British Rail was rebuked by an inquest jury yesterday, with a verdict of "accidental death aggravated by neglect" recorded on a passenger who died after a train caught fire.
Ian Jones jumped in to the path of a high-speed train near Maidenhead station in September last year, after the train on which he was travelling became a "blazing inferno" when a fuel tank fell off and diesel ignited.
His widow, Carol-Ann Jones, who was pregnant when he died and has subsequently given birth to the baby, said she intended to sue Great Western Trains which, at the time of the accident, was owned by British Rail but which is now one of two lines to have been privatised. The verdict will clearly strengthen her case.
Last month, the Health and Safety Executive's report into the incident recommended a radical review of both maintenance and evacuation procedures.
Yesterday, East Berkshire Coroner's court, sitting at Windsor, was told that Mr Jones might not have died if there had been a public address system which could have warned passengers to stay in their seats.
The Health and Safety Executive inspector who examined the train, John Helicar, told the inquest: "In my opinion, if the senior conductor had had immediate access to the PA system and said 'don't panic - sit in your seats' it is likely to have had a significant effect on the behaviour of the passengers.
"If there had been effective access to the PA system it is likely that we would not be here today."
Mr Helicar said that "serious consideration" had been given to bringing criminal prosecutions against British Rail, but instead recommendations had been issued.
Earlier, he told the jury that the sequence of events which led to the fuel tank falling off could not be determined because many of the maintenance documents covering the train's history were "unintelligible" and "illegible".
The 1,250-gallon tank was attached by four large bolts, each secured by two nuts and locked with a safety pin. Mr Helicar found that all four nuts on the bolts were loose.
He said: "It is our conclusion that the sequence of events prior to the final drop of the tank was that the nuts at both front and rear were for some period of time working their way loose."
His team of investigators discovered that two nuts holding the tank in place had come loose, causing the tank to hit the sleepers and ignite.
Mr Helicar added that it had been impossible to work out exactly what had happened, because the documents given to him by Great Western Railways were such a mess.
He said: "I seized six to 10 inches of records. The records were mostly hand-written, sometimes unreadable and unintelligible." They were so disorganised that he could not tell who had worked on the fuel tank.
A spokesman for Great Western Trains said: "We will be studying closely the implications of the verdict and the evidence presented.
"This may provide us with some lessons in addition to those raised by the Health and Safety Executive."Reuse content