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HSE: the Ladbroke Grove Rail Inquiry

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HSE: the Ladbroke Grove Rail Inquiry The Ladbroke Grove Rail Inquiry Part 1 Report The Rt Hon Lord Cullen PC The Ladbroke Grove Rail Inquiry Part 1 Report The Rt Hon Lord Cullen PC © Crown copyright 2000 Applications for reproduction should be made in writing to: Copyright Unit, Her Majesty’s Stationery Office, St Clements House, 2-16 Colegate, Norwich NR3 1BQ First published 2001 ISBN 0 7176 2056 5 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. Front cover: View of crash site taken shortly after midday on 5 October 1999 ii Those who lost their lives Ladbroke Grove, 5 October 1999 Charlotte Andersen Derek Antonowitz Anthony Beeton Ola Bratlie Roger Brown Jennifer Carmichael Brian Cooper Robert Cotton Sam Di Lieto Shaun Donoghue Neil Dowse Cyril Elliott Fiona Grey Juliet Groves Sun Yoon Hah Michael Hodder Elaine Kellow Martin King Antonio Lacovara Rasak Ladipo Matthew Macaulay Delroy Manning John Northcott John Raisin David Roberts Allan Stewart Khawar Tauheed Muthulingam Thayaparan Andrew Thompson Bryan Tompson Simon Wood iii iv Contents List of plates vii Acknowledgements viii Chapters 1 Executive summary 1 2 The Inquiry 7 3 The journey before the crash 13 4 The crash 19 5 The actions of driver Hodder 51 6 The actions of the signallers 83 7 Railtrack and the infrastructure 103 8 Thames Trains and Automatic Train Protection 143 9 Thames Trains and driver management and training 157 10 Her Majesty’s Railway Inspectorate 169 11 Signal sighting 177 12 The work of signallers 187 13 Crashworthiness and fire mitigation 195 14 Passenger protection, evacuation and escape 203 15 Summary of recommendations 225 Appendices 1 Parties and their representatives 239 2 Lay witnesses 241 3 Expert witnesses 249 4 Previous SPADs at signal SN109 251 5 Abbreviations 261 6 Glossary 263 Inquiry team 271 Plates Track and driving diagrams Inside back cover v vi List of plates Plate 1 Gantry 6 Plate 2 Gantry 8 at a distance of 218 metres Plate 3 Gantry 8 at a distance of 188 metres Plate 4 Gantry 8 at a distance of 168 metres Plate 5 Gantry 8 at a distance of 60 metres Plate 6 Gantry 8 at a distance of 17 metres Plate 7 Part of the front car of the Thames Turbo against coach B of the HST Plate 8 Front and middle cars of the Thames Turbo Plate 9 Early stage of the fire in coach H of the HST Plate 10 Later stage of the fire in coach H of the HST Plate 11 Crash site showing coaches F and H of the HST Plate 12 Coach H of the HST Plate 13 Coach H of the HST Plate 14 View towards Paddington from gantry 8 Plate 15 Workstation at IECC, Slough Plate 16 Aerial view of crash site vii Acknowledgements The plates in this report were supplied both by parties to the Inquiry and other photographers as shown below. The Inquiry is particularly grateful to Chris Milner and Marco Deidda for permission to use their photographs. Front cover Chris Milner, The Railway Magazine Plates 1, 2, 3, 4, 5, 6, 14 W S Atkins Plate 7 Health and Safety Laboratory Plates 8, 12, 13, 16 Metropolitan Police Service Plates 9, 10, 11 Marco Deidda Plate 15 British Transport Police Track and driving diagrams Prepared by W S Atkins based on a diagram provided by Railtrack viii Chapter 1 Executive summary 1.1 This Inquiry arises out of the crash at Ladbroke Grove Junction on 5 October 1999 between trains operated by Thames Trains and First Great Western (FGW), which caused considerable loss of life and injuries. Part 1 of the Inquiry is concerned with the investigation of the causes of the crash and the circumstances in which it occurred, lessons which should be drawn from what happened, and recommendations for the improvement of safety in the future. 1.2 In Chapter 2 I outline my approach to Part 1, the preparations for the Inquiry, and the procedures which were followed. 1.3 Chapter 3 describes events leading up to the crash. A Turbo of Thames Trains, driven by Michael Hodder, left Paddington Station at about 08:06 bound for Bedwyn in Wiltshire. At about 08:08:25 the Turbo passed signal SN109 on gantry 8 at red for Danger, travelling at 41 mph. It had passed the previous signal, SN87, at single yellow. The state of the points beyond SN109 was such that the Turbo was inevitably carried towards the Up Main line. Meanwhile a High Speed Train (HST) of FGW was approaching on the Up Main on green signals. Shortly before the crash a signaller at the Integrated Electronic Control Centre (IECC) at Slough, who had been monitoring the progress of trains, put signal SN120 back to red in face of the HST. Both train drivers applied their brakes, but this had no significant effect on the impact, which took place at a combined speed of about 130 mph. Both of them were killed. 1.4 In Chapter 4 I describe what happened in, and as a result of, the crash. The impact was virtually head on. The coaches of the HST absorbed crash energy well, but several of its bogies became detached. On the other hand the Turbo suffered a considerable degree of destruction and failure, with a consequent loss of protection for passengers. The impact was followed by a number of fires which were caused by the dispersal and ignition of diesel fuel. The most horrific was one which engulfed coach H of the HST. 1.5 The chapter indicates where the deceased had been on the trains and where they were found after the crash. It also sets out in some detail the difficulties which were experienced by passengers. There was no organised evacuation. In the case of the HST, the passengers had difficulty in knowing how to open the external doors, and where to find and how to use hammers to break windows. In the case of coaches which had tilted over to a substantial angle, they had difficulty in opening the internal doors which had fallen shut under the force of gravity. As regards the Turbo, a number of passengers were trapped in it. Others could not open the doors between the cars, and found that it was difficult or dangerous to open external doors. There were no emergency hammers. It was fortunate for those who were in the rear car that two Thames Trains employees enabled them to escape through the rear cab. 1 1.6 The chapter also contains a description of the steps taken for the protection of the crash site and the response of the emergency services, who deserve great praise. The chapter concludes with an account of the site investigation. 1.7 Why did driver Hodder pass SN109 and thereafter not attempt to stop until the crash was imminent? In Chapter 5 I consider what factors played a part. The evidence of train drivers, supported by that of independent experts, demonstrated that there was persisting difficulty in the sighting of the signals which formed part of the re- signalling scheme between Paddington Station and Ladbroke Grove, and in particular those on gantry 8. SN109 had been passed at Danger on eight occasions since August 1993. Driver Hodder had recently passed out as a driver. He had been a good trainee, but his experience was slender and there were significant shortcomings in his training. It was acknowledged by Thames Trains that he had not been instructed directly about signals which had been passed at Danger (SPADs), and the assessment of his route knowledge did not specifically cover the section between Paddington Station and Ladbroke Grove. 1.8 I examine the evidence in regard to driver Hodder’s driving up to the point of impact in four stages: (i) in relation to SN87; (ii) at the stage of the initial sighting of the signals on gantry 8; (iii) over the last 168m before reaching SN109; and (iv) beyond that signal. I am satisfied that he believed that he had a proceed aspect at SN109. It is 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 led him to believe that he had a proceed aspect and so that it was appropriate for him to accelerate as he did after passing SN87. After the red aspect of SN109 ceased to be obstructed by the underside of the Portobello Bridge or the overhead line equipment he could have seen it during a period of eight seconds as he approached that signal, but it appears that he either did not see it or did not realise that there was a red aspect. While it might well be expected that if he was concentrating on his duties he would look again at the signal, this depended on his various tasks and the confidence with which he had already identified what he thought that the signal was showing. The unusual configuration of SN109 – a “reverse L” – not only impaired initial sighting of its red aspect, but also might well have misled an inexperienced driver, such as driver Hodder, who was looking at the signal at close range, into thinking that it was not showing a red but a proceed aspect. The fact that he had not been instructed that SN109 was a multi-SPAD signal increased the risk of his making, and not correcting, a mistake as to the aspect shown by that signal.
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