The independent public inquiry set up to examine the rail accident
at Southall has resulted in 93 recommendations to improve safety aimed at the rail industry and the regulatory bodies.
Inquiry Chairman, Professor John Uff QC, found that the primary cause of the accident was the failure of the driver of the high speed Great Western train, to react either to signals SN280 or SN270.
The closing speed of the two trains at the point of collision was probably in excess of 80 mph. The crash resulted in the death of seven passengers and 139 people being injured, some severely.
The report found that although there were no relevant faults on the track or signals, neither of the two main protection systems fitted to the
high speed train - Automatic Warning System (AWS) and Automatic Train Protection (ATP) - were operational at the time of the accident. AWS would have alerted the driver to the warning signals. ATP
would have prevented the train passing the red signal.
Professor Uff's report identifies lessons to be learned and makes recommendations including:-
And his recommendation continued:-
- Driver training and procedures should be tightened up.
- AWS is to be regarded as vital to the continued running of a train and AWS and other train-borne safety equipment should not fail in service
through preventable causes.
- Crashworthiness and safety procedures in passenger vehicles should be reviewed.
- Safety briefings for passengers should be adopted on a trial basis.
- Inter-company rights and obligations in equipment added to rail vehicles must be defined.
- System authorities should be created to oversee safety projects including AWS and ATP.
In addition to considering the causes of the accident, the Southall Report deals with wider safety issues, including crashworthiness of passenger
vehicles and safety systems.
- ATP should be maintained on Great Western lines and an extension to the present coverage of ATP on Great Western lines should be
- Technical accident investigations should be directed by HSE.
- The Rail Industry Inquiry Procedures should be reviewed to ensure that all necessary rail safety issues are subject to rapid
Professor Uff said:
"The Public Inquiry, which was set up within days of the Southall accident, was then delayed for two years as a result of criminal prosecution brought against the driver and Great Western Trains. An
internal inquiry carried out under the Rail Industry Procedures also did not have access to many technical reports because of the ongoing criminal action. I regard this as unsatisfactory and my
report contains recommendations aimed at improving the inquiry process.
"Similarly the technical investigation of the crash, under the control of British Transport Police, had a number of shortcomings and I have
made recommendations about crash investigation procedures.
"Now the report is published I am confident the Health and Safety Commission (HSC) will take my recommendations forward. I will be maintaining
close contact with developments in connection with the joint inquiry with Lord Cullen later this year."