Danger Ahead! Comment
|The Paddington Tragedy!
5 October 1999
Comment on the first days of the Ladbroke Grove Inquiry
by Ray State
|"sensational" details of the events produce fuzzy images, reflections and shadows
by Stanley Hall
Comment on the Paddington Disaster
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.
The CPS is quite correct to point out that with the state of the law on manslaughter, a "directing mind" in any of the companies involved would be difficult to find. Without this, a prosecution would be bound to fail, increasing the distress of the injured and bereaved alike.
What the CPS did say was that it supported a review of the law to permit criminal prosecution of organisations responsible for gross negligence without the "directing mind" test.
As usual, this went largely unreported.
The current Government has repeatedly promised such a review a process supported and campaigned for by the editorials in this web site for more than a year.
Until the Government progresses this issue with vigour the CPS has no option but to decline to pursue unwinable cases on the ground of cost and distress to those involved.
In the meantime the other "sensational" details of the events produce fuzzy images, reflections and shadows.
Claims that the rail industry is running an unsafe railway are reported in detail. This is clearly incorrect and the claim is not supported by any facts or statistics. What is fact is that the industry is more heavily dependent on disparate groups all doing their jobs according to the common rules and when one or more of these departs from the correct path the results are instant and terrible. What the industry is bad at is identifying where the processes are becoming sloppy. Near Misses are recorded only as far as they relate to reportable events and large swathes of "incidents" are ignored or quietly set aside. Individually none are serious but when they work collectively the result is Southall or Ladbroke Grove.
We are told that the driver of the Thames Train had been charged with assault and that had this been known he would not have been employed. The inference is that this made him unfit to drive a train. It was also stated that the testing of his route knowledge was less than adequate. Again the inference is that this was a major issue in the cause of the accident. The fallacy of this argument is brought home to me in the last week.
As a passenger in a car being taken to a mainline station to meet important American visitors the driver unconsciously attempted to run a red traffic light. This was done despite the person having driven across that particular junction every day for 30 years.
The facts were simple. We were late and the driver's attention was focused on the station portico 200 yards further on not on the immediate signal. The fact that I am able to recount this story is down to:
At Ladbroke Grove none of these fallback safeguards were available to the driver of the Thames Trains driver. Criticism of the lack of route knowledge training must be tempered with caution.
Time and time again researchers can document rail accidents in which the lack of alertness on the part of drivers, when matched by infrastructure which is not tolerant to mistakes, produces serious accidents.
When these lapses coincide with junctions the accident is of the most destructive the head-on.
Stan Hall in his book Hidden Dangers (pp16-17) graphically illustrates the dangers in weak infrastructure in magnifying the destruction as a result of the Belgrove accident of 6th March 1989 but others include:
What the public needs to focus on in the Ladbroke Grove tragedy is the fact that an outward bound train on the track it was on and over running signal SN109 had nowhere to go other than into the path of a train coming the other way. This could have only one result that of a head on collision of the most destructive type.
There is no other fact greater than this and the "sensational" findings associated with the driver, ATP and the like must be treated for what its is Smoke and Mirrors.
This file last updated: Monday, 15-May-2000 17:09:33 EDT