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I agree with you about the common sense vs the RULE BOOK. At one time, the railway was a lifetime employment where everybody grew into their job and trained their juniors over a period of years. Nowadays, employment is only until next week and nobody feels any loyalty to their employer (and this is certainly reciprocated).
Unfortunately, accidents do happen, that is why they are accidents - an unforseen circumstance. If public enquiries were called every time, there would be more lawyers on enquiries than people working on the railways. (and all paid from public funds, snouts in troughs?)
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