The tragedy at Cairo’s Ramses railway station in which at least 20 people were killed and some 40 injured, is all the greater because it already seems clear that it was entirely avoidable.

The official investigation ought to discover the full facts. However, there are strong grounds to believe that the locomotive, which smashed into buffers at high speed, had been undergoing maintenance work outside the station.

It appears the engine involved was a US-designed EMD G22 series, built under license and used around the world until 1991. It has been a workhorse of Egyptian National Railways (ENR). It could have had two thousand gallons of diesel fuel aboard when it crashed into the busy station. Though diesel has a far lower flashpoint than petrol, the horrific blaze that followed suggests it may have been carrying a full fuel load. There are unconfirmed reports someone was in the cab yelling that the locomotive had no brakes. This individual jumped clear before the impact but it is not known what happened to him.

Prime Minister Mostafa Madbouli visiting the scene of the disaster vowed that anyone found to be negligent would be held accountable and punished severely. This seems only right. However, Madbouli was certainly wrong to describe what had happened as “an accident”. As with road wrecks, such crashes do not happen accidentally. They are always caused by failures to stick to established guidelines and regulations. The government must clearly look at the procedures, which were not followed that allowed this engine to run away out of control. This review is the more urgent because apparently there have been two other recent cases of unmanned engines rolling off by themselves, though in neither case were there any injuries.

Unfortunately, ENR has a wretched safety record. Two years ago, 43 passengers died and 100 were injured, many of them seriously, when two trains were in a head-on collision outside Alexandria. In 2013 dozens died when a train plowed into a minibus and other vehicles south of Cairo and in 2002 more than 370 passengers perished when fire tore through an overcrowded train near the capital.

Last September the Egyptian government signed a $1.3 billion deal with a Russian-Hungarian consortium for 1,300 new passenger coaches. This substantial investment in ENR may lead to further contracts to upgrade the country’s 4,900 kilometers of track and signaling. There are also plans to renew the aging fleet of locomotives. Such government commitment ought to bring to an end years of underinvestment in this key transport sector.

But unfortunately it is not going to be as simple as that. Lack of money has not helped but many of the failings that afflict ENR are down to bad management, poor decision-making and low morale among workers. Railwaymen around the world tend to be fiercely proud of their jobs, their networks and their locos. Sadly, in recent decades, there has been little to do with the Egyptian rail system in which its employees can take much pride, except perhaps keeping a decrepit system running.

The shake-up needed is not therefore only in new rolling stock, improved permanent way and signaling, nor simply in better management but it requires a psychological change among Egyptian railway men, who should have been deeply ashamed that a locomotive could ever have run away from them.