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Rail infrastructure failures

Event organised by ICE

19 October 2023

This event has now ended

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James Reason compared layers of poor management controls to Swiss Cheese slices with holes. The more holes in the cheese slices the more fallible the system of risk controls in a project.

Case histories from three accidents on rail infrastructure explore six key management controls that failed in each one and lessons that can be learned for future projects. Practical and economic benefits of this approach are also summarised.


Satyajit Maitra

Satyajit Maitra


Railway civil engineer

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Satyajit Maitra

Satyajit Maitra is a railway civil engineer (now retired) with over 40 years’ experience. He was sponsored by British Rail in 1975 on a 1-3-1 sandwich degree course, and then worked for them in a variety of engineering and management roles.

His final position was Works Engineer for structures inspection & maintenance, Midlands Area. After rail privatisation he worked for GTRM, then joined consultants Kennedy & Donkin in 1997 where as an Associate he led a small team on various rail projects, usually in Client support roles for Railtrack. In 2001 he joined HMRI (now ORR) as a specialist railway inspector.

At ORR he provided expert/specialist advice for accident investigations, monitored NR’s financial performance for CP5, CP6 control periods, and authorised infrastructure renewals for compliance with EU Interoperability Regulations