Malahide Viaduct Report Published

[Mark Gleeson]

http://www.raiu.ie/uploads/raiu/Malahide%20Viaduct%20Collapse%20on%20the%20Dublin% 20to%20Belfast%20Line%20on%20the%2021st%20August%2 02009.pdf

[losexpectation]

so name the person responsible for not keeping up the knowledge and training?

[Mark Gleeson]

The RAIU as policy does not name staff involved. That is consistent with transport accident investigation worldwide.

Book stops with the chief civil engineer. The chief civil engineer in charge in 2009 has left the company for reasons unrelated to Malahide. The chief inspector of the Rail Safety Commission retired, unexpectedly this March.

[losexpectation]

ok, grumble, so who was the responsible manager/person who didn't act on this report in 1997, if that person doens't want to take responsibility, then surely the company can have some legal action taken on it for neglect, could there not be some penalty on the IR, so international theres mark on them about this.

you didn't get to respond about the bridge checks tranparency, i presume they just put out a press release about checking the all the bridges but not details?

[Mark Gleeson]

I don't have the name of the chief civil engineer in 1997. Legally the RSC can take Irish Rail to court and the fines are significant.

you didn't get to respond about the bridge checks tranparency, i presume they just put out a press release about checking the all the bridges but not details?

Exactly, date and the report would be nice. I'm amazed there isn't a ring bound folder for every structure which an engineer would simply read to understand the unique aspects of the each bridge.

The engineer sent out wasn't familiar with the viaduct, and assumed it was on piled foundations. Only 2 out of 104 bridges over water with piers in the water are not carried on foundations. Two are carried on gravity piers on weirs

[dowlingm]

Scapegoating Eileen Wilcock (announced as CCE designate in Dec 2007) lets way too many people off the hook. Unfortunately, short of a public inquiry overriding her legal settlement, we'll probably never know what she did or didn't do, and if she tried to do stuff how much support she received.

If this was a LUAS collapse John Lynch would have been calling for heads by now.

Most importantly - there is little significant difference between this bridge and a road viaduct given that everything from the concrete beams up behaved as designed - how many NRA/county council bridges over tidal bodies are built on such foundations? What is their inspection regime? Who's keeping track to make sure it's happening and recorded properly?

[James Howard]

A couple of highlights that struck me as somewhat interesting regarding lack of action taken on an inspection in 1997.

From Page 65
After the removal of the barge, East Coat Diving Services carried out an inspection of the Malahide Viaduct in March 1997. A summary of the inspection findings are as The pointing was generally in “okay condition”;
Scouring and undercutting can be “found on a few piers where rock armour and concrete been washed away”;


“Underwash and undermining of concrete pour due to hole and tidal flow” at Pier 7;
The inspection diver concludes that the rock armour is “too light for the job it is to do”;
The rock armour grout has diminished by approximately 80% on the west side of the Malahide Viaduct and 70% on the east side;
Evidence of cracking and spalling of the concrete deck;
“Scouring starting at the base” of Pier 4 (the Pier which collapsed);
Debris (twisted metal and old railway sleepers) recorded betw
een Piers 4 and 5.



Then skipping forward a bit

The inspection diver who carried out the inspection, did not consider that the weir protection to be substantial enough stating “the rock armour itself is in my opinion too light for the job it is to do”, which indicates that further strengthening works to the rock armour was required in order to protect the weir. Also, in direct reference to Pier 4, the report states that scouring had started at the base.
There is no evidence available to the RAIU to suggest that any works were carried out on the weir post inspection, and therefore it can only be assumed that the weir was allowed to degrade further as described in the „The Failure Mechanism of Malahide Viaduct‟ sections of this report.
Considering that this inspection directly refers to scouring starting at the base of Pier 4, and no works recorded, it is a major concern that IÉ took no remedial actions to carry out any maintenance works.

[James Howard]

Then on page 82, you don't know whether to laugh or cry


The East Coast Diving Services inspection, carried out in 1997, was fortuitously found as a consequence of cleaning out an office at Pearse Station, and had not been filed with the other Bridge Inspection Cards. It should be noted that IÉ carried out an extensive search of documents after the accident, and the East Coast Diving Services inspection had not been discovered at that time.


And the money was just resting in my account.

[ACustomer]

Prosecuting IE and fining them heavily will just leave them even more strapped for cash and may lead to closures and service reductions. Prosecuting and disciplining individuals (or even firing them) would be more appropriate.

But this is the Irish public sector, where the only thing you can be fired for is what in academic life is called "gross moral turpitude", so dream on!

[markpb]

Legally the RSC can take Irish Rail to court and the fines are significant.

Prosecuting IE and fining them heavily will just leave them even more strapped for cash and may lead to closures and service reductions. Prosecuting and disciplining individuals (or even firing them) would be more appropriate.

Exactly. There's no point in one arm of the government fining another -that's just an accounting exercise and a giant waste of time. Someone or several people didn't do their jobs, hundreds of people could have died and those responsible either still have their jobs or are living on a reasonably decent public service pension.

[Mark Gleeson]

The RSC can take a prosecution against a named individual or a corporate entity. They should but a bit like the calls to sack half the senior staff it won't achieve anything and would make matters worse.

[markpb]

The RSC can take a prosecution against a named individual or a corporate entity. They should but a bit like the calls to sack half the senior staff it won't achieve anything and would make matters worse.

If they're not doing their jobs right now, it's hard to see how it could get any worse.

Yes, I'm being slightly tongue in cheek but the acceptable outcome isn't the publication of the RIAU/RSC reports and then... nothing. These people take on a very important job and they failed to do it.

[Mark Gleeson]

Today FM Last Word Matt Cooper 17:15 16/8/2010
http://www.railusers.ie/podcasts/audio/16082010_LastWord_Malahide.mp3

[Mark Gleeson]

If they're not doing their jobs right now, it's hard to see how it could get any worse.

Yes, I'm being slightly tongue in cheek but the acceptable outcome isn't the publication of the RIAU/RSC reports and then... nothing. These people take on a very important job and they failed to do it.

Irish Rail has complied with the recommendations put forward, the RSC did issue a section 78 improvement notice on Irish Rail which has been complied with.

If you went and sacked the entire senior layer of engineers, the RSC would withdraw Irish Rail's safety case and the entire network would be closed down until new staff were found, trained (pretty hard if you sacked the only people who knew the 'system') and the safety case submitted. Not to mention the high court battle as the staff took unfair dismissal proceedings (and would win).

There is a serious question of engineering competence and professionalism. Regardless of the 'system' in place a good engineer will ask questions and continue to ask until answers are found. We saw what happened to the last chief civil engineer when she stood her ground. The critical report was 1997 presumably before the Knockcroghery accident of November 8th that year. Was it deliberately buried? Surely there were at least 2 copies.

Its clear sometime around 1996-1998 something serious went wrong inside Irish Rail. Back then a lot was wrong and the safety assessments suggested multiple passenger fatalities annually. The Malahide report might be shocking, the safety reports back then made for terrifying reading.

Is the network safer now than at any time in the past - yes, that is the most important concern. Now clearly the bulk of this improvement has been through new track, new trains and signaling there is much to be done in the procedures and supporting systems. If you look back at every major past accident, they either couldn't happen today or if they did chances are everyone would walk away with at most cuts and bruises.

[James Howard]

I had a quick skim back thorugh the Cahir Viaduct Collapse Report - yes I know it is a very different structure, but it is interesting to compare the recommendations in this against the Malahide report.

There are some recommendation that appear to have been completely implemented (for example one regarding communciation with the signalman), some which only apply to the type of viaduct and wagons at Cahir, but there are a couple relating to asset management that appear to have been implemented but not done properly.

See
Recommendation 8

IÉ should review, and amend as necessary, its asset management systems to ensure that data is pertinent, comprehensive, concise and accessible and
provides evidence that all outstanding issues are appropriately actioned and closed out.
(Review 3 months, Amendment programme completed 12 months ).

Recommendation 9

IÉ should ensure that, pending full implementation and validation of new data management systems including those currently in course of development, comprehensive and up-to-date records of infrastructure asset inspection and maintenance are maintained and that relevant data is effectively promulgated to inspectors, maintainers and managers.
(Review and implementation 3 months)

One of the other recommendations had the staggering implication that to inspect a structure one must be able to actually see all of it and that measures should be taken to make that happen.

So it would seem to me that several recommendations of an accident report that doesn't go back to the dawn of time haven't actually been implemented. This raises the point that if you are going to have expensive investigations and reports and then ignore the results, why bother having them in the first place.

I don't think particularly that heads need to roll particularly given the fact that loss of corporate memory was pointed out as a contributory factor in the Malahide collapse, but there needs to be some visible evidence of some action being taken.

[Mark Gleeson]

There is a new document management system in place.

There are 6000 odd structures in the Dublin division alone, oldest 1833, newest 2010.

There is a clear failure to address concerns from pervious accidents. The review of the investments made and the somewhat random management and expenditure is interesting http://www.transport.ie/upload/general/11293-1.pdf

[dowlingm]

The RSC report has some interesting add-ons to the RAIU report - search for "coastal defence". Those who commute from Greystones and points south should think about the implications of that part of the report.

One weird thing, the RAIU refers to IE's IAMS but says it's not being used whereas the RSC reckons IE should buy a Document Management System :confused:

[losexpectation]

if the previous chief civil engineers did try to do something about this bridge should we not try to find that out, and if they were prevented then the corporate person who prevented them should be named or fired if still at IR, and if they didn't do something about should that not be noted.

the problem in Ireland is the lack accountabilty, vague talk of systematic failures, "its all in the past", or sentiment shouldn't get in the way of accoutablilty, look at the way fas, you can't trust people who previosuly mismanaged even if there are new syste, in place, sack em and pay them to consult if you have to don't let them continue to mismanage the entire system.

I see you say elsewhere its hard to find who runs IR, could you find the rest of the names the report spends most of the time talking about the a derelict barge, not about the chain of responsibilty for inspections and repair from 1997 till 2010, what does the RSC report really tell us?

love barry kenny yesterday saying of the 1997 inspection report "we know it was deinfilty lost"

[James Howard]

I agree with Mark that clearing out the senior engineers would achieve little and would just end up further undermining the safety regime.

However, there is no reason whatsoever why the board couldn't be cleared out as a means of achieving some level of responsibility.

If this had happened in France - I single them out as they seem to be particularly keen on corporate responsibility, the board would be in court on charges. I am not suggesting that anybody did anything illegal in this case but the fact remains that it is difficult to describe an event that occured and was predicted by reports that were ignored as anything other than negligence. I'll leave the question open as to what you would describe a predicatable event which you failed to stop where people were killed?

It was only pure and simple luck that people weren't killed here and the same goes for the Cahir collapse. Yes, the driver was well trained and responded appropriately to the collapse but he was very lucky. If an Enterprise with 400 passengers had gone barrelling over it at 70mph, what would the likely outcome be?

It seems to me that at this stage Irish Rail have used up all of their luck.

[Mark Gleeson]

I firmly believe that the entire of CIE holding company should be shutdown. Irish Rail already have a board so its a another level of bureaucracy.

There is a question of engineering competence and that may be a matter for Engineers Ireland as regardless of the systems failures inside Irish Rail questions must be asked of the engineers involved. Engineers should regardless of circumstance ensure safety is the first concern

[Colm Moore]

I used to work for a small firm of Quantity Surveyors. When my boss's father (who was also a QS) died, we did a certain amount of clearing out of the office. While a QS will always keep a bill of quantities, there is little obligation to keep drawings and certainly not beyond the statute of limitations (6-12 years depending on the circumstances). There were drawings there from 50 years before, when the father would have been starting out on his own. The drawings were passed to the RIAI Archive (which is admittedly under resourced, but at least it’s there).

Indeed, my boss rescued a few drawings of buildings from an institutional client who had disposed of the buildings and was going to throw out the drawings. He framed them and hung them on the office wall. While relatively simple drawings, they were thorough, done at a time when such drawing was a real craft. While every last detail (paint colour, type of door panels, sanitary ware) may not have been present, one A2 sheet was enough to build the building and anyone familiar with construction would have been able to rebuild it in a relatively authentic style. Those drawings were 120 years old (and possibly worth a pretty penny).

Any discussion I've ever had with an (structural / civil / building services) engineer has always pointed to them having the drawings from the previous construction / alteration of the building. I see no reason why it should be any way else with civil engineers. While the drawing and reality may vary somewhat (builders are notorious for not keeping their excavations and therefore foundations rectangular :)), the vast bulk of the relevant information should be there.

Now, I can understand if someone was introduced to a system whereby documents weren't kept or weren't kept systematically, that they may not be diligent in the future about keeping such things. However, that’s a valid excuse for someone who's 18 and doesn't know any better, not a qualified or senior engineer.

I bet Barry Kenny (not particularly wishing to pick on him, others are responsible here) has a record of every press / media mention of Irish Rail since he started his job - and before that.

[Colm Moore]

https://www.irishrail.ie/news_centre/news.asp?action=view&news_id=871 RAIU Malahide Accident Report by Corporate Communications

Monday 16th August 2010

Iarnród Éireann has today received the Malahide Viaduct accident investigation report of the Railway Accident Investigation Unit (RAIU). (Read the full report here http://www.raiu.ie/uploads/raiu/Malahide%20Viaduct%20Collapse%20on%20the%20Dublin% 20to%20Belfast%20Line%20on%20the%2021st%20August%2 02009.pdf )

This follows the completion of Iarnród Éireann’s accident investigation in February of this year, and the receipt of the Railway Safety Commission’s (RSC) Compliance Audit in March of this year.

At the outset, Iarnród Éireann 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 21st August 2009, and apologise to customers, who experienced significant disruption to services as a result.

Following the accident, Iarnród Éireann commenced a programme of major reform across all aspects of the safety management of infrastructure. The implementation of this programme has ensured that all of the recommendations from the RAIU report and RSC audit are already actioned, with many complete.


Findings, recommendations and actions – summary overview

Iarnród Éireann notes that the key findings and recommendations of Iarnród Éireann’s Malahide Viaduct investigation, and the actions undertaken in the organisation since the incident and the investigation, have been appropriate and closely coincide with the findings and recommendations of both the RAIU and RSC.

Following receipt of the compliance audit, Iarnród Éireann agreed an action programme with the RSC to address the findings, and excellent progress has been made to this end. The company accepts the recommendations from both reports, and implementation of actions arising are well advanced, with many complete.

The company is fully committed to continue to address all of the findings of both the RAIU accident report and RSC audit and will continue to work proactively with stakeholders to ensure all the outstanding issues are addressed.


Change and reform in infrastructure management

These actions, which address the issues arising from the RAIU accident report and RSC audit, are part of a much wider review undertaken by Iarnród Éireann since the accident of the Civil Engineering Department, and the approach towards the management of Iarnród Éireann’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:

- A new Safety Management System for Civil Engineering

- a re-organisation and re-staffing of the Civil Engineering area, with new management and structures

- 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.

- a “compliance verification” process to regularly audit and check that the new processes are continuously followed in practice

- 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 address the requirements and recommendations of the RSC Compliance audit and RAIU investigation, 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.


Detailed overview of action areas

The details of actions taken by Iarnród Éireann relating to the specific recommendations of the RAIU report are contained in Section 44 of the report (www.raiu.ie) . Section 43 of the report also includes details of the physical works undertaken to reinstate and strengthen Malahide Viaduct, which reopened in November 2009.

The actions relating to the recommendations were encompassed in a much wider review of the Civil Engineering Department, and the approach towards the management of Iarnród Éireann’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.

Five fundamental changes, each with intended wide ranging benefits, have been implemented since January 2010:

· A detailed Safety Management System (SMS) has been developed and implemented in the Civil Engineering Department. The SMS specifically describes the roles and responsibilities for managers, supervisors and engineers where these roles affect workplace safety and the safety of the Iarnród Éireann track and structures. In addition, the SMS also describes the procedures that must be followed and the review/control mechanisms that are exercised to ensure that those procedures are followed. One example of the impact of this change is that a formal programme for the inspection of bridges by specific personnel is now established and is maintained in an automated asset management system;

· The Civil Engineering Department has been re-organised and re-staffed in a manner significantly different to the Department structure that previously existed. Following a vacancy arising for the position, a new Chief Civil Engineer has been appointed, as well as a new Technical Manager (for Civil Engineering). The Technical Manager has full accountability for the safety of track and structures and is supported by a team of engineers dedicated to this accountability. This change establishes the unambiguous ownership for the safety of the Iarnród Éireann infrastructure and assigns the appropriate resources to the Technical Manager to achieve that accountability;

· 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;

· The Civil Engineering Department has adopted a ‘compliance verification’ process to regularly audit and check that the new processes are continuously followed in practice. For example, greatly improved control mechanisms are in place to ensure that structural inspections are undertaken in accordance with standards and at the specified frequency;

· The Civil Engineering Department has now implemented a competency management process that is resourced with a Competency Manager who is, in turn, supported by Assessors. This team will implement, over the coming months, different programmes of assessments of Civil Engineering staff competencies. Assessments will be preceded with training modules and will be supported by briefings and follow-up refresher training sessions. The first example of this assessment programme is the training and assessment of track patrollers.

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.

[dowlingm]

How I wish the guy who wrote that had gone nuts and written it in plain English.

"Due to having a falling out with our CCE, she's going to be the scapegoat which means our appointment of a new one looks like we're doing something"

"The IE Dictionary is being reviewed with the definition of Standards being changed from "conditions that are nice to have if we can be bothered" to "conditions that we will do our best to make it look like we're following, subject to inadequate funding and diversion of resources to new lines from nowhereville to ballygobogland".

"We have fancy new safety, training and assessment schemes in place but the most important one is that people have been told that if you hand in inspection forms with only 2 or 3 boxes filled out, and them not even adequately specified, your ass will be fired ^H^H^H^H^H severely told off but since we don't want a strike that will be the end of it."

[Mark Gleeson]

Shockingly similar in many respects

http://www.raib.gov.uk/cms_resources.cfm?file=/100923_R172010_Feltham.pdf

It even references the Malahide Viaduct collapse as a similar event

[dowlingm]

That's England so obviously it's privatisation's fault.

[Colm Moore]

Nope, Continuity Irish Rail.