A catalogue of Network Rail (NR) safety management shortcomings were exposed today in a final report into last year's Cumbria rail crash.
A planned inspection that "should have detected" the faulty set of points which caused the February 2007 derailment at Grayrigg was not carried out, the report from the Rail Accident Investigation Branch (RAIB) said.
After the crash in which 84-year-old passenger, Margaret Masson, died and nearly 90 people were injured, the track section manager said he had forgotten that he had agreed to include the area of the faulty points in his inspection.
Also, records were incorrectly updated to record that the part of the inspection which would have included the faulty points - at Lambrigg near Grayrigg - had been completed.
The report said the crash, on a Virgin London to Glasgow high-speed Pendolino train had occurred after the train, travelling at 95mph, had gone over a set of points in an unsafe state after a combination of failures of the points' three stretcher bars, the lock stretcher bar and their fastenings.
The RAIB said NR:
* Did not fully understood the design, maintenance and inspection of the type of points in use at Lambrigg;
* Reckoned the risk associated with these points was low;
* Carried out little or no investigation of loose or missing fasteners on points;
* Had maintenance instructions that did not specify how the stretcher bar fasteners on points found in need of tightening should be tightened;
* Did not have any comprehensive data about the condition of stretcher bars, brackets and fasteners across its network at the time of the accidents;
* Did not apply as a priority a recommendation made after the 2002 Potters Bar accident;
* Had staff who sometimes often worked 55-60 hour weeks.
The report also said: "There were a number of shortcomings in NR's safety management arrangements which were underlying factors in this accident."
Eight of the Pendolino's carriages fell down an embankment after the derailment, with five turning on to their sides. The train's driver, Iain Black, was one of those seriously injured, but has since returned to work.
The report said the train held up to the accident well but the RAIB added that safety could be improved by improving the design of seat mountings and lighting panels above seats.
In a 255-page report, the RAIB made 29 safety recommendations, of which 21 were directed at NR. The primary long-term recommendations related to a review of the design, inspection and maintenance of points, and particularly non-adjustable stretcher bar systems as used at Lambrigg.
Further recommendations were targeted at NR to address the underlying technical and managerial issues, and an issue of staff fatigue.
In a House of Commons written statement, Transport Secretary Geoff Hoon said: "I will consider the detail of the report carefully and take a decision on the most appropriate way forward, both with regard to the accident at Grayrigg and the derailment at Potters Bar, the inquest for which was adjourned in February 2007 pending the outcome of the investigations into Grayrigg.
"I will also write to the affected parties shortly to seek their views and anticipate announcing my decision to the House early in the new year."
NR chief executive Iain Coucher said today: "The tragedy at Grayrigg was caused by the failure of our infrastructure, something we were devastated to discover.
"We immediately accepted responsibility for the accident and once again apologise today to Mrs Masson's family and all those affected.
"Following a comprehensive and detailed industry investigation we made immediate changes to our maintenance regime. Over a year ago the rail industry published its own detailed report and we made further improvements.
"NR has worked with the RAIB to provide evidence for today's report and our task now is to review the RAIB's findings, together with the Office of Rail Regulation, to see if there is more that can be done.
"Travel by rail is the safest form of travel and despite Grayrigg, the railways are safer than ever before. It is important that the rail industry seeks ways to make it safer still and this report should help that process."
Shadow transport secretary Theresa Villiers said the report would make "uncomfortable reading" for NR, while Anthony Smith, chief executive of customer watchdog body Passenger Focus said he would ensure that the "right questions" were asked at any subsequent inquests or inquiries.
Earlier this month British Transport Police said that two rail workers questioned over the Grayrigg derailment would not face charges, A third worker has had his bail extended until November 3.
Today, Bob Crow, general secretary of the RMT transport union, renewed his call for an apology from the police and also called for a public inquiry into both the Grayrigg and Potters Bar accidents.
He said the report had "pointed clearly at management failures".