Report slams 'lamentable' Railtrack

Railtrack was today accused of "institutional paralysis" in a public inquiry report into the Paddington train crash, which claimed 31 lives.

There was "a lamentable failure" on the part of Railtrack to respond to two earlier instances of signals passed at danger before the October 1999 accident, the report by inquiry chairman Lord Cullen said.

The accident at Ladbroke Grove, west London, was caused when a Thames Trains service passed through a red light and crashed into a Great Western express as it sped towards Paddington station.

Lord Cullen's report said the fact that Railtrack had many groups dealing with similar issues led to confusion.

The report was also critical of Thames Trains, whose driver Michael Hodder, 31, was killed in the crash.

The report said the removal by Thames of all their in–carriage emergency hammers before the crash "compromised the safety of passengers".

The report said there was "a lack of appreciation within Railtrack that deficiencies in the infrastructure could play a significant part in SPADs (signals passed at danger)".

The report added that there was an "obvious lacuna" in procedures in that the Thames driver instructor did not recognise it as part of his job to teach knowledge of the route in and out of Paddington station.

Lord Cullen said: "The fact that he (Mr Hodder) had not been instructed that signal 109 was a multi–SPAD signal increased the risk of his making, and not correcting, a mistake as to the aspect shown by that signal."

Lord Cullen said that the evidence of the signaller and other members of staff at the control centre indicated there was a serious under–rating of the risks involved in SPADs (signals passed at danger) as well as a failure to realise the importance of immediate and direct communication with the driver where that was possible.

There was also "a dangerously complacent attitude to SPADs as being simply a matter of driver error".

If management had applied the lessons of past SPADs, and if signallers had been adequately instructed and trained in how to react to a SPAD, it may well be the case that the signaller would have been able to send the emergency message in time to enable the (Thames) Turbo to be brought to a halt before reaching a point at which it fouled the path of the high speed train.

On the "lamentable failure" on Railtrack's part, Lord Cullen was referring to recommendations of serious SPAD incidents at Royal Oak in London on November 10th, 1995, and at signal 109 on February 4, 1998.

As far as Thames Trains was concerned, Lord Cullen said it was evident that there were "continuing failures to implement fully the recommendations of the Royal Oak inquiry."

Lord Cullen made 88 recommendations in his 270–page report.

Among a large number of suggested improvements he set out the need for improvements in safety information for passengers, emergency lighting, the operation of internal and external doors, escapes through windows, internal and external communications and the training of on–board staff.

He also called for a revision of signal sighting, training in the identification of human factors and in root cause analysis by those investigating SPADs, a national system of radio communication between trains and signallers and improvement to high speed train and turbo train crash–worthiness – the ability to withstand an accident.

Passengers had to endure two fireballs after diesel ignited after the crash. Lord Cullen today said measures should be considered to prevent the recurrence of fires of this type, including efforts to prevent the dispersion of diesel fuel.

He also called for the system for the reception of information about missing persons, casualties and survivors to be computerised.