A public inquiry into the Paddington rail crash which claimed 31 lives was opening in London today.
Inquiry chairman Lord Cullen said everyone should ensure lessons were fully learned from the crash for the sake of those who had suffered.
Those injured in, or bereaved by, the October 1999 accident were attending the inquiry while still angry at yesterday's Crown Prosecution Service decision not to bring manslaughter prosecutions over the crash.
The morning rush-hour accident happened when a Thames turbo train passed through a red light at Ladbroke Grove, two miles outside Paddington station in west London.
The Thames train, driven by Michael Hodder, 31, collided almost head-on with a London-bound Great Western high-speed train. Both Mr Hodder and the Great Western driver Brian Cooper, 52, were among those killed.
More than 400 people were injured in the accident, which led to rescuers fighting to free passengers from fire-engulfed and crash-damaged carriages.
The Health and Safety Executive has already published three interim accident reports. The third of these, which came out in mid-April, said the initial cause of the accident still appeared to be that the Thames train had passed a red signal - signal 109.
But it added that the reason the train had passed the red light were likely to be complex and that "any action or omission on the part of the driver was only one such factor in a failure involving many contributory factors".
The HSE said that Mr Hodder, who had joined Thames in February 1999, had only fully qualified as a driver 13 days before the accident and had completed just nine shifts as the driver in charge.
But it added that there was no reason to doubt his suitability as a driver at the time of his recruitment. The HSE report also said the signals on the gantry which carried signal 109 were of an unusual design.
In addition, the HSE said that had Train Protection and Warning System (TPWS) been fitted at signal 109 the accident was likely to have been preventable.
TPWS, which minimises the worst effects of trains going through danger signals, is be installed at key junctions and on trains by mid-2003.
The HSE report also said it was "conceivable" that a misaligned track joint could have led to Mr Hodder receiving a false "green signal ahead" indication as he approached signal 109.
"Trains have to be safer and if safety recommendations are not implemented they are not worth the paper they are written on," said Carol Bell, vice-chairman of the Safety on Trains Action Group which was set up after the September 1997 Southall rail crash in which seven people were killed.
Lord Cullen, who chaired the inquiry into the Piper Alpha North Sea oil platform disaster in 1988, said today: "We should never lose sight of how it was that this inquiry came to be set up.
"We owe it to all those who have suffered in any way as a result of this disaster to make sure that its lessons are fully learnt and effective recommendations are made for the future safety of all who travel on this country's railways."
The inquiry, which was being held at Central Hall in Westminster, was starting with an opening statement - expected to last about four hours - from Robert Owen, leading counsel to the inquiry.
Opening statements will then follow on Thursday from counsel for the other major interested parties, including the Ladbroke Grove Solicitors Group, Railtrack and the two train companies directly involved - Thames and Great Western.
The inquiry will begin hearing evidence next Monday. Among witnesses expected to appear will be passengers on the two trains, rail industry employees and health and safety inspectors.
This first part of the inquiry is expected to end in July. On September 18, Lord Cullen and Professor John Uff, who chaired the Southall inquiry, will chair a joint inquiry into issues common to both crashes.
This will last about four weeks and then Lord Cullen will chair part two of the Paddington inquiry which will consider general matters of rail safety.Reuse content