RAIU Report into Malahide Viaduct collapse published

KC61

The Railway Accident Investigation Unit has finally published its report into the Malahide Viaduct collapse.

It can be viewed at:
http://www.raiu.ie/uploads/raiu/Malahide%20Viaduct%20Collapse%20on%20the%20Dublin%20to%20Belfast%20Line%20on%20the%2021st%20August%202009.pdf

Judgement Day

The report runs to 134 pages and I have just glanced at the first couple and the stuff is dynamite! It appears to this outsider that CIE/IE are completely out of control - have a look at these findings before going on to read the full report! :eek::eek::eek:


Malahide Viaduct Collapse on the Dublin to Belfast Line, on the 21st August 2009
RAIU iv Investigation Report R2010 – 004
Executive Summary
On the 21st August 2009 as an Iarnród Éireann 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:
 An inspection carried out on the Malahide Viaduct three days before the accident did not identify the scouring defects visible at the time;
 A scour inspection undertaken in 2006 did not identify the Malahide Viaduct as a high-risk structure to the effects of scouring;
 Iarnród Éireanns 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”;
 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:
 Iarnród Éireann 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 Iarnród Éireann not developing this flood/scour management plan was the fact that the Railway Safety Commission closed this recommendation in 2008;
 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;
Malahide Viaduct Collapse on the Dublin to Belfast Line, on the 21st August 2009
RAIU v Investigation Report R2010 – 004
 There was a shortfall in Iarnród Éireann‟s suite of structural inspection standards in that a standard which provided guidance for inspectors in carrying out inspections was not formalised;
 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;
 A formal programme for Special Inspections for structures vulnerable to scour was not adopted, as per Iarnród Éireanns‟s Structural Inspections Standard, I-STR-6510, at the time of the accident.
Underlying factors to the accident were:
 There was a loss of corporate memory when former Iarnród Éireann 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;
 There was a dearth of information in relation to the Malahide Viaduct due to Iarnród Éireanns failure to properly introduce their information asset management system;
 Iarnród Éireanns inadequate resourcing of Engineers for structural inspections to be carried out at the Malahide Viaduct;
 Iarnród Éireanns failure to meet all the requirements of their Structural Inspections Standard, I-STR-6510, in that:
o Visual inspections were not carried out for all visible elements of structures;
o Bridge Inspection Cards, for recording findings of inspections, were not completed to standard or approved by the relevant personnel;
o A formal programme for systematic visual inspections of all elements of a structure, including hidden or submerged elements, despite an independent review recommending that Iarnród Éireann implement this programme in 2006.

Cookie_Monster

Judgement Day's highlights are bad enough, I may read the report later. Suffice to say its damning but will anything be done?

Judgement Day

What's worse we are supposed to believe that IE inspected 100+ viaducts thoroughly since the Malahide accident - my hole! With what equipment might I ask?? I posted on another thread about IE's lack of viaduct inspecting equipment and I haven't had anyone on to correct me yet.

KC61

Cookie_Monster wrote: »

Judgement Day's highlights are bad enough, I may read the report later. Suffice to say its damning but will anything be done?

Not directly related to this but the Chief Civil Engineer at the time is no more.

foggy_lad

Just another set of reasons to get the bus!

Seriously who the Hell is accountable for this lack of basic corporate intelligence? The CEO should resign immediately, in some countries he would already be picked up and "dealt with" but here in good old Ireland the fools just get larger bonuses!

KC61

From breakingnews.ie
http://www.breakingnews.ie/ireland/irish-rail-failed-to-act-on-warning-that-malahide-viaduct-was-unsafe-469550.html

Irish Rail failed to act on warning that Malahide Viaduct was unsafe

An independent inquiry into the collapse of the Malahide Viaduct in Dublin last year found that Irish Rail had been warned in 1997 that the structure was not safe, but had failed to act.

Tragedy was narrowly avoided on August 21, 2009 when a crowded passenger train had just passed over the viaduct when it collapsed.

Upon inspection it was found that scouring had undermined the weir supporting one of the piers, causing it to give way.

Today's report from the Railway Accident Investigation Unit finds that safety inspections were not adequate, and that engineers were not appropriately trained to carry them out.

Iarnród Éireann says it accepts the findings, which are regrettable.

Minister for Transport is Noel Dempsey welcomed the report.

"This is an important report into a very serious event," he said in a statement.

"This report gives a detailed and worrying account of the inadequate maintenance and inspection regime in Iarnród Éireann (IE) of recent years which failed to safeguard the viaduct structure from the impact of scour and erosion in Broadmeadow Estuary.

"It sets out a series of recommendations addressed to IE in areas such as future inspection standards and their implementation, training of key personnel, risk assessment of railway structures and the provision of physical and flood protection for structures at high risk.

"I understand from the report and from updates by IE that significant changes have now taken place to meet the short-comings identified and to ensure that there is no repetition of this event.

"Since this incident the Malahide Viaduct has been significantly strengthened and the weir profile has been restored and improved.

"There has also been a substantial reorganisation of the IE Civil Engineering department including the appointment of a new Chief Civil Engineer and a Technical Manager for civil engineering.

"There is a thorough review of technical standards being conducted, as well as compliance verification in areas such as inspection standards and their frequency and a new competency management process to ensure enhanced training of civil engineering staff."

"I also note that that IE has identified 105 bridges that are particularly susceptible to scour and has conducted detailed surveys on those bridges and has not found any scour related risks with any of these bridge structures."

Hungerford

Downloading now. Could make interesting reading. It's certainly a biggie: 134 pages and 15 recommendations. The glossary alone seems to be five or six pages long.

Judgement Day

On Today FM now after AD break.

Hungerford

The one thing that jumps out to me from the body of the report is that IE were supposed to inspect the bridge thoroughly every two years but the RAIU could only find evidence of inspections in 1998, 1988, 1985, 1982, 1975 and 1972. :eek:

It seems that IE's engineering department has a long-standing aversion to paperwork and records, which IE was forced to admit to the RAIU!

Judgement Day

Anybody catch the Matt Cooper piece? As usual Barry Kenny was all over the place and could give no answer as to how an earlier report highlighting the dangerous condition of the viaduct in 1996 had got lost! Mark Gleeson stated that the Irish Rail network has never been safer - I hope that those words don't come back to haunt him as I don't feel particularly safe on IE. As I stated on a previous thread I know of another similar bridge which I am concerned about but I can't go into further detail until I get to see it.

Hungerford

Judgement Day wrote: »

Mark Gleeson stated that the Irish Rail network has never been safer - I hope that those words don't come back to haunt him as I don't feel particularly safe on IE.

I am not convinced by IE's safety at all - the 1997 document clearly warned about the first signs of the issue that led to the viaduct's collapse.

Their records management is a shambles - the 1997 report was found by chance in a place where it shouldn't have been. They have failed consistently to maintain adequate inspection records and, where those records do exist, they are incomplete.

They also have been operating in defiance of their own safety standards. Barry Kenny told us about the six-year review process but he forgot to mention that IE decided not to carry it out and do a 'once-off' review of a seemingly random list of structures instead.

Even more worryingly, it seems that IE came seconds to disaster - there were two trains in the area at the time. We all know about Train 2 because that was the one whose driver alerted signalling control to the collapse. But the report indicates the collapse started when Train 1 crossed over Pier 4 [the one that crumbled].

If the rate of collapse had been a little quicker, either Train 1 and/or 2 would have gone in and we'd be discussing the need for corporate manslaughter laws in this country...

Lifelike

Judgement Day wrote: »

Anybody catch the Matt Cooper piece? As usual Barry Kenny was all over the place and could give no answer as to how an earlier report highlighting the dangerous condition of the viaduct in 1996 had got lost! Mark Gleeson stated that the Irish Rail network has never been safer - I hope that those words don't come back to haunt him as I don't feel particularly safe on IE. As I stated on a previous thread I know of another similar bridge which I am concerned about but I can't go into further detail until I get to see it.

Are you referring to the bridge over the Suir near Waterford? I heard that it's expensive to maintain it.

Judgement Day

Lifelike wrote: »

Are you referring to the bridge over the Suir near Waterford? I heard that it's expensive to maintain it.

Nope a relatively minor bridge of recent and 'apparently' dubious construction.

Judgement Day

RTE's Drivetime asked BK different questions and seem not to have picked up on the report that got lost! However, it got comical when Philip Boucher Hayes asked were all the same management in IE still in place and did anyone carry the can for the Malahide fiasco - BK did a lot of dithering before saying that there was now a new Chief Civil Engineer in place. Barry neglected to mention the dismissal of the previous Chief Civil Engineer which resulted in CIE/IE having to pay the latter €200k. Thanks to Hungerford in a previous post.

---

Rail worker in safety row paid six-figure sum
Chief engineer settles case after being 'sent home for refusal to waive speed limit on water-risk line'


Sunday May 23 2010

IRISH Rail has paid a six-figure sum to its former chief civil engineer, who claimed she was threatened with demotion for refusing to lift a speed limit on a railway line for safety reasons.

The state rail company reached a settlement with Eileen Kelly for a sum believed to be in the region of €200,000. Ms Kelly, who was promoted to chief civil engineer two years ago, sued the company after she was sent home from work on full pay last year. It followed ongoing differences over the level of repairs required on the Newbridge to Portlaoise railway line. The case was settled out of court last month.

The payment is the second substantial settlement made by the state transport company in recent months. The company was ordered to pay €190,000 to another employee when the Equality Tribunal found she had been discriminated against and victimised. The company is also being sued by its former head of human resources, John Keenan, who has claimed that his suspension was linked to his work investigating and exposing fraud in the company. That case is due for hearing in June.

The case taken by Eileen Kelly centred on concerns that the Kildare railway line was at risk from flooding and embankment collapse caused by heavy rain. Ms Kelly commissioned a consultant's report which recommended relaying the track. But Irish Rail commissioned a second report from the same consultant that approved the less costly option of heavy maintenance to the line.

Ms Kelly imposed a 75kph speed restriction on the track for safety reasons and claimed that she was threatened with demotion by the company's chief executive unless she lifted it. She took an injunction against the company in November to prevent her demotion and her position being filled and began legal proceedings that were due to go to full hearing in April.

A spokesman for Irish Rail confirmed that the case with Ms Kelly was settled but said the terms were confidential. Ms Kelly worked for international railway companies in Germany, Slovakia and Thailand before returning to work at Irish Rail.

The boards of Irish Rail and CIE, its parent company, have refused to appear before an Oireachtas Committee on Transport to answer questions on safety and accounting.

They were asked to appear before the committee on June 2 but the request was turned down. The committee resolved to seek new powers to compel witnesses to attend.

CIE chairman, Dr John Lynch and other senior managers have already been questioned by the committee about a consultants' report that disclosed fraud and malpractice that was estimated to have cost the state public transport company almost €2.5m in four years.

- MAEVE SHEEHAN

Sunday Independent

dowlingm

Be worth asking the NRA and the Councils how many of their viaducts are similarly at risk and how regular their inspection regimes are. After all, apart from the ballasted deck it seems to me that that could just as easily have been a road bridge.

KC61

Judgement Day wrote: »

RTE's Drivetime asked BK different questions and seem not to have picked up on the report that got lost! However, it got comical when Philip Boucher Hayes asked were all the same management in IE still in place and did anyone carry the can for the Malahide fiasco - BK did a lot of dithering before saying that there was now a new Chief Civil Engineer in place. Barry neglected the dismissal of the previous Chief Civil Engineer which resulted in CIE/IE having to pay the latter €200k. Thanks to Hungerford in a previous post.

---

Rail worker in safety row paid six-figure sum
Chief engineer settles case after being 'sent home for refusal to waive speed limit on water-risk line'


Sunday May 23 2010

IRISH Rail has paid a six-figure sum to its former chief civil engineer, who claimed she was threatened with demotion for refusing to lift a speed limit on a railway line for safety reasons.

The state rail company reached a settlement with Eileen Kelly for a sum believed to be in the region of €200,000. Ms Kelly, who was promoted to chief civil engineer two years ago, sued the company after she was sent home from work on full pay last year. It followed ongoing differences over the level of repairs required on the Newbridge to Portlaoise railway line. The case was settled out of court last month.

The payment is the second substantial settlement made by the state transport company in recent months. The company was ordered to pay €190,000 to another employee when the Equality Tribunal found she had been discriminated against and victimised. The company is also being sued by its former head of human resources, John Keenan, who has claimed that his suspension was linked to his work investigating and exposing fraud in the company. That case is due for hearing in June.

The case taken by Eileen Kelly centred on concerns that the Kildare railway line was at risk from flooding and embankment collapse caused by heavy rain. Ms Kelly commissioned a consultant's report which recommended relaying the track. But Irish Rail commissioned a second report from the same consultant that approved the less costly option of heavy maintenance to the line.

Ms Kelly imposed a 75kph speed restriction on the track for safety reasons and claimed that she was threatened with demotion by the company's chief executive unless she lifted it. She took an injunction against the company in November to prevent her demotion and her position being filled and began legal proceedings that were due to go to full hearing in April.

A spokesman for Irish Rail confirmed that the case with Ms Kelly was settled but said the terms were confidential. Ms Kelly worked for international railway companies in Germany, Slovakia and Thailand before returning to work at Irish Rail.

The boards of Irish Rail and CIE, its parent company, have refused to appear before an Oireachtas Committee on Transport to answer questions on safety and accounting.

They were asked to appear before the committee on June 2 but the request was turned down. The committee resolved to seek new powers to compel witnesses to attend.

CIE chairman, Dr John Lynch and other senior managers have already been questioned by the committee about a consultants' report that disclosed fraud and malpractice that was estimated to have cost the state public transport company almost €2.5m in four years.

- MAEVE SHEEHAN

Sunday Independent

The fact remains JD that Ms Kelly was in charge of that department during the time before the viaduct collapse and was responsible for the systems that were in place.

While there obviously was this disagreement over 75 mph restriction - there seems to be no questioning about what systems she ensured were in place in the running of her department. The fact that she won compensation in the above case does not absolve her from her responsibilities in ensuring proper systems of control.

I would say that she and indeed her predecessor have a lot of questions to answer.

We can go on and on about other people, but the person with direct responsibility for the running of the Civil Engineering section is the Chief Civil Engineer. And I find it extraordinary that neither she nor her predecessor have been called to account for themselves.

Judgement Day

Agreed, but not only was she in the job a wet weekend but BK seemed to imply that she had been replaced due to the Malahide incident whereas it seems that it was the Kildare speed limit fiasco. It is her predecessor and the likes of that overpaid buffoon John Lynch who should be in the firing line.

KC61

Judgement Day wrote: »

Agreed, but not only was she in the job a wet weekend but BK seemed to imply that she had been replaced due to the Malahide incident whereas it seems that it was the Kildare speed limit fiasco. It is her predecessor and the likes of that overpaid buffoon John Lynch who should be in the firing line.

I would suggest that being in a job for over a year was more than enough time to make sure that proper procedures were in place. Hardly a wet weekend.

To be fair BK said nothing about her in the RTE interview - it would be a bit of a legal minefield for the company given the circumstances.

However, I will repeat my own opinion that I expressed at the time of the viaduct collapse that she and her predecessor really do need to be called to account for this.

dowlingm

http://www.transport.ie/viewitem.asp?id=10013&lang=ENG&loc=2127
3 December 2007

I would also like to take this opportunity to congratulate three people who have recently been appointed to important positions where they can influence the development of the safety culture within Iarnród Eireann:

-Eileen Wilcock has been appointed Chief Civil Engineer designate;

I think it's pretty unfair to think, given the litany of cultural failings exhibited in the RAIU report, that they could have been turned around in the 20 months before this disaster. I imagine it would be convenient to some parties within IE to think it could have been. It would have been interesting to see Ms Wilcock's answers to a public inquiry as to the culture she found and what if anything she did about it / what support she had for any change she attempted.

shamwari

KC61 wrote: »

To be fair BK said nothing about her in the RTE interview - it would be a bit of a legal minefield for the company given the circumstances.

Correct because both sides would have been subjected to a confidentiality clause in the settlment, and going anywhere near that in the radio interview would have been way off limits and potentially resulted in further litigation. As below

Sunday Independent wrote:

A spokesman for Irish Rail confirmed that the case with Ms Kelly was settled but said the terms were confidential.

shamwari

Judgement Day wrote: »

the likes of that overpaid buffoon John Lynch who should be in the firing line.

I agree. The is the same John Lynch who waded unwisely into the Luas / Dublin Bus crash, and couldn't help but point the finger at who he felt was responsible for the Luas impaling itself in the side of that bus.

Strangely now, he's kind of quiet following an incident which could have cost a lot of lives........:rolleyes:

I think he should resign. Immediately.

runway16

shamwari wrote: »

I agree. The is the same John Lynch who waded unwisely into the Luas / Dublin Bus crash, and couldn't help but point the finger at who he felt was responsible for the Luas impaling itself in the side of that bus.

Strangely now, he's kind of quiet following an incident which could have cost a lot of lives........:rolleyes:

I think he should resign. Immediately.

This is pretty damning stuff. If any airline in this country violated accepted safety practice in the way IE has on the rails, it would have been shut down pronto by the IAA.

Clearly, whoever regulates IE, if anyone does, is also not doing their job.

Neilor

Listened to Cooper earlier, and what I gathered from the CIE spin doctor is that in this great country of ours it is perfectly acceptable to admit your inspectors didn't know what they were looking at when occasionally checking a viaduct to ensure that the lives of 1000s of commuters were not put at risk on a daily basis. You would swear we were back in the early days of the railway the way that guy was explaining away the lack of technical know-how to ascertain that the viaduct was safe to use. This isn't a regulatory problem, this is gross incompetence that shouldn't be tolerated in any civilised country. I hope the papers & media spend as much time putting pressure on the CIE board, Engineering & Safety heads to resign this week as they did chasing that paedophile last week.

Carawaystick

One thing that isn't mentioned is that the driver had to ring and get the signals set to red, even though the bridge was in the sea.
Surely some automated system should be in place to detect a bridge falling down. What if it had fallen in at night or between trains?

shamwari

Carawaystick wrote: »

One thing that isn't mentioned is that the driver had to ring and get the signals set to red, even though the bridge was in the sea.
Surely some automated system should be in place to detect a bridge falling down. What if it had fallen in at night or between trains?

IIRC an automated bridge monitoring / warning system has been implemented since reopening. But none was available at the time.

Even though the signal man had to be contacted to set the signals to danger (red) I heard from elsewhere that the track circuits were broken when the bridge collapsed, and this set the signals north of Malahide to red anyway. The immediate danger was the next train due was heading from Malahide northwards and he had to be stopped as he was not calling there, and would have been running at line speed towards the bridge.

KC61

runway16 wrote: »

This is pretty damning stuff. If any airline in this country violated accepted safety practice in the way IE has on the rails, it would have been shut down pronto by the IAA.

Clearly, whoever regulates IE, if anyone does, is also not doing their job.

As it happens the Chief Inspector of the Rail Safety Commission also retired early (somewhat unexpectedly) earlier this year.

markpb

shamwari wrote: »

Even though the signal man had to be contacted to set the signals to danger (red) I heard from elsewhere that the track circuits were broken when the bridge collapsed, and this set the signals north of Malahide to red anyway.

The report says that the driver of the last train over the bridge placed a track signalling device across the tracks and shorted the circuit. You can see from the photo on the first page of the report that the track is (more or less) intact, just the supports are gone. It's crazy in so many ways.

Cookie_Monster

"Contributory" factors included a lack of training for engineers, the lack of a formal inspection regime, and an "unrealistic requirement" to carry out annual checks.

Lifted from the paper this morning.

Why is it unrealistic to carry out annual checks on a structure that old?

dan_d

Hmm. I don't post here, but I heard the CIE spin doctor on Today FM yesterday evening, and I've had a look at that report. I know that viaduct well, travelled over it for years by train.

Reading between the lines, these are the main points to me.

• Inspections were not as frequent as they should have been.
• The "gangers" were expected to carry out a number of these inspections. Gangers to me are general foremen. They are not trained or qualified in anything structural. They are not engineers. They should NOT have been relied upon to do these inspections
• Gangers were expected to carry out inspections of the piers from above the water. And to be able to tell the level of scour from there, as IE wouldn't provide them with boats/equipment to get any nearer, let alone under the water. Enough said.
• Iarnrod Eireann do not appear to have a central database with detailed drawings of their structures. Extremely worrying that they rely on the memories of individuals who work in the company to give them the details of their structures.Hence the phrase "corporate brain drain". Even the most basic of building sites has a set of drawings for whatever they're building, either on paper, or on a computer, which are then handed over as part of an O&M manual to the end user of the building. Apparently, our massive semi-state company that we pour millions of taxpayers money into can't even manage that most basic of tasks for their own structures.
• 12 years ago a report indicated to them that there was a problem with this pier. And it "got lost". It was found in Pearse Station - one copy of it. Where are the engineers located now ie, the people who would actually need access to a report like that? Out in CityWest somewhere. I think that speaks for itself.

Listening to the guy on the radio yesterday, it sounded to me like IE spent the last 10-15 years awarding their drivers and general operatives massive pay increases and pandering to unions, while completely ignoring everything else. The treatment of their chief engineer as indicated in that newspaper article is a pretty good indication of their attitude towards engineers. She told them there was danger on the Kildare line, commissioned a report, and they ignored it and proceeded to commission a report from the SAME consultant to contradict hers. How would any of you like it if you told your bosses something, only to have them come back to you several days later and say, well we asked the guy ourselves, and while we appreciate that's your job and it's what you're qualified in, we didn't like what you were saying and we'll just go ahead and do what we want? Even though they weren't qualified to have a clue about what they were talking about?

Obviously - I'm an engineer myself. It's a typical attitude you regularly meet - "don't be so silly, we don't need to do that, nothing will happen, it'll be fine". Always from people who haven't a notion what they are talking about. 9 times out of 10 it might be. But that one time....then everyone will start screaming for your head. She did what she thought was right, and was treated like dirt for it.I would imagine she came into a system that was accepted - like everything in this country, IE became lax and stopped following regulations. And stopped listening to the people who are paramount to their system remaining safe - presumably because it would have cost them time, effort and money. And as a result their engineers became lax - nobody cared anyway.

As with everything around here - they are a complete disgrace, and there is no getting past that report. They failed miserably on a number of fronts where they should have been most vigilant and there's no defending it. And heads should be rolling. I don't know whose, but they most certainly should be getting rid of as many senior members as possible - they are all obviously stuck in a rut of complacency as many other semi-state companies, and I'm doubtful that anything can change properly when the same people are still in charge.

Cookie_Monster

dan_d wrote: »

. And heads should be rolling. I don't know whose, but they most certainly should be getting rid of as many senior members as possible - they are all obviously stuck in a rut of complacency as many other semi-state companies, and I'm doubtful that anything can change properly when the same people are still in charge.

But they won't unfortunately, nothing will change in IE as a result of this. Sure they agree with the recommendations but they will just be buried and it'll be back to normal for everyone.

The train driver is extremely lucky IMO, if the train had derailed the entire of IE would have used him as a scapegoat and he'd be the only victim of the fallout.

KC61

dan_d wrote: »

[*]12 years ago a report indicated to them that there was a problem with this pier. And it "got lost". It was found in Pearse Station - one copy of it. Where are the engineers located now ie, the people who would actually need access to a report like that? Out in CityWest somewhere. I think that speaks for itself.

The Divisional Engineers office is in Pearse Station.

KC61

Cookie_Monster wrote: »

But they won't unfortunately, nothing will change in IE as a result of this. Sure they agree with the recommendations but they will just be buried and it'll be back to normal for everyone.

I don't think that the company would be allowed do that. There is no way that a company could continue as was after a report as damning as this.

As it is the Chief Civil Engineer now reports to the Chief Engineer (Deputy Chief Executive) who has himself insisted on necessary engineering work being done rather than being reprioritised in favour of operations, be it of a mechanical or civil nature.

Hence the nightly closing of Connolly/Bray for example.

Cookie_Monster

KC61 wrote: »

I don't think that the company would be allowed do that. There is no way that a company could continue as was after a report as damning as this.

As it is the Chief Civil Engineer now reports to the Chief Engineer (Deputy Chief Executive) who has himself insisted on necessary engineering work being done rather than being reprioritised in favour of operations, be it of a mechanical or civil nature.

no one in senior management will be sacked, the Dail have already proven they have no powers over IE, existing management will continue merrily along. Even the radio interview yesterday have an air of "well it happened but what do you expect us to do?"

Both the engineers should be given the boot for a start (though I assume the woman who won the separate case is no longer there anyway), either not knowing about it or knowing and not acting are both serious failings on their parts as they are responsible for the teams and reports that should have picked it up, that's the reason they are there. Whoever the senior safety officer is is in the same boat. CEO should resign as an embarrassing failure, that such incidents can be allowed happen under his watch, like any other major company.

KC61

Cookie_Monster wrote: »

no one in senior management will be sacked, the Dail have already proven they have no powers over IE, existing management will continue merrily along. Even the radio interview yesterday have an air of "well it happened but what do you expect us to do?"

Both the engineers should be given the boot for a start (though I assume the woman who won the separate case is no longer there anyway), either not knowing about it or knowing and not acting are both serious failings on their parts as they are responsible for the teams and reports that should have picked it up, that's the reason they are there. Whoever the senior safety officer is is in the same boat. CEO should resign as an embarrassing failure, that such incidents can be allowed happen under his watch, like any other major company.

I would agree with the sentiments expressed above by Shamwari - The Executive Chairman is the person who should take the rap for this as he is ultimately responsible.

As I said above the two people directly responsible for these areas both in Irish Rail (Chief Civil Engineer) and in the Railway Safety Commission (Chief Inspector) have already left with new people now in their place.

So I think it's a little unfair to say that nothing will change. The Chief Civil Engineer reporting to the Chief Engineer is a recent change - until recently there was no Chief Engineer.

Cookie_Monster

KC61 wrote: »

So I think it's a little unfair to say that nothing will change. The Chief Civil Engineer reporting to the Chief Engineer is a recent change - until recently there was no Chief Engineer.

So the change they've made is another layer of management, on 100k+ a year no doubt. Great! Chief civil or chief, no difference really, they could have just expanded the chief civil engineers role, and that of the mech and elec one to cover everything the Chief Engineer does...

Hungerford

Cookie_Monster wrote: »

Why is it unrealistic to carry out annual checks on a structure that old?

The unrealistic bit refers to what IE wanted their staff to do: to inspect for scour without having any training and from track level only [where it would ever never be visible].

Hungerford

KC61 wrote: »

The Divisional Engineers office is in Pearse Station.

That raises a whole layer of other questions then - how come were IE unable to retrieve the report from such an obvious location until the RAIU were finalising their report? Was there a failed cover-up within the company?

KC61

Cookie_Monster wrote: »

So the change they've made is another layer of management, on 100k+ a year no doubt. Great! Chief civil or chief, no difference really, they could have just expanded the chief civil engineers role, and that of the mech and elec one to cover everything the Chief Engineer does...

I would rather have someone taking an overall view than not to be honest.

The litany of failures outlined in that report would tend to back that up.

KC61

Hungerford wrote: »

That raises a whole layer of other questions then - how come were IE unable to retrieve the report from such an obvious location until the RAIU were finalising their report? Was there a failed cover-up within the company?

Or just bad filing (it does happen) - who knows?

dynamick

according to the dept of transport, over a billion has been spent on railway safety in the last decade

The first programme (1999-2003) resulted in expenditure of €661 million, the bulk of which was on infrastructural safety investment. The second programme (2004-2008) resulted in expenditure of €510 million and put more emphasis on the safety management systems of Iarnród Éireann.

I would have thought that they would have started with bits of the railway network where the trains cross elevated bridges over valleys and bridges over water as these must present the highest risk to passengers.

Maybe we should give the next 500 million to somebody else to administer.

Judgement Day

Same ****, different day! Will anybody ever take responsibility for anything at CIE/IE?

Malahide Viaduct - near disaster - from the company that brought you:

Gormanston in 1974 (2 dead 29 injured) - poor maintenance and poor staff operating practices.
Rosslare Strand in 1974 (13 injured) low speed head-on collision between two passenger trains. Poor operating practices.
Dalkey in 1979 (a number of passengers injured) - signalling fault and staff errors.
Buttevant in 1980 (18 dead 75 injured) - unsafe operating practices.
Cherryville in 1983 (7 killed 55 injured) defective equipment and poor operating practices - amongst other things.
Knockroghery in 1997 (4 hospitalised) - broken rail undetected.

There have been many other incidents but some have been outside CIE control such as that at Clogh nr.Gorey and I have only used some relatively recent incidents involving passenger trains, and where CIE were found to be majorally at fault through their own operating practices.

Hungerford

RSC compliance report into viaduct collapse - finished in March but not published until now:

http://www.rsc.ie/uploads/rsc/100329%20TB10-006%20RSC%20Compliance%20Audit%20Report%20Following%20The%20partial%20collapse%20of%20the%20Broadmeadow%20Viaduct%20Final%20Website.pdf

dowlingm

JD's post makes the point I was going to - KC61 thinks this report will of itself spark cultural change in IE. I (and it appears JD) disagree. IE is no stranger to damning reports. By the way JD you missed Cahir. (edit - on a re-read of his post I see he only mentions passenger, but I think for a catastrophic failure of structure Cahir is definitely pertinent)

It looks like they may have too few on the ground engineers. I think it was mentioned that two guys were responsible for 800 bridge structures in addition to whatever other duties they had. Having a CE several layers over their heads won't do that any good, and the "package" that CE will get is probably equivalent to several engineers out there working on the network.

As for filing - IE has a document management system (IAMS), it's not being used. That IS a failure of management layers. Their staff have to be told that the IAMS is to be treated as authoritative with the paper file becoming secondary. The time to complete an inspection task must include a reasonable interval to perform the admin stuff such as adding reports to IAMS - even in the report there was a reference to such activity as being "extra" which still gives the impression of something supplemental to rather than integral to the task.

If IAMS isn't working then it should be fixed. More seriously though, if the documents in the system are useless (like the inspection forms which were mostly blank) it doesn't matter what can be found.

KC61

dowlingm wrote: »

JD's post makes the point I was going to - KC61 thinks this report will of itself spark cultural change in IE. I (and it appears JD) disagree. IE is no stranger to damning reports. By the way JD you missed Cahir.

It looks like they may have too few on the ground engineers. I think it was mentioned that two guys were responsible for 800 bridge structures in addition to whatever other duties they had. Having a CE several layers over their heads won't do that any good, and the "package" that CE will get is probably equivalent to several engineers out there working on the network.

As for filing - IE has a document management system (IAMS), it's not being used. That IS a failure of management layers. Their staff have to be told that the IAMS is to be treated as authoritative with the paper file becoming secondary. The time to complete an inspection task must include a reasonable interval to perform the admin stuff such as adding reports to IAMS - even in the report there was a reference to such activity as being "extra" which still gives the impression of something supplemental to rather than integral to the task.

If IAMS isn't working then it should be fixed. More seriously though, if the documents in the system are useless (like the inspection forms which were mostly blank) it doesn't matter what can be found.

I never said the report itself will change things, but I said that it could not be ignored. However there have been several personnel changes and some structure changes too on the engineering front that should deliver some improvements.

I am also aware that things have changed to a degree, in that, for example the engineering department are insisting that trains get serviced when they are supposed to, rather than when operations can release them. This is important in delivering a safer more reliable railway.

Cookie_Monster

KC61 wrote: »

I never said the report itself will change things, but I said that it could not be ignored. However there have been several personnel changes and some structure changes too on the engineering front that should deliver some improvements.

The fact that it is barely in the media today say it all, swept under the carpet already. There should be huge coverage of this, it is a completely damning report of IE and it operations and safety and yet there is little in the paper or on the radio..

KC61 wrote: »

I am also aware that things have changed to a degree, in that, for example the engineering department are insisting that trains get serviced when they are supposed to, rather than when operations can release them. This is important in delivering a safer more reliable railway.

Am I the only one that finds it totally unbelievable that this even happens in the first place :eek:

dowlingm

The RSC report is an interesting read. While some of it overlaps with RAIU's report, the following caught my eye:

While RAIU mentions the IAMS doc management system, the RSC says they don't have one and should considering buying one! (doc page 29, pdf p31)

Some interesting comments about coastal defence which will interest people who commute from south of Bray Head (d/p21-22, p/p23-24)

Some interesting comments on ganger reports (d/p27-28, p/p29-30)

expectationlost

reports a bit useless ,wheres the investigation into the chain of responsibility from 1997 till 2010, name all those corporate people and investigate whether they did something or not, and if they tried to, who prevented them and name those managers. its all in the past is not an excuse to not investigate and name corporate people

Cookie_Monster

expectationlost wrote: »

reports a bit useless ,wheres the investaigation into the chain of responsibilty from 1997 till 2010, name all those corporate people and investigate whether they did something or not, and if they tried to, who prevented them and name those managers. its all in the past is not an excuse to not investigate and name corporate people

+1
A very good point

devnull

Really disgraceful reading, if they were a private company they would have been slaughtered all over the press much more with the usual statements saying how private companies put shareholders before funds.

But not that much fuss seems to have been kicked up as they are semi-state, heads should roll and as stated earlier in the thread those who oversaw it should offer the resignation if they have not gone already.

foggy_lad

KC61 wrote: »

I never said the report itself will change things, but I said that it could not be ignored. However there have been several personnel changes and some structure changes too on the engineering front that should deliver some improvements.

I am also aware that things have changed to a degree, in that, for example the engineering department are insisting that trains get serviced when they are supposed to, rather than when operations can release them. This is important in delivering a safer more reliable railway.

there will be lots of following the rules for a few months or a year then back to the same auld crack with irish rail and the untouchables, i saw a lot of newly welded rail and points in limerick junction today and am wondering was this done just before an inspection to make that area of track look better than it is?

i noticed lately a 22000 set hidden behind a big blue works shed in heuston beside where the train wash is, it has been parked up there for a number of weeks now so can we assume this is another broken beyond repair set from taiwan/korea? it is not only their safety standards that are up the creek, they have no idea how to purchase anything that is supposed to work!