A signalman could have prevented the deaths of the 31 victims of the Paddington rail crash if he had acted more quickly, the official report into the disaster says.
The 300-page document confirmed that the cause of the crash was a signal being passed at danger (Spad) by a Thames Trains local service leaving Paddington station, putting it on collision course with an incoming First Great Western express. But the report also accused Railtrack's signalling centre at Slough of having a "dangerously complacent" attitude to trains going through red lights.
The report says that for a vital few moments a signaller, Dave Allen, failed to act despite being alerted to the fact that the Thames Turbo train had passed signal SN109 set at danger. Mr Allen was expecting the Thames train to stop.
When he realised the service was continuing its journey he turned a signal to red in front of the express and sent an emergency stop message to the Thames train by radio. Lord Cullen said that because of the "poor quality" of evidence from signallers he was unable to determine whether the message was received before the crash, "let alone how long before it".
The evidence from Mr Allen and his colleagues at the Slough signal box indicated there was a "serious under- rating of the risks involved in Spads, a failure to realise the importance of immediate and direct communication with the driver where that was possible and a dangerously complacent attitude to Spads as being simply a matter of driver error".
Lord Cullen said the main cause of those deficiencies lay with senior Railtrack management at the signalling centre. If management had applied the lessons learnt in other such incidents, and if signallers had been adequately trained, the emergency message might have been sent earlier.
The report told how Michael Hodder, a recently qualified driver, took his train out of Paddington at 8.06am on 5 October 1999 bound for Bedwyn in Wiltshire. Just over two minutes later he passed SN109 set at red. Lord Cullen said he was satisfied that Mr Hodder, who died in the crash, believed he had a "proceed aspect" at the signal. The report said it was probable the poor siting of SN109 which was on an overhead gantry and the effect of bright sunlight at a low angle led him to misread the signal.
As trains approached the signal it could be seen from some way away, but it was then obscured by the underside of a bridge and overhead line equipment. When the signal came back into view Mr Hodder had eight seconds to see it. While he should have checked it again, that would depend on what other tasks he was doing at the time and the confidence with which he had earlier decided it was set at "proceed".
The unusual configuration of SN109 a reverse "L" impaired the visibility of its red aspect and may have led Mr Hodder to believe he was cleared to continue, the report said.
The Thames train travelled for another 700 yards into the path of the express with which it collided "virtually head-on" at a combined speed of 130mph. The impact was followed by a series of fires, the "most horrific" of which engulfed coach H of the express train.
Lord Cullen attacked Railtrack for a "lamentable failure" to respond to recommendations made after two previous accidents in the Paddington area, one of which involved SN109. Most damningly, that signal had been passed on eight occasions since August 1993. The two-mile stretch of track governed by SN109 has been closed since the disaster.
The inquiry chairman said he agreed with the analysis of counsel for the bereaved and injured that the infrastructure company was guilty of "institutional paralysis" because of its inability to respond to constant criticism of the signalling in the Paddington area. There was "a serious and persistent failure" by Railtrack to convene committees to look at how well signals could be sited. That was due to a combination of "incompetent management and inadequate procedures".
Lord Cullen referred to evidence given to the House of Commons Transport Committee by the former Railtrack chief executive Gerald Corbett in July 1998. He said he found it "extraordinary" that Mr Corbett had told the committee that Railtrack believed Paddington "to be the best protected major terminal station anywhere in the world". Lord Cullen said Mr Corbett, who resigned late last year, agreed now that it was an unfortunate statement for him to have made.
The system for instructing trainee drivers at Thames Trains was also criticised. The assessment of Mr Hodder's route knowledge did not cover the section between Paddington and Ladbroke Grove one of the most complicated parts of the network. The report also pointed out that Mr Hodder was not told that SN109 was a "multi-Spad" signal.
The safety culture at Thames Trains, as far as driver training was concerned, was "slack and less than adequate" and there were "significant failures of communication within the organisation", the report said. Immediately after the crash, there was no organised evacuation and Great Western passengers had difficulty in knowing how to open the external doors, and where to find hammers to break windows.
There were no emergency hammers on the Thames train and it was "fortunate" for those in the rear car that two company employees helped them escape through the rear cab.
The Health and Safety Executive's rail inspectorate received relatively little criticism. The inquiry had been told that inspectors had been "overwhelmed with work". Lord Cullen said: "In such circumstances they should, in my view, have pressed for increased resources."
In his report Lord Cullen paid tribute to the "outstanding efforts" of passengers and members of the public in the aftermath of the crash. "Many of those travelling on the trains showed acts of great courage and humanity," he said.
He added that the work of the fire brigade, police and ambulance services also deserved "the highest praise".
Lord Cullen is due to produce another report analysing safety systems in the rail industry and making recommendations about how they should be improved.