The report found that Civil Engineering and Inspection Departments had permitted too low a standard of maintenance on the line and had failed to assess the implications of increasing the speed of the trains.
報告書により、Civil Engineering and Inspection Departmentsが同線に低すぎるメンテナンス基準で許可し、また列車速度の増加の影響を評価できていなかったことが判明した。