The reopened inquiry into the crash on 19 September 1997 was also told that privatisation and the introduction of the profit motive may have contributed. Financial penalties against companies for running late services may lead to a "conflict of interest" between safety and punctuality, said counsel to the inquiry.
Police evidence showed the company, fined pounds 1.5m for its part in the disaster, rarely took trains out of service when their critical automatic braking systems were out of operation, said Ian Burnett QC.
And a post-privatisation decision to allow all train operating companies equal access to track meant slow trains were allowed to move on to track in front of express services, he said. The old system that gave priority to fast passenger trains had a "ring of commonsense about it".
The inquiry, chaired by Professor John Uff QC, will try to discover the causes of the crash that came after the express passed three danger signals with its faulty Automatic Warning System switched off. Professor Uff will also make recommendations and examine subsequent safety changes.
Mr Burnett said Mr Harrison had attracted the attention of several passengers at Bristol Parkway. "They have independently described him as having both feet on the dashboard as he drove the train into the station." Mr Harrison gave a "casual impression of undertaking an important job", said Mr Burnett, and it raised the question of how he managed to operate the safety device or "dead man's handle", a pedal that stops the train if the driver removes his foot from it. There was speculation Mr Harrison had placed his bag on it but police failed to prove that.
After the crash, the driver said he was "fumbling" in his bag when he suddenly noticed a signal at red, having already passed one double yellow and single yellow warning lights. Mr Harrison applied the brakes when he saw the red signal and managed to slow to about 60mph. When he realised he was too late to avoid the goods train, he moved back to the engine- room. "I only got as far the fan compartment when the impact took place," he told investigators.
Dr John Body, of Cardiff, a passenger, said his emotions about Mr Harrison were "complex". He added: "At one level I feel sorry for him. Psychologically he's a wreck since the crash. It's got to be recognised that human beings are going to make mistakes."
He said primary blame should be attached to the train operating company for not having adequate safety systems in place. Other passengers said the disaster had caused lasting psychological impact and many now avoided public transport.
There were three immediate causes of the disaster, said Mr Burnett. The first was the driver's failure to respond to the signals, and the second was the AWS, which would have alerted him to the signals, was out of commission. The third was that the most sophisticated device, Automatic Train Protection (ATP), which stops the train when signals are at danger and cannot be overridden by the driver, was also switched off. Great Western inherited an ATP pilot project, but not all drivers were trained to use it.
Great Western was fined pounds 1.5m at the Old Bailey earlier this year after admitting offences under the Health and Safety Act, in particular for allowing the train to leave Swansea without AWS.
The hearing is expected to last until the end of November. Professor Uff will then compile a report for the Health and Safety Commission.
He denounced as "unacceptable" the two-year delay between the crash and the start of the inquiry.Reuse content