Badly maintained points caused the death of a woman in the Grayrigg train crash, an inquest jury has ruled.
Margaret Masson, 84, died after a Virgin Pendolino London to Glasgow express train derailed on the West Coast Main Line near the remote village of Grayrigg in Cumbria at 8.12pm on February 23 2007.
All eight carriages of the Class 390 tilting train were derailed and 86 passengers and two crew from the 105 people aboard were injured as the train came off the rails at 95mph, scattering carriages down an earth embankment.
Mrs Masson, known as Peggy, from Glasgow, was travelling on the train with her daughter Margaret Langley, who sat with other members of her family to hear Ian Smith, HM Coroner for South and East Cumbria, sum up the evidence from more than 30 witnesses during the two week hearing
The 11 jurors at the inquest at the county offices in Kendal, Cumbria had heard how a subsequent Rail Accident Investigation Branch (RAIB) inquiry ruled the "immediate cause" of the crash was that the train had gone over a "degraded and unsafe" set of points, known as Lambrigg 2B.
One of three stretcher bars, which keep moving rails a set distance apart, was missing while the other two were fractured and bolts were missing. But the coroner warned the jurors that their job was to find out the facts and not to apportion blame, and told them they could not use any words in a verdict that implied criticism.
Earlier in the hearing, David Lewis, a track section manager for Network Rail, held back tears as he told the inquest that just five days before the crash, already overworked with his supervisor responsibilities, he had also agreed to do a routine check of the points. He forgot to carry out the check.
The jury was also told of "underlying factors", also cited in the RAIB report, detailing a catalogue of safety management shortcomings involving Network Rail, which owned and maintained the rail network.
The inquest heard that workers were often not given enough time or the right tools to properly check and maintain the rail lines and there were "bully boy" tactics from management who told them to just get on with the job. Faster Pendolino tilting trains meant access to inspect the line was cut by 60% and workers were hurried along to complete patrols of the line looking for defects.
Mr Lewis sent an email to his bosses, one year before the crash, telling them to "stop ducking the issue and sort this shambles out once and for all." The coroner told the jury it was a "tragic irony" the man who tried to flag up concerns was the person who also missed the inspection.