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Ladbroke Grove Rail Crash

Wednesday, 5th October marked 17 years since the major Ladbroke Grove rail crash that happened on the Great Western Main Line at 8:09am, resulting in 31 fatalities and a further 227 people admitted to hospital and 296 people being treated onsite for minor injuries. The incident itself involved two trains; one High Speed Train (operated by First Great Western) and one Turbo train (operated by Thames Trains), meeting in a head-on collision at a combined speed of about 130 mph.

The incident (also known as the Paddington rail disaster), which to date is the worst rail accident on the Great Western Main Line, resulted in a public inquiry by Lord Cullen in 2000 and the resulting recommendations led to a large change in how regulations for the rail industry were to be managed moving forward, including the creation of the Rail Safety and Standards Board in 2003 and the Rail Accident Investigation Branch in 2005 (in addition to the Railway Inspectorate). Thames Trains & Network Rail were also prosecuted and both fined in relation to the accident.

The Incident

Those boarding their respective trains early in the morning on Tuesday, 5th October 1999 could never have dreamed that within the next couple of hours they would be involved in a high speed head on collision between two trains that was caused by a number of reasons, including defective driver training and poor signal placement on the line.

The Thames Trains Turbo train, which was bound for Bedwyn in Wiltshire, had left Paddington Station 3 minutes before at 08:06am and had in error passed signal SN109, which was showing a red aspect. With this signal on red, the train should have been stopped by the driver to allow the 06:03 HST from Cheltenham to Paddington through on the Up Main Line (“Up” referring to trains travelling to London). As the main line switched at Ladbroke Grove from bi-directional (which allow trains to travel in either direction on the same lines using signals) to the more conventional layout of two lines in each direction – “up” and “down” ( down referring to trains travelling from London), this train would have been routed onto the Down line, but as it ran the signal, it was instead routed onto the Up Main line and collided with the 06:03 First Great Western HST which was due to terminate at Paddington.

Upon impact, the leading car of the Turbo train was completely destroyed and the diesel fuel from the HST ignited, resulting in a fireball that caused fires throughout the overall wreckage and burnt out coach H which was at the front of the HST. Both drivers were killed immediately and a further 29 passengers also died between both trains.

Causes

The primary cause of the crash was the Thames Trains Turbo train running through signal SN109 which was on red, especially as the preceding signal SN87 had been showing a single yellow. The Cullen Inquiry looked further into why the driver of the train, Michael Hodder, may have made the decision to keep the train moving instead of stopping and the following conclusions were reached:

Signal Visibility

Due to the limited trackside space, the signals were held in gantries over the tracks. This, combined with the curvature of the lines on the approach, had previously been noted to lead to confusion as to which signal belonged to which track (although at the time of the incident, all 9 signals in the gantry were on red, a clear order to stop all trains). The spacing and proximity to a nearby road bridge (less than 100m to the west) did mean that drivers of trains leaving Paddington could not see the signals until they were relatively close to the gantry. The overhead electrification equipment also in place also further obstructed the signals, with SN109 particularly affected.

In addition, the time of day and weather conditions meant sunshine would have been low in the sky and at the driver’s back, reflecting off the signals and potentially making it harder for him to see the colours, to the extent that he could have seen the red signal as yellow due to the way the sun fell onto the gantry, and as such thought he had a proceed signal.

SPAD reduction initiatives

SPAD (Signal Passed at Danger) reduction initiatives in place were seen to be “disjointed and ineffective”. At the time, there were four separate groups in place that aimed to reduce SPAD incidents, but no one group seemed to be able to get the situation under full control.

Signal Visibility Management

In the past 6 years running up to 1999, there had been eight other occasions where SN 109 had been passed at danger. With this in mind, a “signal sighting committee” should have reviewed the location of the signal and identified causes to ascertain why this signal was being ignored when on red, with remedial action taken to rectify these reasons. Incompetent management and inadequate processes were found to be at the root.

Driver Training

The driver of the Turbo train had only qualified two weeks previously, and had undertaken the legacy Thames Trains training package, which had been flagged in February that year as not “fit for purpose”. There was no clear pass/fail criteria for trainees and, in Hodder’s specific case, he had no previous experience of railway work prior to becoming a train driver, something that should be been kept in mind as the approach to Paddington was notoriously difficult. Previous training schemes operated by British Railways (from whom Thames Trains inherited their training package) would never have allowed a driver with only 13 days experience to undertake this route, preferring instead to only have drivers with 2 years’ experience as a minimum on this route.

Cullen Inquiry

The Cullen Inquiry for this incident was held in 2000 and dealt, in part, with the management and regulation of UK railway safety following the accident. The primary shortcomings identified in this report were:

- Inspection Procedures undertaken by the HSE’s HM Railway Inspectorate.
- Lack of an automatic train protection system on the Turbo train
- Lack of flank protection on the lines at Paddington
- The slow response of the signalmen at the Railtrack signalling centre in Slough, upon realising a train had SPAD SN109.

Final Outcomes

- In 2003, the Rail Safety and Standards board was created, followed by the Rail Accident Investigation Branch in 2005. Both of these are in addition to the Railway Inspectorate. With this structure in place, the three elements of standards-setting, accident investigation and regulatory functions were clearly separated with proper measures in place to assess risks and set responsibilities as required.
- Both Thames Trains and Network Rail were found guilty of negligence and fined.
- Signal SN 109 was changed to a single-lens type signal (alongside many others in the Paddington area). It was initially taken out of service, but came back into service in February 2006.

Eventual Prosecution of Thames Trains & Network Rail

In 2004, Thames Trains were found guilty after admitting violations of H&S law and ordered to pay a record £2 million as well as £75,000 in costs. This was primarily in relation to the standard of training given to Michael Hodder, the driver of the Turbo train.

Network Rail were also found guilty in 2006 of charges under the Health and Safety at Work Act 1974 and ordered to pay £4 million and £225,000 in costs. Officers at Railtrack (which went on to become Network Rail) had been warned numerous times prior to the crash of the potential risk of accidents at Paddington due to the layout of the track and signals, but no action had been taken.

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