.” |
“In conclusion, the actions completed by the Civil Engineering team comprehensively covers the requirements and recommendations of the RSC Compliance audit, and will ensure that the issues arising from this incident – both in relation to the physical infrastructure of the viaduct, and the systems and processes supporting our management of infrastructure – are addressed, and our safety management significantly strengthened.”
