Ladbroke Grove rail crash

Ladbroke Grove rail crash

Cullen report cover
Date	5 October 1999
Time	08:08
Location	Ladbroke Grove
Country	United Kingdom
Rail line	Great Western Main Line
Operator	Thames Trains & First Great Western
Cause	Signal passed at danger
Statistics
Trains	2
Deaths	31
Injuries	523
List of UK rail accidents by year

The Ladbroke Grove rail crash (also known as the Paddington train crash) was a rail accident which occurred on 5 October 1999 at Ladbroke Grove in London, United Kingdom. With 31 people killed and more than 520 injured, this remains the worst rail accident on the Great Western Main Line. This was the second major accident on the Great Western Main Line in just over two years, the first being the Southall rail crash of September 1997, a few miles west of this accident. Both crashes would have been prevented by an operational Automatic Train Protection (ATP) system, wider fitting of which had been rejected on cost grounds. This severely damaged public confidence in the management and regulation of safety of Britain's privatised railway system.

A public inquiry into the crash by Lord Cullen was held in 2000. Since both the Paddington and Southall crashes had reopened public debate on ATP, a separate joint inquiry considering the issue in the light of both crashes was also held in 2000; it confirmed the rejection of ATP and the mandatory adoption of a cheaper and less effective system, but noted a mismatch between public opinion and cost-benefit analysis. The Cullen inquiry was carried out in two blocks of sittings, sandwiching the 'joint inquiry'; the first block dealt with the accident itself, the second block dealt with the management and regulation of UK railway safety; this had always been part of the inquiry terms of reference, but was given additional urgency by a further train crash at Hatfield in October 2000.^[1] Major changes in the formal responsibilities for management and regulation of safety of UK rail transport ensued.

Incident

At about 08:06 BST on 5 October 1999, a Thames Trains service to Bedwyn railway station in Wiltshire left Paddington Station. From Paddington to Ladbroke Grove Junction (about 2 miles (3.2 km) to the west), the lines were bi-directional (signalled to allow trains to travel in either direction, in and out of the platforms of Paddington Station); beyond Ladbroke Grove the main line from London to South Wales and the West of England switched to the more conventional layout of two lines in each direction ('Up' for travel to London, 'Down' for travel away from London) carrying fast and slow trains. As an out-bound train, the train (a three-car turbo class 165 'Turbo' diesel unit) would have been routed onto the Down Main line at Ladbroke Grove. It should have been held at a red signal at Ladbroke Grove until this could be done safely. Instead, it ran past the signal; the points settings beyond this brought it, in under 600 metres, onto the Up Main Line; at about 8:09 as it was entering this it collided nearly head-on and at a combined speed of about 130 miles per hour (210 km/h) with the 06:03 First Great Western train from Cheltenham to Paddington.^[2]

The latter train was a High Speed Train, driven by 52-year-old Brian Cooper, who was killed in the accident. It comprised eight Mark 3 coaches with a Class 43 diesel power car at each end. It was of much more substantial construction than the Turbo train, the leading car of which was totally destroyed. The diesel fuel carried by this train was dispersed by the collision and ignited in a fireball, causing a series of separate fires in the wreckage, particularly in coach H at the front of the HST, which was completely burnt out. The drivers of both trains involved were killed, as well as 29 others (24 on the Turbo train, nine on the HST as a result of the impact, with a further fatality as a result of the fire), and 227 people were admitted to hospital. A further 296 people were treated at the site of the crash for minor injuries.^[3]

In early British Rail InterCity livery, Class 43 No.43079 (254012), similar to the one in the accident, leaves York railway station .

No.165119 at Didcot Parkway. This unit is painted in the original Network SouthEast livery like the one in the accident.

Immediate cause

The immediate cause of the disaster was identified as the Turbo train passing signal SN109 (located on an overhead gantry – gantry 8 – with four other signals serving other tracks) at which it should have been held. It was established that the signal had been showing a red aspect, and the preceding signal (SN 87) had been showing a single yellow which should have led the driver to be prepared for a red at SN109. Since the Thames Turbo driver, 31-year-old Michael Hodder, had been killed in the accident, it was not possible to establish why he had passed the signal at danger. However, Hodder was inexperienced, having qualified as a driver only two weeks before the crash.^[4] His driver training was found to be defective,^[5] whilst the signalling in the Paddington area was known to have caused problems – SN 109 had been passed at danger on eight occasions in six years,^[6] but Hodder had no specific warning of this.^[7] Furthermore, 5 October 1999 was a day of bright sunshine and at just past 8 o'clock the sun would have been low and behind Hodder, with low sunlight reflecting off yellow aspects.^[8][9] Poor signal placement meant that Hodder would have seen sunlit yellow aspects of SN109 at a point where his view of the red aspect of SN109 (but not of any other signal on the gantry) was still obstructed.^[10] The inquiry considered it more probable than not that the poor sighting of SN109, both in itself and in comparison with the other signals on and at gantry 8, allied to the effect of bright sunlight at a low angle, were factors which had led Hodder to believe that he had a proceed aspect.^[11] Since 1998 a campaign to have the signal SN109 properly sited had been running and the Bristol HST drivers were re-routed as not to pass this signal.

Contributory factors

The inquiry noted that the lines into Paddington were known to be prone to 'signal passed at danger' (SPAD) events - in particular there had been eight SPADs at signal SN109 in the preceding six years - and attempted to identify the underlying causes.

Problems with signal visibility

Paddington approaches had been resignalled by British Rail in the early 1990s^[12] to allow bidirectional working. The number of signals and limited trackside space meant that most signals were in gantries over the tracks;^[13] the curvature of the lines meant that it was not always obvious which signal was for which track.^[14] Reflective line identification signs had therefore been added but, the inquiry report noted,^[15] they were closer to the signal to the right hand side than to the signal for the line to which they related. However, misreading of which signal related to which track cannot have caused the fatal crash, because at the time all the other gantry 8 signals were also showing red.^[16] The spacing between signals and points was designed to allow fast through running by freight trains^[17] and meant that gantry 8 was less than 100 m to the west of a road bridge;^[18] this compromised the distance from which the signal could be seen by drivers of trains leaving Paddington. To allow the higher ('proceed') aspects to be seen sooner, the standard signals (with the four aspects arranged vertically) were replaced with non-standard 'reverse L' signals, with the red aspect to the left of the lower yellow.^[19] The Paddington resignalling scheme had been implemented ahead of formal HMRI approval; this had still not been received at the time of the crash.^[20]

The line had subsequently been electrified to allow the new Heathrow Express service to operate from 1994, and the new overhead electrification equipment further obstructed drivers' view of signals:^[21]

..from the outset there was not an adequate overall consideration of the difficulties which would face drivers, in particular in signal sighting, on which the safety of travellers critically depended. Secondly, when difficulties did emerge, there was not an adequate reconsideration of the scheme. There was a resistance to questioning what had already been done. Cost, delay and interference with the performance objectives underlay that resistance.

The red aspect of SN 109 was particularly badly obscured by the overhead electrification equipment; it was last of all the gantry 8 signal aspects to become clearly visible to the driver of a Class 165 approaching from Paddington.^[22]

Problems with signal visibility management

All new or altered signals^[23] or which had had multiple SPADs^[24] should have been reviewed for sighting issues by a 'signal sighting committee', but none had been held for signals around Paddington since Railtrack assumed responsibility for this in April 1994. An internal audit in March 1999 had reported this, but a follow-up audit in September 1999 found no evidence of any remedial action being taken.^[25]

The failure to have signal sighting committees convened was persistent and serious. It was due ...to a combination of incompetent management^[26] and inadequate process, the latter consisting in the absence of a process at a higher level for identifying whether those who were responsible for convening such committees were or were not doing so.^[27]

There had been over the years a number of proposals or recommendations for the risk assessment of the signalling in the Paddington area: none of them was carried into effect.^[28] Multiple SPADs at SN 109 in August 1998 should have triggered a risk assessment; none took place. An inquiry into a Feb 1998 SPAD at SN 109 had already recommended risk assessment of signalling on the Paddington - Ladbroke Grove bi-directional lines; this and many other inquiry recommendations had not been implemented:^[29] the Railtrack employee with formal responsibility for action-tracking had been told his responsibility ended once someone accepted an action, and did not extend to checking that they had acted upon it.^[30]

'Disjointed and ineffective' SPAD reduction initiatives

Between February 1998 and the accident there had been four separate groups set up with the aim of reducing SPADs; their existence, membership and functions overlapped.^[31] A Railtrack manager told the inquiry how he struggled on his arrival in October 1998 to understand how "so many apparently good people could produce so little action": people had burdens that were too complex; they were not prioritising; people were "square pegs in round holes"; some were not competent; and, in summary, "the culture of the place had gone seriously adrift over many years".^[31] The chief executive of Railtrack spoke of a seemingly endemic culture of complacency and inaction, which he said reflected the culture of the old British Rail "The culture is one in which decisions are delegated upwards. There has been little empowerment. People have tended to manage reactively, not proactively. The basic management discipline of ‘plan-do-review’ is absent the further down the organisation one goes".^[32]

Problems with driver training

Thames Trains had inherited a driver training package^[33] from British Rail, but this had evolved to the point where in February 1999, a concerned incoming training manager commissioned an external audit which reported^[34]

“The trainers did not appear to be following the training course syllabus and supporting notes as they considered these to be ‘not fit for purpose’ with inappropriate time allowances for some sessions. The traction and introduction to driving section of the course has been extended and the six week route learning session is being used as additional practical handling”.

Indeed, Michael Hodder's 16 weeks practical training had been given by a trainer who felt that “I was not there to teach ... the routes. I was totally to teach ... how to drive a Turbo; the training manager was unaware of this.^[35] Details of signals which had been repeatedly passed at danger should have been supplied to trainers and passed on to trainees; no trainer had done so,^[36] and the practical trainer quoted above was unaware that SN 109 was a multi-SPAD signal.^[35]

Testing of trainees was similarly unstructured and unstandardised, with no clear pass/fail criteria.^[37]

Under the previous British Railways training regime, trainees would have spent far longer in training and once qualified, were not allowed to drive over the notoriously difficult approach to Paddington until they had at least two years' experience on less complex routes.^[38] Hodder had only qualified 13 days earlier; he was ex-navy with no previous experience as a railway worker, but no special attention was paid to this in either training or testing.^[39]

It must be concluded therefore that [the driver’s] training was not adequate for the task for which he was being prepared. The very favourable comments made as to his progress by his various teachers have to be viewed against the background that his teachers were working with a less than perfect training programme.^[40]

Other issues

Train protection

The Thames train had been fitted with AWS (Automatic Warning System) which required the driver to acknowledge a warning every time he approached a signal not at green. If an Automatic Train Protection (ATP) system had been fitted and working it would have automatically applied brakes to prevent the train going beyond any signal at red. National adoption of ATP, British Rail's preferred train protection system, had been recommended after the Clapham Junction rail crash, but later abandoned because the safety benefits were considered not great enough to justify the cost.^[41] After a previous SPAD, Thames Trains had commissioned a cost–benefit analysis (CBA) study specific to the Paddington situation which came to the same conclusion.^[42] The Ladbroke Grove accident was felt to cast doubt on the wisdom of these decisions. However, the Cullen inquiry confirmed that CBA would not support the adoption of ATP by Thames Trains.^[43]

Flank protection

The design of the points on the approaches to Paddington did not provide ‘flank protection’ (where the points beyond a signal at red are set so that a train passing the signal at red is routed so as to minimise the possible consequences). This would have meant routing a train running past SN109 at red onto the Down Relief line.^[44] This should have been considered at the design stage when it would have been easy to implement. The reasons for not doing so were not known but it was noted that the introduction of Automatic Train Protection (ATP) had been thought to be imminent.^[45] Flank protection would have increased the ‘overlap’ (the distance for which a train could run past the signal before fouling other lines) at SN109; the desirability of doing so should have been considered by the risk assessment which had not taken place.

Response of signalmen

The written instructions for Railtrack signalling centre staff at Slough were that as soon as they realised that a train had passed a signal at danger they should set signals to danger and immediately send a radio "emergency all stop" signal to the driver of the train by Cab Secure Radio (CSR) as soon as they realised that it had done so.^[46] In the event, only when the Thames train was 200m past the signal did they start to send a radio "emergency all stop" signal (it is not clear^[47] whether the signal was actually sent before the crash). Their understanding of the instructions was that they should wait to see if the driver stopped of his own accord before attempting to contact him; this interpretation was supported by their immediate manager.^[48] The signalmen had never been trained in the use of CSR, nor had they ever used it in response to a SPAD.^[49]

The general picture which emerged was of a slack and complacent regime, which was not alive to the potentially dire consequences of a SPAD or of the way in which signallers could take action to deal with such situations.^[50]

Regulatory shortcomings

The Health and Safety Executive's HM Railway Inspectorate was also criticised for its inspection procedures. The then head of HSE told the Inquiry^[51] the HSE were concerned about, first, the length of time taken for the approval of the signalling scheme; secondly, the slow progress by Railtrack and the HMRI in bringing issues to a conclusion; and, thirdly, the inadequate risk analysis. Matters had not been followed up with more urgency. More could have been done to enforce health and safety legislation. She attributed these deficiencies to three causes:

• a lack of resources on the part of the HMRI;
• a lack of vigour by the HMRI in pursuing issues; and
• the placing of too much trust in the duty holders^[52]

Wider ramifications

National policy on train protection systems

A fortnight before the accident the HSE had announced an intention to require the adoption of TPWS (an upgrade of AWS, which could stop trains travelling at less than 70 mph within the overlap distance of a red signal- delivering, according to HSE, about 2/3 the safety benefits of ATP at much lower cost) by 2004 (advanced, a week after the accident, to 2003^[53]).

The separate ‘joint inquiry’ on the problem nationally noted that both ATP and AWS (and therefore TPWS) had continuing reliability problems and were obsolescent technology inconsistent with the impending standardisation EU-wide on the ETCS European Train Control System. In the year between Ladbroke Grove and the joint inquiry the rail industry (if not the general public) had become largely committed to the adoption of TPWS. Consequently, although the joint inquiry expressed considerable reservations about the effectiveness of TPWS it concurred with its adoption.^[54]

The joint inquiry noted that public reaction to catastrophic rail accidents .. should be and is taken into account in the making of decisions about rail safety but did not align with the output of CBA. Any future ATP^[55] system will entail expenditure at levels many times higher than that indicated by any approach based upon CBA. Despite its cost, there appears to be a general consensus in favour of ATP. Both TPWS and ETCS would be mandatory and therefore their cost implications need not be considered by any body other than the UK government and the EU Commission.

Management and regulation of rail safety

The Inquiry noted evidence that railway safety statistics had not worsened after privatisation, nor had there been any evidence that however privatisation had been carried out it would have been detrimental to safety.^[56] Concerns were however expressed about how privatisation had been carried out

• The fragmentation of the industry had created numerous, complex interfaces exacerbated by defensive or insular attitudes (expected to worsen in the future as managers who had got broader experience in BR passed out of the system). It also gave problems with the management, development and implementation of large scale projects; and meant that little real research and development was being carried out.^[57]
• The quality of safety leadership and communications varied between the various successor organisations.
• A stress on performance targets had diluted the perceived importance of safety. Cullen contrasted multimillion-pound penalties for poor punctuality with much lower fines for serious safety breaches.^[58]
• Train Operating Company (TOC) franchises had been awarded for too short a period, and with inadequate consideration of safety aspects.^[59]
• Railtrack relied extensively on contractors to carry out safety critical work; there were too many contracting organisations, contracts were for too short a period, and were inadequately supervised by Railtrack

Beyond the obvious exhortations to do better, the Inquiry endorsed in its recommendations a number of changes in the industry structure. Railtrack had not merely had responsibility for railways infrastructure, but also a lead responsibility for safety; both for acceptance of TOC safety cases and for setting "Railway Group Standards" (system-wide standards on matters affecting safety). Since it also had commercial interests in these issues the rest of the industry was unhappy with this:^[60] Cullen recommended that safety case acceptance should be directly by HSE in future, and a new body should be set up to manage Railway Group Standards.^[61]

In 1996 ScotRail had initiated the creation of a rail safety group (later to become CIRAS) by a team from Strathclyde University. Other rail lines expressed interest in the project and several rail lines in Scotland voluntarily joined the system. Following the Ladbroke Grove rail crash, John Prescott mandated that all mainline rail in the UK come under the Confidential Incident Reporting & Analysis System (CIRAS) to involve every rail employee in the rail safety process.^[62] CIRAS now provides services to all rail workers and operating sectors throughout England, Scotland and Wales.^[63][64]

The Railways Inspectorate had a responsibility for advising on and inspecting against matters affecting railway safety; they were also the usual investigating body for serious railway accidents. Cullen felt that there was ‘a strong argument for an investigating body which enjoys real and perceived independence’ and therefore recommended that rail accident investigation should become the responsibility of a separate body.^[65]

Aftermath

The recommendations of the Cullen inquiry led to the creation in 2003 of the Rail Safety and Standards Board and in 2005 of the Rail Accident Investigation Branch in addition to the Railway Inspectorate. Standards-setting, accident investigation and regulation functions were henceforth clearly separated, on the model of the aviation industry.

On 5 April 2004, Thames Trains was fined a record £2 million after admitting violations of health and safety law in connection with the accident. It was also ordered to pay £75,000 in costs.^[66]

On 31 October 2006, Network Rail (the successor body to Railtrack, formed in the wake of a subsequent train crash at Hatfield) pleaded guilty to charges under the Health and Safety at Work Act 1974 in relation to the accident. It was fined £4 million on 30 March 2007, and was also ordered to pay £225,000 in costs.^[67]

Signal SN109 was brought back into service in February 2006.^[68] It and many other signals in the Paddington area are now single-lens type signals.

A memorial garden has been set up, partially overlooking the crash site and accessible from the adjacent Sainsbury's supermarket car park.

Power car 43011 sustained heavy damage in the crash and was subsequently written off, being officially withdrawn in November. After the completion of the inquiry of the incident it was cut up by Sims Metals in Crewe, Cheshire in June 2002. Apart from one of the prototypes, it is one of the only three class 43 (HST) locomotives (power cars) to be scrapped.^[69] The Turbo train was also written off in the accident. While the front two carriages were scrapped; the rear carriage was undamaged and is now a spare carriage.

Pam Warren wrote the book From Behind the Mask which narrates her experiences during the crash, her recovery, and how it has affected her life and relationships.^[70]

Dramatisation

On 20 September 2005, Derailed, a 90-minute documentary-drama programme based on the Ladbroke Grove crash, was aired on BBC1. This dramatisation was heavily criticised in the railway press, with the editor of Rail magazine, Nigel Harris, describing it as a "trashy piece of subjective story-telling" (issue 523). The programme stated that the chronology of actual events had been changed, and some scenes fabricated, to "add clarity".

On 19 September 2011, National Geographic Channel aired an episode of Seconds From Disaster exploring the chain of events that had led up to the collision.

See also

• Southall rail crash - an earlier incident on the Great Western Main Line caused by a SPAD (Signal passed at danger), also involving a High Speed Train
• 2005 Glendale train crash - an incident in the United States which was also followed by a fire caused by spilt diesel

Further reading

• Hall, Stanley (2003). Beyond Hidden Dangers: Railway Safety into the 21st Century. Ian Allan. ISBN 0-7110-2915-6. 
• Vaughn, Adrian (2003). Tracks to Disaster (revised ed.). Ian Allan. ISBN 0-7110-2985-7. 

References

External links

• The Ladbroke Grove Rail Inquiry Part 1 by The Rt Hon Lord Cullen PC (3.2 MB pdf file) - The Ladbroke Grove Rail Inquiry Part 1
• The Ladbroke Grove Rail Inquiry Part 2 by The Rt Hon Lord Cullen PC (1.4 MB pdf file) - The Ladbroke Grove Rail Inquiry Part 2
• Paddington Survivors Group - Website of the Paddington Survivors Group, which campaigned for better rail safety and supports survivors.
• Locomotion No.1 to simulation: A brief history of train driver training on Britain’s railways a Rail Safety And Standards Board review (with comments - including on the transition from British Rail)
• Research Programme Management -Review of driver training programmes in Great Britain railways -Locomotion No.1 to simulation: A brief history of train driver training on Britain’s railways
• 1999: Death toll rising in Paddington crash BBC NEWS

Railway accidents in 1999 (1999)
Location and date	Bermondsey, United Kingdom (8 January) Bourbonnais, United States (15 March) Winsford, United Kingdom (23 June) Gaisal, India (1 August) Zanthus, Western Australia (18 August) Ladbroke Grove, United Kingdom (5 October) Glenbrook, Australia (2 December)
1998 2000

Coordinates: 51°31′26″N 0°12′43″W / 51.524°N 0.212°W / 51.524; -0.212