Network Rail Incident Investigation

Project Overview

West Coast Main Line: Critical Asset Failure Investigation & ORR Remediation Report

Employer: AtkinsRéalis / Network Rail
Sector: Rail, Telecommunications, Asset Management, Compliance
Location: West Coast Main Line, UK
Role: Senior Telecoms Engineer / Asset Lead Investigator
Period: May 2023 – August 2023

Executive Summary

In response to three significant and unrelated telecommunications failures on the West Coast Main Line (WCML), I was appointed by AtkinsRéalis to lead a structured root cause investigation on behalf of Network Rail. The investigation aimed to uncover not only the technical causes of the failures, but also to evaluate procedural, organisational, and environmental factors. Using a People, Process, and Technology (PPT) framework, I conducted a wide-ranging analysis—interviewing all departments with direct or indirect involvement in telecoms and signalling. My final report provided a robust evidence base and a set of actionable recommendations accepted by the Office of Rail and Road (ORR).

Objectives / Challenge

Identify the root causes of three major telecoms failures affecting WCML operations and passenger safety.

Evaluate all contributing technical, procedural, and environmental factors—beyond asset-level fault tracing.

Deliver an investigation report that meets ORR regulatory expectations and provides clear remedial pathways.

Recommend changes to improve resilience, reduce recurrence risk, and strengthen cross-functional governance.

Approach / Solution

People, Process, and Technology (PPT) Framework:

  • People: Conducted interviews with stakeholders across signalling, telecoms, maintenance, asset management, operations, and third-party contractors. Captured undocumented practices, procedural assumptions, and knowledge gaps.
  • Process: Reviewed maintenance records, escalation workflows, and change control documentation. Assessed procedural weaknesses including inconsistent configuration management and fragmented fault triage protocols.
  • Technology: Investigated SDH/PDH nodes, fibre links, remote comms shelters, and backup power systems. Cross-referenced firmware states, configuration histories, and legacy routing anomalies.

Contextual Risk Factors Considered:

  • Analysed each failure within its operational context:
    • Weather exposure (e.g. thermal stress, ingress risks)
    • Industrial action, which delayed or reduced response capabilities
    • Time-of-day dependencies, affecting fault detection latency and operational risk

Root Cause Analysis:

  • Applied FMEA and fault-tree analysis to map propagation chains and assess failure likelihood, consequence, and detection controls.
  • Correlated SCADA logs, NMS alerts, site inspection findings, and asset schematics to build a unified timeline for each incident.

Remediation Reporting:

  • Compiled a structured, audit-grade report for submission to Network Rail and the ORR. Included event summaries, RCA evidence, annotated diagrams, and remedial actions categorised by priority and impact.
  • Recommendations spanned from immediate field fixes to long-term improvements in process ownership and asset assurance.

Outcomes / Results

Root Cause Clarity:

  • Traced each event to a unique root cause:
    • Legacy hardware with an increasing intollerance to temperature changes
    • Severe weather causing microbends in fibre optic cabling
    • Siloed departments preventing effective use of resources

ORR Compliance Achieved:

  • Investigation and remediation report accepted by Network Rail and forwarded to ORR. No follow-up clarification required—closing the regulatory action item.

Process & Governance Enhancements:

  • Recommended the establishment of a cross-functional configuration control board and improved post-incident RCA workflows with multi-department participation.

Resilience Uplift:

  • Actions initiated to address identified gaps in telecoms power resilience, fibre routing assurance, and firmware governance.

Recognition:

  • Praised internally by AtkinsRéalis and Network Rail for the clarity, rigour, and stakeholder coordination shown under regulatory pressure.

Key Technologies & Methodologies

  • SDH/PDH network systems and legacy transmission infrastructure
  • People–Process–Technology (PPT) analysis framework
  • Root Cause Analysis (RCA), FMEA, fault-tree techniques
  • Alarm log correlation via SCADA/NMS systems
  • Fibre optic attenuation diagnosis and backup power system evaluation
  • ORR regulatory remediation reporting (Network Rail compliance format)
  • Stakeholder engagement: NR Operations, Maintenance, Design, ORR

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