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Danger Ahead!
Danger Ahead! Feature
The Paddington Tragedy!    
5 October 1999         

Disaster at Ladbroke Grove
"The Cullen Inquiry"

Reports   Terms of Reference   Related Items   Earlier Reports
the inquiry into the ladbroke grove disaster began hearing evidence on 10 May

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Comment on the Paddington Disaster

Smoke and Mirrors
The Public Inquiry into the accident at Ladbroke Grove opened on the 10th May. Already the press is reporting selective details and statements which produce a shadow play of facts and circumstances and lead the public into believing the causes are obvious and simple.
The justified call of the bereaved relatives for prosecution of rail managers and the criticism of the Crown Prosecution Service for declaring that it will not seek a prosecution, diverts attention from where the blame really lies in this emotive issue.

No way to run a railway
Evening Standard Editorial Comment
From day one, the Paddington rail crash inquiry has begun to expose a series of appalling safety lapses.
Human error can never be completely eliminated from the operation of a railway, but the way in which trains were run in and out of Paddington made it likely that a single mistake by one driver would sooner or later lead to disaster.

The inquiry into the Paddington rail accident opened on 10 May 2000 under the chairmanship of Lord Cullen. News and links to reports on the inquiry will be published here and updated regularly.

7 July 2000
Paddington disaster: 'we expected extra safety measures'
Ananova 07 Jul 2000
A witness at the Paddington disaster inquiry, who worked at the station in the early 1990s, has said he had expected to see extra safety measures long before last year's fatal crash.
Peter Woodbridge, who tested proposals in 1992/93 for a remodelling of Paddington which took place in 1994, said he thought there would be an "imminent incorporation" of automatic train protection which would eliminate the risk of trains passing danger signals.

14 June 2000
Safety ideas 'left out of Paddington signals'
News Unlimited 14 Jun 2000
Safety precautions which could have prevented or lessened the impact of the Paddington train crash were not built into the development of the track outside the mainline station, the public inquiry into the accident was told yesterday.
At one point in a risk assessment of Paddington signalling arrangements, managers used pennies on a diagram because computer generated equipment refused to work

Paddington crash: five-year failure to install signal alarm
Ananova 14 Jun 2000
Railtrack failed to implement a recommendation made five years ago to install an audible alarm to warn railway signallers of impending danger on the lines, the Paddington crash inquiry has heard.
John Hendy QC, for those bereaved and injured in the disaster, said the proposal was made following the Royal Oak Inquiry in 1995, but no action had been taken.
Matthew Spencer, signal engineer for Railtrack's Great Western Zone, said there had been problems with the computer software needed to operate the alarm system.

Railtrack rejected anti-crash devices
Electronic Telegraph 14 Jun 2000
A safety scheme that might have prevented the Paddington disaster is being considered by Railtrack five years after it rejected the proposal, the public inquiry into the crash was told yesterday.
Colin Bray, a senior Railtrack signalling engineer, said he had put forward a "flank protection" plan for Paddington's approaches in 1995 after a low-speed collision between two trains just outside the station. The scheme was intended to ensure that any train passing a stop signal would be diverted from potentially conflicting traffic on to a line on its own.
At signal SN109, which a local Thames train passed at danger last October, leading to a collision that killed 31 people, one set of points could have been used for flank protection, although this would have been technically difficult and expensive to install retrospectively. Mr Bray told the inquiry that Railtrack managers rejected the plan, partly out of concern that it might increase the risk of side-on collisions.

13 June 2000
Risk assessment 'never left pennies on map stage'
Ananova 13 Jun 2000
The Paddington rail crash inquiry has heard how a risk assessment of the signalling got no further than pennies being placed on a map.
Colin Bray, Railtrack's signalling development engineer, said managers resorted to the coins on the table exercise after plans for computer-generated alternatives failed to work.

Railtrack 'ignored safety proposals'
BBC Online 13 Jun 2000
Railtrack bosses ignored suggestions to improve safety on the approaches to Paddington Station for almost five years, an inquiry into the rail disaster has heard.
Railtrack's signalling engineer Colin Bray recommended a number of safety improvements as early as 1995, but his suggestions were constantly deferred or delayed, the inquiry was told.
He was finally given six months to implement the measures, which included making some tracks one-way only, in September last year.

12 June 2000
Drivers 'not always to blame' for passing red lights
Ananova 12 Jun 2000
Blame for passing red signals should not necessarily fall on train drivers, the Paddington rail crash inquiry has been told.
A psychology professor told the public inquiry that signal passes at danger were not always down to driver negligence.

07 June 2000
Paddington driver may have misread signal
Ananova 07 Jun 2000
Rookie driver Michael Hodder may have believed that signal 109 was telling him to proceed, the public inquiry into the Paddington train crash was told.
Psychologist Roger Watt, of Stirling University, said the crucial signal came into view in a piecemeal fashion.
Prof Watt, who travelled past the site of the accident nine times as he tried to investigate its cause, found that sunlight reflected from the yellow lamps in signal 109 could have made them look as though they were lit.

06 June 2000
Drivers joked about signal problems, inquiry hears
Ananova 06 Jun 2000
Train drivers who worked the route in and out of Paddington joked about problems seeing the signals, the Ladbroke Grove rail disaster inquiry has heard.
Overhead cables installed when the Heathrow Express line was electrified in the early 1980s obscured the central equipment, drivers said.
New gantries erected at the same time were too close to road bridges and stopped signals being seen from a distance, the inquiry was told.

02 June 2000
Drivers Use Hand-Drawn Maps, Probe Told
Excite News 02 Jun 2000
Thames Trains drivers use hand-drawn route maps because no official versions have been printed, the company's general manager told the Paddington rail crash inquiry Thursday.
Thames Trains has come under a barrage of criticism about its driver training program since the start of the inquiry into last October's collision of two trains near the London rail station that killed 31 people.
"It is thought to be desirable that they draw their own maps...that it leaves an impression in the mind of the drivers," Thames Trains general manager Terence Worrall said, adding that he did not subscribe to this theory.
"I would acknowledge that something official needs to be published," he told an audience of victims, relatives, lawyers and reporters.

31 May 2000
Crash train driver 'thrown in at the deep end'
Ananova 31 May 2000
Rookie train driver Michael Hodder had to rely on sketch maps because rail bosses did not provide him with proper route plans, the Paddington crash inquiry has heard.
The 31-year-old Thames Trains driver was "thrown in at the deep end", his instructor Raymond Adams said.
But Mr Hodder was a "very good driver ... and competent at his job", the hearing was told.
Mr Adams revealed a catalogue of failings in the Thames Trains driver training programme.

Signallers 'trained to wait and see' on danger trains
Ananova 31 May 2000
The Railtrack manager responsible for assessing the signallers involved in the Paddington crash said a delay in stopping trains that overshot red lights was normal.
Heinz Winters, head of the signal control centre in Slough, told the inquiry into the disaster that trains passing signals at danger (SPADs) usually pulled up within seconds.
Signalman David Allen earlier said he waited up to 25 seconds before reacting when the Thames turbo service went through Signal SN109 and into the path of the First Great Western express. The crash on October 5 1999 at Ladbroke Grove left 31 dead, including the two train drivers, and hundreds injured.

30 May 2000
Weeping signalman tells crash probe of delayed reaction
Ananova 30 May 2000
A railway signaller on duty at the time of the Paddington rail crash wept as he told the inquiry into the disaster how he delayed reacting by up to 25 seconds after seeing a train go through a red signal.
David Allen said he had watched in horror on his computer screen as the Thames Trains service headed on a collision course with the First Great Western express - but he said there was a "short period of time" before he took any action as he expected the Thames turbo driver to stop.

Earlier reports from the inquiry

Train chiefs 'put shareholders before lives'
BBC Online, 11 May 2000

Paddington: profit before safety
ThisIsLondon, 11 May 2000

The Ladbroke Grove Rail Inquiry
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Terms of Reference of the Ladbroke Grove Inquiry
  1. To inquire into, and draw lessons from, the accident near Paddington station on 5 October 1999, taking account of the findings of the HSE’s investigations into immediate causes.

  3. To consider general experience derived from relevant accidents on the railway since the Hidden Inquiry, with a view to drawing conclusions about:

    1. factors which affect safety management
    2. the appropriateness of the current regulatory regime.

  5. In the light of the above, to make recommendations for improving safety on the future railway.


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This file last updated: Friday, 07-Jul-2000 19:03:15 EDT
Copyright © David Fry 1999, 2000