PFD report

Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 25 Sep 2019•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
16

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised7

  1. Failure of track-engineer challenge of missed fence inspections
    Part of recurring concern: Ineffective controls preventing access to railway tracks
  2. Failure to determine whether fencing inspection failures are national
  3. Failure of the dual-submission inspection recording system
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.15

  1. Action

    Complete the national review of sampled Off Track sections to assess compliance with the boundary inspection requirements.

    Stated by Network RailStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2019.
  2. Action

    Re-brief Tottenham inspectors on conducting non-tactile inspections, including vegetation clearance and access from alternative sides or vantage points.

    Stated by Network RailStated completedThe respondent said that this action was complete when they made their response on 5 November 2019.
  3. Action

    Train delivery-unit personnel to use the electronic inspection system and associated MyWork forms through additional support training.

    Stated by Network RailStated completedThe respondent said that this action was complete when they made their response on 5 November 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The standard then in force permitted either paper or electronic inspection records, disputing that the dual-recording system was inherently flawed.

    Stated by Network RailDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of track-engineer challenge of missed fence inspections

Wider context from the report

“Paddy and Ben died on 21 March 2019. The last time the broken fence was checked was 27 October 2016. In the intervening two and a half years, reasonable endeavours had not been made to inspect (and repair) the fence. 1. The fence was marked down for annual inspections because there was no history of problems in that area. However, the inspectors conducting the inspections on 27 October 2017 and 27 October 2018 (a different inspector on each occasion) did not consider the relevant part of the fence because dense vegetation blocked their view from trackside. Neither inspector attempted to view the fence from the other (public) side, which they could easily have done. This represents a failure of the two individuals and/or a failure of their training and/or both. There are only four inspectors at Tottenham, so two inspectors represents half the inspections workforce. 2. Both inspectors inputted their inspection onto a computer system, but neither submitted a paper form as they were mean to do. This represents a failure of the two individuals and/or a failure of their training and/or both. In any event, such a system of dual submission was inherently flawed. 3. As a consequence of no paper forms being submitted, the track engineer did not see the evidence of the failure to inspect the fence, and so was not in a position to challenge this. This represents a system failure. 4. As a consequence of no paper forms being submitted, the internal auditors did not see the evidence of the failure to inspect the fence or the evidence of the failure to challenge, and so were not in a position to highlight this. This represents a system failure. 5. Network Rail identified the gap in the fence within a week of the deaths but, despite what was described as a full internal investigation, the system failures were only discovered after the inquest had resumed on 30 August 2019. Their original investigation was inadequate. Network Rail had been operating for the previous five and a half months on the basis that this was a localised problem. Even after an adjournment to facilitate further investigations, a senior Network Rail representative gave evidence to that effect on 13 September 2019. Yet the reality is that Network Rail does not know if it has a national system failure of fencing inspection. Paddy and Ben were adults who had responsibility for their own actions, but the fence gap was accessible to children and appeared to be worn. And I heard no evidence that the two had planned to go up onto trackside. A determined effort can be difficult to thwart, but an impulsive action (with judgement and motor skills impaired through alcohol) might well be avoided if the route to danger is not so very easily taken. ”

Is this part of a recurring concern?

Yes — Ineffective controls preventing access to railway tracks.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to determine whether fencing inspection failures are national

Wider context from the report

“Paddy and Ben died on 21 March 2019. The last time the broken fence was checked was 27 October 2016. In the intervening two and a half years, reasonable endeavours had not been made to inspect (and repair) the fence. 1. The fence was marked down for annual inspections because there was no history of problems in that area. However, the inspectors conducting the inspections on 27 October 2017 and 27 October 2018 (a different inspector on each occasion) did not consider the relevant part of the fence because dense vegetation blocked their view from trackside. Neither inspector attempted to view the fence from the other (public) side, which they could easily have done. This represents a failure of the two individuals and/or a failure of their training and/or both. There are only four inspectors at Tottenham, so two inspectors represents half the inspections workforce. 2. Both inspectors inputted their inspection onto a computer system, but neither submitted a paper form as they were mean to do. This represents a failure of the two individuals and/or a failure of their training and/or both. In any event, such a system of dual submission was inherently flawed. 3. As a consequence of no paper forms being submitted, the track engineer did not see the evidence of the failure to inspect the fence, and so was not in a position to challenge this. This represents a system failure. 4. As a consequence of no paper forms being submitted, the internal auditors did not see the evidence of the failure to inspect the fence or the evidence of the failure to challenge, and so were not in a position to highlight this. This represents a system failure. 5. Network Rail identified the gap in the fence within a week of the deaths but, despite what was described as a full internal investigation, the system failures were only discovered after the inquest had resumed on 30 August 2019. Their original investigation was inadequate. Network Rail had been operating for the previous five and a half months on the basis that this was a localised problem. Even after an adjournment to facilitate further investigations, a senior Network Rail representative gave evidence to that effect on 13 September 2019. Yet the reality is that Network Rail does not know if it has a national system failure of fencing inspection. Paddy and Ben were adults who had responsibility for their own actions, but the fence gap was accessible to children and appeared to be worn. And I heard no evidence that the two had planned to go up onto trackside. A determined effort can be difficult to thwart, but an impulsive action (with judgement and motor skills impaired through alcohol) might well be avoided if the route to danger is not so very easily taken. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of the dual-submission inspection recording system

Wider context from the report

“Paddy and Ben died on 21 March 2019. The last time the broken fence was checked was 27 October 2016. In the intervening two and a half years, reasonable endeavours had not been made to inspect (and repair) the fence. 1. The fence was marked down for annual inspections because there was no history of problems in that area. However, the inspectors conducting the inspections on 27 October 2017 and 27 October 2018 (a different inspector on each occasion) did not consider the relevant part of the fence because dense vegetation blocked their view from trackside. Neither inspector attempted to view the fence from the other (public) side, which they could easily have done. This represents a failure of the two individuals and/or a failure of their training and/or both. There are only four inspectors at Tottenham, so two inspectors represents half the inspections workforce. 2. Both inspectors inputted their inspection onto a computer system, but neither submitted a paper form as they were mean to do. This represents a failure of the two individuals and/or a failure of their training and/or both. In any event, such a system of dual submission was inherently flawed. 3. As a consequence of no paper forms being submitted, the track engineer did not see the evidence of the failure to inspect the fence, and so was not in a position to challenge this. This represents a system failure. 4. As a consequence of no paper forms being submitted, the internal auditors did not see the evidence of the failure to inspect the fence or the evidence of the failure to challenge, and so were not in a position to highlight this. This represents a system failure. 5. Network Rail identified the gap in the fence within a week of the deaths but, despite what was described as a full internal investigation, the system failures were only discovered after the inquest had resumed on 30 August 2019. Their original investigation was inadequate. Network Rail had been operating for the previous five and a half months on the basis that this was a localised problem. Even after an adjournment to facilitate further investigations, a senior Network Rail representative gave evidence to that effect on 13 September 2019. Yet the reality is that Network Rail does not know if it has a national system failure of fencing inspection. Paddy and Ben were adults who had responsibility for their own actions, but the fence gap was accessible to children and appeared to be worn. And I heard no evidence that the two had planned to go up onto trackside. A determined effort can be difficult to thwart, but an impulsive action (with judgement and motor skills impaired through alcohol) might well be avoided if the route to danger is not so very easily taken. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequacy of internal investigation into fencing inspection system failures

Wider context from the report

“Paddy and Ben died on 21 March 2019. The last time the broken fence was checked was 27 October 2016. In the intervening two and a half years, reasonable endeavours had not been made to inspect (and repair) the fence. 1. The fence was marked down for annual inspections because there was no history of problems in that area. However, the inspectors conducting the inspections on 27 October 2017 and 27 October 2018 (a different inspector on each occasion) did not consider the relevant part of the fence because dense vegetation blocked their view from trackside. Neither inspector attempted to view the fence from the other (public) side, which they could easily have done. This represents a failure of the two individuals and/or a failure of their training and/or both. There are only four inspectors at Tottenham, so two inspectors represents half the inspections workforce. 2. Both inspectors inputted their inspection onto a computer system, but neither submitted a paper form as they were mean to do. This represents a failure of the two individuals and/or a failure of their training and/or both. In any event, such a system of dual submission was inherently flawed. 3. As a consequence of no paper forms being submitted, the track engineer did not see the evidence of the failure to inspect the fence, and so was not in a position to challenge this. This represents a system failure. 4. As a consequence of no paper forms being submitted, the internal auditors did not see the evidence of the failure to inspect the fence or the evidence of the failure to challenge, and so were not in a position to highlight this. This represents a system failure. 5. Network Rail identified the gap in the fence within a week of the deaths but, despite what was described as a full internal investigation, the system failures were only discovered after the inquest had resumed on 30 August 2019. Their original investigation was inadequate. Network Rail had been operating for the previous five and a half months on the basis that this was a localised problem. Even after an adjournment to facilitate further investigations, a senior Network Rail representative gave evidence to that effect on 13 September 2019. Yet the reality is that Network Rail does not know if it has a national system failure of fencing inspection. Paddy and Ben were adults who had responsibility for their own actions, but the fence gap was accessible to children and appeared to be worn. And I heard no evidence that the two had planned to go up onto trackside. A determined effort can be difficult to thwart, but an impulsive action (with judgement and motor skills impaired through alcohol) might well be avoided if the route to danger is not so very easily taken. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of internal audit to identify missed inspections and absent challenge

Wider context from the report

“Paddy and Ben died on 21 March 2019. The last time the broken fence was checked was 27 October 2016. In the intervening two and a half years, reasonable endeavours had not been made to inspect (and repair) the fence. 1. The fence was marked down for annual inspections because there was no history of problems in that area. However, the inspectors conducting the inspections on 27 October 2017 and 27 October 2018 (a different inspector on each occasion) did not consider the relevant part of the fence because dense vegetation blocked their view from trackside. Neither inspector attempted to view the fence from the other (public) side, which they could easily have done. This represents a failure of the two individuals and/or a failure of their training and/or both. There are only four inspectors at Tottenham, so two inspectors represents half the inspections workforce. 2. Both inspectors inputted their inspection onto a computer system, but neither submitted a paper form as they were mean to do. This represents a failure of the two individuals and/or a failure of their training and/or both. In any event, such a system of dual submission was inherently flawed. 3. As a consequence of no paper forms being submitted, the track engineer did not see the evidence of the failure to inspect the fence, and so was not in a position to challenge this. This represents a system failure. 4. As a consequence of no paper forms being submitted, the internal auditors did not see the evidence of the failure to inspect the fence or the evidence of the failure to challenge, and so were not in a position to highlight this. This represents a system failure. 5. Network Rail identified the gap in the fence within a week of the deaths but, despite what was described as a full internal investigation, the system failures were only discovered after the inquest had resumed on 30 August 2019. Their original investigation was inadequate. Network Rail had been operating for the previous five and a half months on the basis that this was a localised problem. Even after an adjournment to facilitate further investigations, a senior Network Rail representative gave evidence to that effect on 13 September 2019. Yet the reality is that Network Rail does not know if it has a national system failure of fencing inspection. Paddy and Ben were adults who had responsibility for their own actions, but the fence gap was accessible to children and appeared to be worn. And I heard no evidence that the two had planned to go up onto trackside. A determined effort can be difficult to thwart, but an impulsive action (with judgement and motor skills impaired through alcohol) might well be avoided if the route to danger is not so very easily taken. ”

Is this part of a recurring concern?

Yes — Ineffective controls preventing access to railway tracks.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to inspect relevant fence sections from an accessible alternative viewpoint

Wider context from the report

“Paddy and Ben died on 21 March 2019. The last time the broken fence was checked was 27 October 2016. In the intervening two and a half years, reasonable endeavours had not been made to inspect (and repair) the fence. 1. The fence was marked down for annual inspections because there was no history of problems in that area. However, the inspectors conducting the inspections on 27 October 2017 and 27 October 2018 (a different inspector on each occasion) did not consider the relevant part of the fence because dense vegetation blocked their view from trackside. Neither inspector attempted to view the fence from the other (public) side, which they could easily have done. This represents a failure of the two individuals and/or a failure of their training and/or both. There are only four inspectors at Tottenham, so two inspectors represents half the inspections workforce. 2. Both inspectors inputted their inspection onto a computer system, but neither submitted a paper form as they were mean to do. This represents a failure of the two individuals and/or a failure of their training and/or both. In any event, such a system of dual submission was inherently flawed. 3. As a consequence of no paper forms being submitted, the track engineer did not see the evidence of the failure to inspect the fence, and so was not in a position to challenge this. This represents a system failure. 4. As a consequence of no paper forms being submitted, the internal auditors did not see the evidence of the failure to inspect the fence or the evidence of the failure to challenge, and so were not in a position to highlight this. This represents a system failure. 5. Network Rail identified the gap in the fence within a week of the deaths but, despite what was described as a full internal investigation, the system failures were only discovered after the inquest had resumed on 30 August 2019. Their original investigation was inadequate. Network Rail had been operating for the previous five and a half months on the basis that this was a localised problem. Even after an adjournment to facilitate further investigations, a senior Network Rail representative gave evidence to that effect on 13 September 2019. Yet the reality is that Network Rail does not know if it has a national system failure of fencing inspection. Paddy and Ben were adults who had responsibility for their own actions, but the fence gap was accessible to children and appeared to be worn. And I heard no evidence that the two had planned to go up onto trackside. A determined effort can be difficult to thwart, but an impulsive action (with judgement and motor skills impaired through alcohol) might well be avoided if the route to danger is not so very easily taken. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Accessible worn fence gap creating an easy route to trackside danger

Wider context from the report

“Paddy and Ben died on 21 March 2019. The last time the broken fence was checked was 27 October 2016. In the intervening two and a half years, reasonable endeavours had not been made to inspect (and repair) the fence. 1. The fence was marked down for annual inspections because there was no history of problems in that area. However, the inspectors conducting the inspections on 27 October 2017 and 27 October 2018 (a different inspector on each occasion) did not consider the relevant part of the fence because dense vegetation blocked their view from trackside. Neither inspector attempted to view the fence from the other (public) side, which they could easily have done. This represents a failure of the two individuals and/or a failure of their training and/or both. There are only four inspectors at Tottenham, so two inspectors represents half the inspections workforce. 2. Both inspectors inputted their inspection onto a computer system, but neither submitted a paper form as they were mean to do. This represents a failure of the two individuals and/or a failure of their training and/or both. In any event, such a system of dual submission was inherently flawed. 3. As a consequence of no paper forms being submitted, the track engineer did not see the evidence of the failure to inspect the fence, and so was not in a position to challenge this. This represents a system failure. 4. As a consequence of no paper forms being submitted, the internal auditors did not see the evidence of the failure to inspect the fence or the evidence of the failure to challenge, and so were not in a position to highlight this. This represents a system failure. 5. Network Rail identified the gap in the fence within a week of the deaths but, despite what was described as a full internal investigation, the system failures were only discovered after the inquest had resumed on 30 August 2019. Their original investigation was inadequate. Network Rail had been operating for the previous five and a half months on the basis that this was a localised problem. Even after an adjournment to facilitate further investigations, a senior Network Rail representative gave evidence to that effect on 13 September 2019. Yet the reality is that Network Rail does not know if it has a national system failure of fencing inspection. Paddy and Ben were adults who had responsibility for their own actions, but the fence gap was accessible to children and appeared to be worn. And I heard no evidence that the two had planned to go up onto trackside. A determined effort can be difficult to thwart, but an impulsive action (with judgement and motor skills impaired through alcohol) might well be avoided if the route to danger is not so very easily taken. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete the national review of sampled Off Track sections to assess compliance with the boundary inspection requirements.

Verbatim wording from the response

“5.1 Network Rail Response Q5:”

Source location

2019-0314-Response-by-Network-Rail
Page 5 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Re-brief Tottenham inspectors on conducting non-tactile inspections, including vegetation clearance and access from alternative sides or vantage points.

Verbatim wording from the response

“1.1.5 Tottenham Delivery Unit improvements”

Source location

2019-0314-Response-by-Network-Rail
Page 3 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Train delivery-unit personnel to use the electronic inspection system and associated MyWork forms through additional support training.

Verbatim wording from the response

“2.1.2 Additional Support Training”

Source location

2019-0314-Response-by-Network-Rail
Page 4 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct onsite reviews of route inspectors’ non-tactile inspection reports and processes.

Verbatim wording from the response

“As a further measure, the Route Lineside Senior Asset Engineer within the Route where Tottenham Delivery Unit are located is undertaking a set of onsite reviews with all Route inspectors using recently created non-tactile inspection reports. This is to review the reports and the process followed prior to submission of the reports. All inspectors in the Route will have been reviewed by 31st December 2019. We can confirm the inspectors involved with the fencing inspections linked to the tragic deaths have already been reviewed by the Route Lineside Senior Asset Engineer.”

Source location

2019-0314-Response-by-Network-Rail
Page 3 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Amend the audit protocol by adding guidance to review example F3212 forms from inspectors.

Verbatim wording from the response

“The previous Standard in force allowed the use of either paper or electronic systems. The lesson from these tragic deaths will be shared with our national audit teams so they can share the lesson. The audit protocol has been changed, since the audit referenced above, to reflect the new Standard and all auditors will be checking to the new Standard including checking of the electronic records.”

Source location

2019-0314-Response-by-Network-Rail
Page 5 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the revised Boundary Fencing Inspection Standard requiring electronic inspection records, non-tactile inspection documentation and supervisory approval.

Verbatim wording from the response

“1.1.3 New Boundary Fencing Inspection Standard”

Source location

2019-0314-Response-by-Network-Rail
Page 2 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Issue a National Safety Bulletin instructing boundary inspectors to use alternative methods when tactile inspection is unavailable.

Verbatim wording from the response

“1.1.1 National Safety Bulletin”

Source location

2019-0314-Response-by-Network-Rail
Page 1 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Commission a national special-topic audit of compliance with the revised boundary inspection standard for non-tactile forms.

Verbatim wording from the response

“new boundary inspection Standard re non-tactile forms will be undertaken by the Network Rail National Audit Team within the next 3 months to identify whether we have a national failure and to what extent.”

Source location

2019-0314-Response-by-Network-Rail
Page 6 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide engineers with a report flagging consecutive non-tactile inspections and inspection forms not completed within 180 days.

Verbatim wording from the response

“• The Engineers will be receiving a new report showing what is in the system for processing and the report will flag two consecutive non-tactile inspections, plus any forms not processed to completion within 180 days. This will allow the Engineers to check that suitable challenges have occurred for those locations or actions to close are in progress.”

Source location

2019-0314-Response-by-Network-Rail
Page 5 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Brief Anglia Track Maintenance Engineers to use and maintain electronic inspection records instead of paper records.

Verbatim wording from the response

“3.1.2 On a local level, the failure has been addressed by taking the following steps:”

Source location

2019-0314-Response-by-Network-Rail
Page 5 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Amend the boundary inspection standard to specify work required to enable future tactile inspections.

Verbatim wording from the response

“1.1.4 Future enhancement to the Boundary Fencing Inspection Standard”

Source location

2019-0314-Response-by-Network-Rail
Page 3 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Apply the revised audit protocol to check electronic inspection records against the new boundary inspection standard.

Verbatim wording from the response

“4.1.1 Internal auditing”

Source location

2019-0314-Response-by-Network-Rail
Page 5 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Investigate nationally whether boundary inspections continue to use dual paper and electronic recording systems.

Verbatim wording from the response

“3.1 Network Rail Response-Q3:”

Source location

2019-0314-Response-by-Network-Rail
Page 4 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update the mandatory boundary inspection competency module to specify how inspectors must proceed when trackside tactile inspection is impossible.

Verbatim wording from the response

“1.1.2 Competency Training Module”

Source location

2019-0314-Response-by-Network-Rail
Page 2 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Issue a National Special Inspection Notice requiring electronic form use, correct sign-off and risk assessment of repeat non-tactile locations.

Verbatim wording from the response

“2.1.3 National Special Inspection Notice”

Source location

2019-0314-Response-by-Network-Rail
Page 4 · response
Published 5 November 2019

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The standard then in force permitted either paper or electronic inspection records, disputing that the dual-recording system was inherently flawed.

Verbatim wording from the response

“2.1.1 The ‘Boundary Measures Network Rail Standard’ (NR/L2/TRK/5100) in force at the time of the 2017 and 2018 inspections and in force at the time of Benjamin Michael Haddon-Cave and Patrick Thomas Bolster’s tragic deaths, made it permissible to use either paper or electronic forms. Network Rail was aware of the flaws in this Standard prior to the inquest and had revised the national Standard to (NR/L2/OTK/5100) which came into force in April 2019. This Standard specifies that only electronic records are to be used from the 31st August 2019. In terms of the system we now require a single electronic system to be used.”

Source location

2019-0314-Response-by-Network-Rail
Page 3 · response
Published 5 November 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Share the lessons from the deaths with national audit teams.

    Stated by Network RailStated plannedThe respondent said that this action was planned when they made their response on 5 November 2019.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share the lessons from the deaths with national audit teams.

Verbatim wording from the response

“4.1.1 Internal auditing”

Source location

2019-0314-Response-by-Network-Rail
Page 5 · response
Published 5 November 2019

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026