Investigation into the Clapham Junction Railway Accident Anthony Hidden QC MAJESTY'S STATIONERY OFFICE A Cm 820 ISBN 0 10 1082029 CORRECTIONS The following two recommendations should be added to page 169. Project Management 29. BR shall ensure that new works schemes in future shall have one clearly identified person in overall charge of all aspects of the project who would nominate a Project Manager from within his chain of command. For predomin- antly signalling schemes that individual would, in the present BR structure, report to the Regional S&T Engineer. (Paragraphs 12.28 - 12.34) 30. The Project Manager nominated in 29 above shall be responsible for the execution within budget and timescale of the whole project from the original estimate preparation to the project completion. He shall report to the person in overall charge as necessary for approval. (Paragraphs 12.28 - 12.34) NOVEMBER 1989 LONDON HER MAJESTY'S STATIONERY OFFICE Investigation into the Clapham Junction Railway Accident Presented to Parliament by the Secretary of State for Transport by Command of Her Majesty November 1989 A THE DEPARTMENT OF TRANSPORT LONDON HER MAJESTY'S STATIONERY OFFICE Cm 820 E16.50 net Frontispiece Investigation into the Clapham Junction Railway Accident Inspector: Room S5/03 Yr Anthony Hidden QC 2 Marsham Street London SW 1P 3EB Fax. No. 01-276 6364 27 September 1989 Direct line 01-276 0838/5420/5433/5959/6539 Switchboard 01-276 3000 The Rt. Hon. Cecil Parkinson M.P. Secretary of State for Transport Department of Transport 2 Marsham Street London SWlP 3EB CLAPHAM JUNCTION RAILWAY ACCIDEN'I' INVESTIGATION On 13 December 1988 your predecessor as Secretary of State invited me to hold a formal Investigation into the causes of and circumstances attending the Clapham Junction railway accident. I have now completed that Investigation and enclose my Report. ANTHONY HIDDEN Q.C. Regulation of Railways Act 1871 In the matter of a collision near Clapham Junction Station on 12 December 1988 Whereas: (1) a collision occurred between the 07:18 Basingstoke to Waterloo train, the 06:14 Poole to Waterloo train and a train of empty coaches south west of Clapham Junction Station at about 08:lO on 12 December 1988 (hereinafter called "the accident") which was an accident of which notice is for the time being required by or in pursuance of the Regulation of Railways Act 1871 to be sent to the Secretary of State for Transport (hereinafter referred to as IIthe Secretary of State"), and (2) it appears to the Secretary of State that a formal investigation of the accident is expedient NOW THEREFORE the Secretary of State, in exercise of the powers conferred by section 7 of the Regulation of Railways Act 1871 and now vested in him hereby makes the following Order - The Secretary of State directs that a formal investigation of the accident and the causes thereof and of the circumstances attending the same be held and he hereby appoints Anthony Brian Hidden QC to hold the same with the assistance of Major Christopher Basil Holden, an Inspecting Officer of Railways, Dr Thomas Bryce McCrirrick, CBE and Dr Alan Arthur Wells, OBE as assessors. Signed by authority of the J R COATES Secretary of State An Under Secretary in the Department of 6 January 1989 Transport STRUCTURE OF THE REPORT Page PROCEDURAL HISTORY INTRODUCTION PART ONE: THE ACCIDENT Chapter 1: How the new signal went wrong Chapter 2: The morning of the accident Chapter 3: The accident itself Chapter 4: The immediate aftermath Chapter 5: The response of the emergency services Chapter 6: The response of BR and its initial investigation PART TWO: THE IMMEDIATE CAUSES Chapter 7: The wiring errors which caused the accident Chapter 8: How those errors came to be made - working practices and programmes in the S&T Department Chapter 9: The testing of the work - the failure of "the last defence" PART THREE: MANAGEMENT AND THE UNDERLYING CAUSES Chapter 10: Management and the S&T Department Chapter 11: S&T Departmental instructions, communications and training Chapter 12: WARS - the project: its planning, management and execution STRUCTURE OF THE REPORT (contd.) PART FOUR: THE CONCEPT OF SAFETY Chapter 13: The management of safety Chapter 14: The funding of safety Chapter 15: The future of safety PART FIVE: CONCLUSIONS Chapter 16: Where responsibility lies Chapter 17: The lessons to be learned THE RECOMMENDATIONS STRUCTURE OF THE REPORT (contd.) Page PART FOUR: THE CONCEPT OF SAFETY Chapter 13: The management of safety Chapter 14: The funding of safety Chapter 15: The future of safety PART FIVE: CONCLUSIONS Chapter 16: Where responsibility lies Chapter 17: The lessons to be learned THE RECOMMENDATIONS APPENDICES Page Appendix A: List of those who died 178 Appendix B: List of parties and their representation 179 Appendix C: List of witnesses 181 Appendix D: Videos 184 Appendix E: Glossary of terms 185 Appendix F: The signalling failure: a technical assessment 189 Appendix G: The rolling stock: a technical assessment 191 Appendix H: Figures produced by BR on wrong-side signalling failures prior to the accident 200 Appendix J: BR's specification for a consultants' study into its Management of Safety Systems 208 Appendix K: Plans and diagrams: 1. The Weymouth to London Waterloo railway line. 213 2. Relevant sections of the signalling system and track circuits around the accident scene. 215 3. Extract from Design Office working diagram for Job Nos. 104 and 201, showing Mr Hemingway's pencil additions. 21 7 4. Diagram of the accident site and Spencer Park, showing the emergency services control vehicles and additional buildings used. 219 5. Waterloo Area Resignalling diagram: the extent of the scheme. 22 1 6. British Rail's organisational structure, relevant to the Clapham Junction disaster (as at 12 December 1988). 223 7. Extract of organisational structure of British Rail's Southern Region Signal & Telecommunications Department from September 1986 until reorganisation in May 1988. 225 8. Clapham Junction "A''. Part detail of control circuits for Automatic Signal WF138. 226 APPENDICES (contd.) Page Appendix K (contd.): 9. Control circuits for signal WF138. 227 10. View showing the basic construction of a Mark I coach (Class 423 VEP). 228 11. Plan view of the permanent deformation of DMS 62146 (leading coach of the Poole train). 229 12. A line diagram of a typical four-aspect signal as supplied by ML Engineering (Plymouth) Limited. 23 1 13. Diagrams showing signal aspect sequences in normal operation and with the fault. 233 viii . 1' LIST OF PHOTOGRAPHS Figures 1 & 2: Aerial views of the accident site. Figure 3: Driver Pike's train stationary approximately 60 yards from the rear of the Poole train. Figure 4: An interior view of a driver's cab showing the controls. Figure 5: An interior view of the type of buffet car on the Poole train, showing the non-fixed seating, facing forward in the direction of travel. Figure 6: A further interior view of the type of buffet car again facing forwards, showing the closed shutters on the left, behind which are the kitchen and serving areas, and the passenger space on the right. Figure 7: A view of the buffet car of the Poole train taken on the evening of Monday, 12 December, showing the destruction of the kitchen and serving areas on the left (nearside) of the coach, and the damaged loose seating. Figure 8: An interior view of Mark I rolling stock similar to some carriages of the Poole train, showing lateral luggage racks. Figure 9: An interior view of a carriage of the Basingstoke train, showing damaged transverse luggage racks. Figure 10: A view of Clapham Junction "A" signal box with the relay room at the extreme right above the first third of the leading coach of the passing train. Figure 11: A view of the relay room looking towards the entrance, showing the relay racks; and the trees of the wiring. Relays TRR DM and TRR DN are on the bottom shelf on the right in the last section towards the door. Figure 12: Relays in Clapham Junction "A" relay room, showing track relay "DN" adjacent to track repeater relay "DM". Figure 13: Relay TRR DM, taken on 12 December 1988, at approximately 14.00 hours. Figure 14: Fuse racks. Row 12-fl07, taken on 13 December 1988. Figure 15: Extract from the working model demonstrating Job Nos. 104 and 201 and the wiring errors made. The black wire along the top of the diagram connected at DM TRR and Row 12-f107 should have been disconnected at both ends but was wrongly left connected at the fuse end of Row 12-fl07. Although disconnected at the relay end the wire was left loose and made metal-to-metal contact at DM TRR, a false feed of current to by-pass DL TRR. Hence the occupation of track circuit DL by a train had no effect on signal WF138 and it did not turn back to red as it should have done. Figure 16: Working model of the relevant signalling circuit, showing wiring errors, and topographical model of the crash site. ACKNOWLEDGEMENTS Figures reproduced by courtesy oj British Transport Police: Figures 3,4,5,6,8,11,12,13 and 14 British Railways Board: Figure 9 Central Office of Information: Figures 15 and 16 London Fire and Civil Defence Authority: Figure 7 Metropolitan Police: Cover picture, Frontispiece and figures 1 and 2 The Guardian: Figure 10 xii PROCEDURAL HISTORY At 8:10 a.m. on the morning of Monday, 12 December 1988, a crowded commuter train ran head-on into the rear of another which was stationary in a cutting just south of Clapham Junction station.