A catalogue of failings in the track inspection and maintenance regime of Network Rail's Lancashire and Cumbria area led to the Pendolino crash at Grayrigg in February this year, says an industry report into the derailment.

Faulty facing points at Lambrigg on the West Coast main line were the immediate cause of the crash in which one person died and 22 other people were injured. The Virgin West Coast train driver was among those seriously injured.

Yet the points, known as 2b facing points, had already been found to have vital bolts or nuts missing on 7 January by a patrol. These were replaced.

The points had further inspections in January and should have been visually inspected on 18 February, just five days before the crash.

But a patroller stopped short of the site of the points at Lambrigg for an unknown reason and they were never checked.

After the crash, investigators found that the left hand switch rail had become disconnected from the right hand switch rail and was moving freely.

Two wheelsets of the train, travelling at 94 mph, rode over the switch rail and derailed the train. Later one of the three stretcher bars which should keep the switch rails the correct distance apart was found some 50 metres north of the points. Another bar was broken.

Network Rail immediately accepted the blame for the derailment, which happened at 20.12 hours as the train was heading north from London Euston to Glasgow Central on 23 February.

The train careered down an embankment and sparked a huge rescue and train recovery operation.

Speaking at a press briefing when the Network Rail report was published on 4 September, Iain Coucher, chief executive of Network Rail renewed the apology of the company:

He said: "We said at the start of the investigation into this derailment that we would leave no stone unturned to find out exactly why this happened.

"We are devastated that this happened on our watch. We said we would be open and transparent in our findings however uncomfortable that would be.

"The report makes for sombre reading. There are lessons to be learnt and we are determined to change things as quickly as we can."

Since the accident 14 recommendations have been acted upon by Network Rail to change the roles and responsibilities of the maintenance organisation and tighten up training and skill levels and to change the way in which repairs are carried out to points.

In addition 19 specific action plans have been launched to prevent such an accident happening again.

Immediately following the derailment 1,437 sets on points - all high speed, fixed stretcher bar systems - were checked and nothing untoward was found.

A further check of 120 sets of fixed stretcher bar points with similar characteristics to those at Lambrigg was made and apart from a few minor adjustments no similar conditions were found.

However, all of those 120 points are having their stretcher bars replaced with new ones, using a new nut and bolt assembly.

Specialist 'points squads' are being created within Network Rail's maintenance function.

A maintenance leadership conference has been held involving hundreds of managers and supervisors has been held.

Routine 13 week checks on all 14,000 points have been completed.

The Lambrigg points have now been removed and will not be replaced.

British Transport Police, the Rail Accident Investigation Branch and the Health and Safety Executive, now part of the Office of Rail Regulation, are continuing their investigations.

In a section entitled 'underlying causes' the report says:

"Deficiencies in the asset inspection and maintenance regime employed on Lancs and Cumbria maintenance area resulted in the deterioration of 2B points not being identified. These deficiencies included:

A breakdown in the local management/supervisory structure that leads, monitors and regulates asset inspection and maintenance activities.

A systematic failure in the track patrolling regime employed on the local area.

The issue and subsequent briefing of mandated standards not being carried out in a robust and auditable manner.

A lack of sample verification to test the quality and arrangements for inspection undertaken.

Later the report, written after reviewing 7,000 documents and interviewing 30 people, and a technical analysis of the damaged points, says that there was discord between the local management team and the area line management particularly around issues such as track access and training.

This created a disrespectful environment and reinforced the 'them and us' mentality.

Patrols of the track had been carried out by people whose certification had lapsed and although the situation was reported to local management, it was not corrected.

This has led to a lowering of the importance associated with patrolling activity.

"This local environment created a culture of learned helplessness which affected decisions and actions, resulting in a management style where breaches were left unchecked and observance was unrewarded."

The report added: "Patrolling without lookouts formed part of the behavioural culture. The unauthorised splitting of the patrolling by using the lookout to patrol part of the section of line was a routine violation and required the minimum time to achieve the task."

Later the report said no effective surveillance of patrollers was in place and no verification of paperwork was being undertaken. "The fact that the missed basic patrol mileage at Lambrigg on 18 February was not picked up by the local team is a further illustration of this fact."