“ 2.3 The conclusions which both AEA and Interfleet independently reached were:- • It is possible to propagate a crack in a wheel with a pre-existing crack-like defect in it and hence this explains the wheel that failed at Sandy. • Cracks are extremely unlikely to initiate in wheels with ‘good’ holes. (See 3.1 for definition/criteria for a ‘good’ hole • There is no need to continue with wheel MPI provided the holes are to an acceptable standard (defined as a ‘good’ hole – see 3.1). 2.4 There is a requirement however to carry out on-track tests to measure real wheel web strains in order to underpin both the AEA and Interfleet theoretical work which has been carried out to date. 3. Definition of a ‘Good’ Balance Weight Hole 3.1 The following definition of a good hole was agreed following discussions involving all parties (See Appendix 1 for details). A good hole is a balance weight hole which no longer requires MPI in service. To be designated a good hole it must satisfy the following criteria….”
“ 3.3 A key piece of information given by D. Ward at the meeting was that MPI would in this application guarantee to find a 1mm or greater crack size, if the MPI process were repeated at the same hole on 4 separate occasions. From this it was concluded that if the chamfer size was then increased by 1mm, following 4 MPI’s this would ensure that any smaller undetectable defects were eliminated. 3.5 GNER will be developing a plan to re-assess all balance weight holes and implement measures to bring holes up to the standard which satisfies the criteria of a ‘good’ hole. This may require replacement of some wheels. GNER’s proposal was for Interfleet to manage this task.”
“ Q. Now, would you accept that if the advice that you had been getting about these wheels was that the only problem, or potential problem about them was that they had not been properly deburred and chamfered – I appreciate that you were getting different advice and there were other problems with them but I would like you to put yourself in [that] position: if the advice you had been getting was the only potential problem on the wheels was that they needed to be deburred and chamfered, would you accept that the good hole programme would have been complete by about 5th August ? A. Well, if that was the – those were the only two things that needed to be done, there would have been no necessity for a good hole programme … Q. I think everybody agrees it probably would have been appropriate to have some MPI testing at 10-day intervals for, I think on your side they say four periods, and on our side they say three periods ? A. Yes, the advice we had was that if you did four – and it was possibly three and four to be absolutely sure – then you should pick up a latent small crack. And the reason for the four is that if you miss it on one of them, you probably get it on the next one. Q. And the rectification that had taken place between 16th and 22nd June ought to have remedied any of the original deburring or failure to chamfer problems on the wheels because that is what you were rectifying over that period, was it not ? A. What we were trying to do over that period was to make the wheels and the holes as safe as we could in the time and with the resources we had available. At that stage, we were right at the beginning of this exercise we had, as it were, ad hoc advice in terms… advice which was being developed as the situation became more understandable, and clearly, we wanted to get our trains back into service as soon as possible.”
“ 1) Inspect wheels visually for cracks, flats, pitting, damage or any sign of possible failure in tyre, rim and hub. 2) Inspect brake discs visually for cracks, damage or any sign of possible failure. 3) Inspect visible parts of axle for cracks, damage or any sign of possible failure. 4) Check that the balance weights are not loose. Refer to Maintenance Procedure U-34 for re-torquing. Record any that are found loose on the exam/repair card. 5) Record and report any defects to the Supervisor.”
“ 5) Visually check the wheelsets for signs of damage or defect. … 6) Record and report any defects to the Supervisor.”
“ Q. … if there was a crack through the wheel which had penetrated both onto the inner and outer surfaces there ought to be two opportunities to see it, both underneath the train and along the side of the train ? A. That is correct. Q. Now, paragraph 12 of your statement …. You say at the end of Paragraph 12: ‘If there had been a very obvious crack then our A examiners would certainly have been expected to note and report it.’ How long would a crack be before it would be something that you would describe as ‘very obvious’ ? A. Using the terminology ‘obvious’ in that the crack would be visible and open. The length is relatively immaterial if, in our view, the crack is obvious. Q. So, if it is an open crack, how long or how short would it be before you would describe it as something your A examiners would have been expected to note ? A. It is very difficult to put a figure to that. Q. Well, let me try to help you. Suppose it is a total of 85 centimetres long, both sides of the balance weight. A competent inspector ought to notice that on an A exam ? A. I would have expected that to be so. Q. The same is true of anything above 30 centimetres, is it not? A. Again, I would expect the crack to be visible. I would not only be persuaded that the crack was visible by its length. Q. You have made that point but assuing that it is a crack which is visible and an open crack, if it were 30 centimetres or more, you would expect someone to see it on an A exam if they were doing their job properly..? A. I would say yes. ”
“ There can only be one of two explanations for why the crack was not spotted at this B examination. Either neither man looked properly at the area surrounding the balance weight hole or they did not look at all.”
“ 3.2.1. It is clear that the only relevant problem with the vehicle was the very poorly finished balance weight fixing hole. 3.2.5. Inspection and maintenance of the vehicle had been carried out exactly as laid down at the time. 3.2.6. With hindsight, the maintenance regime which only ever provided a visual inspection of wheelsets, must be questioned. 3.2.7. It seems certain that, at24 March 1998 ‘B’ examination, the cracks were already quite well developed, having probably been propagating since June 1997. While dirt and debris particles on the wheel combined with the effects of artificial lighting from the pit, may well have made the defects invisible to the naked eye, magnetic particle inspection at this stage would surely have revealed the problem. 3.2.9. By ‘A’ examination dated (10 June 1998 ), the cracks must have been very well advanced. However, wheel inspection (even visual) was not part of the process….”
“ Q. So, maybe you do not like the use of the word ‘negligence’ but at the end of the day, it is your opinion that there has been an unprofessional B inspection and an unprofessional series of A inspections which do not live up to the standards of competence that you would expect ? A. I do not feel comfortable agreeing to those words … I would use different words, but if this is the implication, I repeat the wording that I would prefer is that to me, it is an indication that the inspection regime has failed and that the standards of inspection have been lacking. Q. Both on the B and also on the A ? A. Both on the B and on the A.”
“ Q. … what I have to suggest to you, Mr. Etwell, is that this is a pretty serious allegation, is it not, that is being run in this case against GNER ? The case is that GNER’s negligence – admittedly along with the defendants – caused the derailment. That is the allegation, is it not ? A. I have not made that allegation ….”
“ Q. … What I am putting to you is: the reason why you have frequent inspections, frequency being something that you have particularly stressed, is that because there is a risk that an operator may not detect a crack on a particular inspection? A. Yes. Q. And an operator may not detect a crack, even a significant crack, on a particular occasion, for all sorts of reasons which have nothing to do with professional culpability ? A. On a once-off basis… yes, but you rely on it being done and that is with the frequency. The B exam cannot be looked at independently of the A because the B exam does include the A exam content and the frequency of the safety inspection is heavily dependent upon this general visual examination on the A exam frequency. So on a once off, one may say yes to answer that question, but the general answer, I would have to say no. Q. … on a once-off basis on 24th March, 1998, you cannot say, can you, that the failure to detect the crack on this one-off occasion is only consistent with negligence ? A. Well, I can only repeat the context of my previous statement, that I could only look at that B exam really in the context of regular A examinations as well as the B with the A examination over a pit in a similar inspection situation in visibility. So, I would expect it to be found at one of those examinations.”
“ The idea that either Mr. Lumb or Mr. Tham would have done MPI testing, without the initial rectification work, is fanciful. Given the opportunity to do the work, with the wheels jacked up, balance weights removed and paint stripped off, and faced with obvious stress raisers or initiators in the form of burrs and lack of chamfering, it is quite clear that GNER would have done exactly what in fact they did at the time.”
“Q. But you accept that it was an entirely reasonable thing for them to have done what they did at the time ? A. I accept it was reasonable for them, but I accept that I myself would not have done that. Q. Forgive me, Mr. Etwell. It may be that we are at cross purposes. I want to make it clear. It may be that you would have done things in a different way and you have made that clear but you are here giving evidence … in support of a case that if GNER had acted in a particular way, that would have been unreasonable for them to have done so. So… the issue is not how you would have done it but if you are prepared to say the way in which GNER say they would have approached this matter would have been beyond the bounds of acceptable professional conduct, would have been unreasonable. …Are you saying – can we cut through this – that if in fact GNER had decided to deburr and chamfer at the same time as MPI testing on scenario C, are you saying that it would have been an unreasonable thing for them to have done? A. I would have considered it not unreasonable but a risk. Because, I repeat, at that point in time there is a high likelihood that there would be a second stage necessary because to do the rectification immediately, you are in a risk where experts will come back and redefine their standards. Q. Yes. Not unreasonable but a risk of having to improve the quality of the work that you are doing at short notice when you have the wheelsets there being MPI tested, is that how you would put it ? A. It is not unreasonable to do an immediate ream and chamfer to recondition the holes to acceptable state. It is not unreasonable. Q. No, that is very fair and it must be right, must it not? If you see a burr, as you have the wheelset jacked up and you strip the paint off, and you know that a burr is a stress raiser or a stress initiator, to say to GNER it is unreasonable to remove that burr would be very hard to say, would it not ? A. I repeat, it is not unreasonable but it is also a risk and I would be aware of a risk of experts coming back in time to say we have rethought and we think there is additional work that you need to undertake. Q. Yes, but you would not criticise them for doing it? A. No, I would not. ”
“ I would comment (in case it is not clear from my first report) that I would not myself have found it necessary for GNER to carry out deburring and chamfering while doing the initial MPI examination after the derailment.”