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:-

• 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.

• ATP should be maintained on Great Western lines and an extension to the present coverage of ATP on Great Western lines should be considered.
• 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 action.

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."

Source:

Health & Safety Executive