The Southall Rail Accident Inquiry Report Professor John Uff QC Freng
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iealth 6 Safety Commission The Southall Rail Accident Inquiry Report - Professor John Uff QC FREng 2 Erratum The Southali Rail Accident Inquiry Report iSBN 0 7176 1757 2 Annex 09 Passengers & Staff believed to have sustained injury as a result of the accident Include 'Stuttard, Janis, Mrs Coach H' Delete ' Stothart, Chloe Helen, Miss Coach C' MlSC 210 HSE BOOKS 0 Crown copyright 2000 Applications for reproduction should be made in writing to: Copyright Unit, Her Majesty's Stationery Office, St Clernents House, 2-16 Colegate, Nofwich NR3 1BQ First published 2000 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the copyright owner. LIST OF CONTENTS Inquiry into Southall Railway Accident Preface Glossary Report Summary PART ONE THE ACCIDENT Chapter l How the accident happened Chapter 2 The emergency response Chapter 3 The track and signals Chapter 4 Why was the freight train crossing? Chapter 5 Driver competence and training Chapter 6 Why were the safety systems not working? Chapter 7 Why the accident happened PART TWO EVENTS SINCE SOUTJULL Chapter 8 The Inquiry and delay to progress Chapter 9 Reactions to Southall Chapter 10 Ladbroke Grove and its aftermath PART THREE WIDER SAFETY ISSUES Chapter 11 Crashworthiness and means of escape Chapter 12 Automatic Warning System (AWS) Chapter 13 Automatic Train Protection (ATP) Chapter 14 Railway Safety Issues PART FOUR CONCLUSION Chapter 15 Discussion and Conclusions Chapter 16 Lessons to be learned Chapter 17 Recommendations ANNEXES THIS Report follows an Inquiry held between September and December 1999 into the cause of a major rail accident which occurred on 19 September 1997 at Southall, 9 miles west of Paddington. The trains involved were the Great Westem Trains (GWT) 10:32 Swansea to Paddington High Speed Train and a freight train operated by English Welsh and Scottish Railway (EWS), which was crossing the Up Main line to enter Southall Yard. Seven people died as a result of the accident and a further 139 people were injured, some severely. The Inquiry was set up within hours and directed to sit in public. The terms of reference are as follows : The purpose of the Inquiry is to determine why the accident happened, and in particular to ascertain the cause or causes, to identify any lessons which have relevance for those with responsibilities for securing railway safety and to make recommendations. The Inquiry proceedings began in December 1997 with a formal opening in February 1998. The driver was charged with manslaughter in April 1998, but no further progress could be made by the Inquiry pending decisions on criminal charges being considered against GWT. This was not resolved until December 1998 when manslaughter charges and charges under the Health and Safety at Work Act 1974 were brought against the driver and against the operating company. Criminal proceedings took their course and were not finally resolved until July 1999. The Inquiry proceedings then commenced at the earliest possible date. During the proceedings, a further tragic accident occurred at Ladbroke Grove which has led to the setting up of further Inquiries and to a review of the issues to be dealt with in the present Inquiry. The Southall collision was the first major accident to occur within the British rail network since privatisation of the railway industry, which formally started with the transfer of the railway infrastructure to Railtrack on 1 April 1994. The public sale of Railtrack and letting of operating franchises followed. GWT had been set up as a separate operating division before privatisation. The company acquired its franchise on I February 1996 and had therefore been operating independently for some 19 months only, when the accident occurred. It would be wrong to see the Inquiry and this Report as an inquiry into privatisation. Nevertheless, the new structure of the industry has inevitably affected the events under consideration. At the same time it will be seen that the new industry is still heavily influenced by procedures and structures inherited from British Rail. It should be emphasised that the objective of this Report is to set down the facts and to draw appropriate conclusions in accordance with the Terms of Reference set by the Health and Safety Commission. A large proportion of those who gave evidence at the Inquiry were railwaymen and women, all experts in their respective fields. Most of this Report deals with technical issues of varying complexity. While the Recommendations contained at the end of this Report are addressed to the railway industry, the Report itself is intended to be read by the travelling public who are entitled, through this Inquiry, to know how the railway operated and precisely what went wrong so as to cause such a tragic accident. The Inquiry heard witnesses and representations on behalf of a large number of parties including passenger groups and representatives, Trades Unions, rail operators, a rolling stock leasing company, an infrastructure maintenance company and Railtrack. Also represented were the emergency services including ambulance, fire and police services, and the Health and Safety Executive which includes HM Railway Inspectorate. A full list of parties and their representatives is at Annex 1. A full list of witnesses, including those whose statements were read to the Inquiry, is included at Annex 2. A list of terms and abbreviations follows this Preface. I extend my gratitude to the skilled and experienced Inquiry team with which I was privileged to work. In order of their appointment, David Brewer took on the role of Inquiry Secretariat before my own appointment and has organised the efficient running of every aspect of the Inquiry throughout, including masterminding an information database which has been appreciated by all the parties who have appeared at the Inquiry. Major Anthony King OBE, himself a highly experienced Inspector of Railways and Chairman of many Inquiries, was appointed Technical Assessor. His tactful guidance on railway issues throughout the Inquiry has been invaluable. Counsel to the Inquiry was Ian Burnett QC, who appeared with Richard Wilkinson. Their capacity for mastering the huge volumes of documents generated by the Inquiry proved to be as prodigious as the task and their contribution has been appreciated by all. Last to be appointed to the team was Laurance O'Dea, Treasury Solicitor, who took on the task of collating the written evidence and organising the attendance of 107 witnesses who were heard in person, many of whom appeared on several different occasions. His success is measured by the fact that the Inquiry managed to achieve all of its timetable objectives, despite the intervention of the Ladbroke Grove crash. A list of Inquiry personnel is at Annex 3. Finally, appreciation is due to David Brewer and to my secretary, Dorothy Dixson for producing the Report. Keating Chambers 10 Essex Street Outer Temple John Uff QC FREng London WC2R 3AA 3 1 January 2000 Glossary of Terms AbbreviationITerm Definition ACEC Suppliers of ATP equipment AEA Technology Technical Consultants ALARP As Low As Reasonably Practicable Amey Rail Maintenance contractors ARS Automatic Route Setting ATC Angel Train Contracts ATOC Association of Train Operating Companies ATP Automatic Train Protection Audit Procedural Check e.g. on Maintenance or Safety Provisions AWS Automatic Warning System AWS test box Equipment used to test AWS BR British Rail BRB British Rail Board BRIMS British Rail Incident Monitoring System BTP British Transport Police CBA Cost Benefit Analysis Country end Leading Power car on leaving Paddington CPS Crown Prosecution Service CIRAS Confidential Incident Reporting and Analysis System CRUCC Central Rail User's Consultative Committee DRI Driver Restructuring Initiative Diagram Driver's route card DM Driver Manager DNV Technica Technical Consultants DO0 Driver Only Operation DRA Driver Reminder Appliance DSM Driver Standards Manager DSD Driver Safety Device DVD Driver Vigilance Device EQE Technical Consultants EROS Emergency Restriction of Speed EWS English Welsh and Scottish FRAME Fault Reporting And Monitoring of Equipment Computer System Group Standard Mandatory documents defining minimum requirements to ensure system safety and safe interworking on Railtrack's infrastructure. GWR Great Western Railway GWT Great Western Train Company HEX Heathrow Express HMRI Her Majesty's Railway Inspectorate HSC Health and Safety Commission HSE Health and Safety Executive HST High Speed Train IECC Integrated Electronic Control Centre 1 TO22319 00239'73 2LO 1 IS0 International Standards Organisation Mark I Older Type Rolling Stock - Mark I11 Post 1974 Rolling Stock (m use at Southall) London End Leading Power Car on train entering Paddington LMS London Midland and Scottish Railway LRM Layout Risk Method NRS AWS maintenance contractors OHL Overhead Line OPRAF Office Of Passenger Rail Franchising ooc Old Oak Common maintenance depot OTDR On Train Data Recorders POIS Passenger Operations Information System Railway Group Group comprising Railtrack and duty holders of Railway Safety Cases accepted by Railtrack Rail Regulator Individual appointed to enforce Railway Group Standards and the Track Access Conditions. RIA Right Away system RI1 Rail Industry Inquiry Right Side Failure to a safe condition RIO Rail Incident Officer ROSCO Rolling Stock Company