Recommendation Status Report: Train striking debris at Yarnton near Hanborough, Oxfordshire
This report is based on information provided to the RAIB by the relevant safety authority or public body.
The status of the recommendation(s), as reported to us, are described by the following categories:
                                                                 Key to Recommendation Status
Open                                 Actions to address the recommendation are ongoing.
 (replaces Progressing and
 Implementation On-going)
Closed                               ORR consider the recommendation to have been taken into consideration by an end implementer and
 (replaces Implemented, Implemented   evidence provided to show action taken or justification for no action taken.
 by alternative means, and Non-
 implementation)
Insufficient response:               The end implementer has not provided sufficient evidence that the recommendation has been taken into
                                      consideration, or if it has, the action proposed does not address the recommendation, or there is
                                      insufficient evidence to support no action being taken.
Superseded:                          The recommendation has been superseded either by a newer recommendation or actions have
                                      subsequently been taken by the end implementer that have superseded the recommendation.
Awaiting response:                   Awaiting initial report from the relevant safety authority or public body on the status of the
                                      recommendation.
RAIB concern over the way that an organisation has responded to a recommendation are indicated by one of the following:
Red – RAIB has concerns that no actions have been taken in response to a recommendation.
Blue – RAIB has concerns that the actions taken, or proposed, are inappropriate or insufficient to address the risk identified during the investigation.
White – RAIB notes substantive actions have been reported, but the RAIB still has concerns.
Recommendation Status Report
Report Title           Train striking debris at Yarnton near Hanborough, Oxfordshire
Report Number          01/2024
Date of Incident       10/02/2023
Rec No.            Status                RAIB Concern     Recommendation                                                                RAIB Summary of current status
01/2024/01         Open                  None             The intent of this recommendation is to ensure that effective standards       ORR has reported that Network
                                                          and processes are in place which will reduce the likelihood of ineffective    Rail has a proposed action plan
                                                          repair work being undertaken to masonry.                                      and timescale for delivery to be
                                                                                                                                        taken in response to the
                                                          Network Rail should review the relevant standards and procedures that         recommendation. ORR will advise
                                                          deal with the specifying of repairs to fractured masonry to ensure that       when the status of this
                                                          complex defects, such as bulging with fractures, are subject to appropriate   recommendation changes.
                                                          review and further investigation to ensure that suitable repairs are
                                                          undertaken. This review should specifically consider how the repair of
                                                          masonry which is already in a poor condition is undertaken. Network Rail
                                                          should develop a timebound programme to make any appropriate
                                                          changes identified to standards and processes (paragraphs 115a.i, 115a.ii
                                                          and 116).
01/2024/02         Open                  None             The intent of this recommendation is to improve the quality of                ORR has reported that Network
                                                          information available to staff responsible for making safety-critical         Rail has a proposed action plan
                                                          decisions on the stability of structural defects.                             and timescale for delivery to be
                                                                                                                                        taken in response to the
                                                          Network Rail should develop and implement improved methods for                recommendation. ORR will advise
                                                          managing defects in masonry structures, such as wing walls, to gain a         when the status of this
                                                          better understanding of the asset. This should include consideration of:      recommendation changes.
a) Introducing a standardised and repeatable method for accurately
                                                          measuring the shape of bulges in masonry walls that is suitable for use by
                                                          structures examiners, where the routine examination regime is
                                                          insufficient. This method should be available for use where bulges exist or
                                                          the need for monitoring has been identified through the examination
                                                          review process. This method should enable the likelihood of failure to be
                                                                                                                                                 Created on 07 April 2025
Recommendation Status Report
assessed with greater confidence and should define the actions to be
                           taken in specific circumstances, such as identifying the trigger for
                           additional monitoring.
b) Reviewing the guidance for structures examiners so that photographs
                           of masonry fractures included in examination reports are taken from a
                           location perpendicular to the surface and that bulges are photographed at
                           an oblique angle and from both sides where it is practical and safe to do
                           so. Network Rail should develop a timebound programme to make any
                           appropriate changes identified to standards, guidance and processes
                           (paragraphs 115b.i, 116).
01/2024/03   Open   None   The intent of this recommendation is to improve the risk scoring of            ORR has reported that Network
                           structures defects and the interpretation of their significance.               Rail has a proposed action plan
                                                                                                          and timescale for delivery to be
                           Network Rail should review the training and working practices associated       taken in response to the
                           with allocating risk scores and the examination report review process to       recommendation. ORR will advise
                           ensure that defects affecting parts of structures which could present a        when the status of this
                           direct risk to the railway in the event of collapse are given an appropriate   recommendation changes.
                           defect risk matrix severity factor in accordance with Network Rail standard
                           NR/L3/CIV/006, ‘Structures, Tunnels and Operational Property
                           Examinations’, Part 1B, ‘Undertake examinations’.
This review should specifically consider if, when defects from different
                           parts of a structure are aggregated into a single recommendation, the
                           recommendation’s risk score reflects the highest risk item.
Network Rail should develop a timebound plan to make any appropriate
                           changes identified to training, working practices and processes (paragraph
                           115b.ii).
01/2024/04   Open   None   The intent of this recommendation is to improve asset knowledge of wing        ORR has reported that Network
                           walls which are not fully encompassed by existing processes to enable          Rail has a proposed action plan
                           asset engineers to make better informed, consequence-based decisions.          and timescale for delivery to be
                                                                                                          taken in response to the
                                                                                                                     Created on 07 April 2025
Recommendation Status Report
Network Rail should review its bridge assets and establish if it has clearly   recommendation. ORR will advise
                        identified those wing walls which may fail with a potentially high safety      when the status of this
                        consequence. Network Rail should also consider the benefits of                 recommendation changes.
                        introducing a wing wall risk tool to assess load paths and consequences of
                        failure to improve its knowledge of these assets (paragraph 116).
Created on 07 April 2025

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