The Ladbroke Grove rail crash (also known as the Paddington rail crash) occurred on 5 October 1999 at Ladbroke Grove in London, England, when a Thames Trains passenger train passed a signal at danger, colliding almost head-on with a First Great Western passenger train. With 31 people killed and 417 injured, it was one of the worst rail accidents in 20th-century British history.
It was the second major crash on the Great Western Main Line in just over two years, the first being the Southall rail crash of September 1997, several miles west of this crash. Both crashes would have been prevented by an operational automatic train protection (ATP) system, wider fitting of which had been rejected on cost grounds. The crash severely damaged public confidence in the management and regulation of safety of Britain's privatised railway system.
A public inquiry into the crash by Lord Cullen was held in 2000. Since both the Paddington and Southall crashes had reopened public debate on ATP, a separate joint inquiry considering the issue in the light of both crashes was also held in 2000; it confirmed the rejection of ATP and the mandatory adoption of a cheaper and less effective system, but noted a mismatch between public opinion and cost-benefit analysis. Major changes in the formal responsibilities for management and regulation of safety of UK rail transport ensued.
Incident
At 08:06 BST on 5 October 1999, a British Rail Class 165 Turbo diesel multiple unit or DMU, No. 165 115, left Paddington Station on a Thames Trains service to Bedwyn railway station in Wiltshire, driven by 31-year-old Michael Hodder. From Paddington to Ladbroke Grove Junction (about to the west), the lines were bi-directional (signalled to allow trains to travel in either direction, in and out of the platforms of Paddington Station); beyond Ladbroke Grove the main line from London to South Wales and the West of England is a more conventional layout of two lines in each direction ('up' for travel to London, 'down' for travel away from London) carrying both fast and slow trains.
Being an outbound train, it would have been routed onto the down main line at Ladbroke Grove. It should have been held at a red signal at Portobello Junction until it could be rerouted safely. Instead, it passed the signal; and the points directed the multiple unit onto the Up Main Line at Ladbroke Grove. At about 8:09, as it was entering the Up Line, it collided nearly head-on and at a combined speed of approximately with the 06:03 First Great Western train from Cheltenham to Paddington.See section 3 of the Inquiry Report Volume 1
The 06:03 InterCity 125 high speed train (HST) was driven by 52-year-old Brian Cooper. It consisted of a rake of eight Mark 3 coaches with a Class 43 diesel power car at each end, here led by No. 43 011. The chassis and body of the HST are notably stronger than the structure of the Class 165 DMU, the leading car of which was totally destroyed. The diesel fuel it was carrying was dispersed by the collision and ignited, leading to a series of fires in the wreckage, particularly in coach H near the front of the HST, which was completely burnt out.
The drivers of both trains were killed, as well as 29 others (23 on the Class 165, five on the HST as a result of the impact, with a further fatality as a result of the fire), and 417 people were injured.Inquiry Report Vol 1 paras 4.52–4.54, 4.57–4.59 (pp. 29–30) One of the survivors was the author Jilly Cooper, who was travelling on the HST.
Immediate cause The immediate cause of the disaster was determined to be the Class 165 passing a red signal (numbered SN109 on gantry 8 overhead beside four signals serving other tracks) at which the train should have been stopped. The signal was displaying a red aspect, and the preceding signal a single yellow which should have alerted the driver of the red signal ahead. Since Hodder, the driver, was killed in the collision, it was not possible to establish why he had passed the signal at danger. However, Hodder was inexperienced, having qualified as a driver only two weeks before the crash.Inquiry Report Vol 1 para 5.51 His driver training was found to be defective on at least two grounds: assessing situation-handling skills, and being notified of recent local incidents of signals passed at danger (SPAD).Inquiry Report Vol 1 para 5.46 The local signals were known to have caused other near misses – SN109 had been passed at danger on eight occasions in six years,Counsel for Railtrack: "One could say SN109 was a black spot" Inquiry Report Vol 1 para 5.22 but Hodder had no specific warning of this.Inquiry Report Vol 1 para 5.43 Furthermore, 5 October 1999 was a clear day and at just past 08:00 the sun would have been low, behind Hodder, meaning that sunlight would reflect off yellow aspects, reducing visibility.Inquiry Report Vol 1 para 5.81 The driver of a previous westbound train reported that "all the signals right the way across all lit up like a Christmas tree" at gantry 6 at about 7:50 that morning.Inquiry Report Volume 1 para 5.62 Poor signal placement meant that Hodder would have seen the reflection of the yellow aspects of SN109 at a point where his view of the red aspect (but not of any other signal on the gantry) was still obstructed.Inquiry Report Vol 1 para 5.77 The inquiry considered it more probable than not that the poor visibility of SN109, caused by not only its own position but the positioning of other signals at gantry 8, along with the reflections of sunlight, led Hodder to believe that he was able to proceed and pass the red signal.Inquiry Report Vol 1 para 5.111
Contributory factors The inquiry noted that the lines out of and into Paddington were known to be prone to SPAD mishapshosting an unusual concentration of eight SPADs at signal SN109 in the preceding six yearsand attempted to identify the underlying causes.
Problems with signal visibility Paddington approaches had been resignalled by British Rail in the early 1990s to allow bidirectional working.Phase 1 commissioned July 1993: Inquiry Report Vol 1 para 7.4 The number of signals and limited trackside space meant that most signals were in gantries over the tracks;Inquiry Report Vol 1 para 7.4 the curvature of the lines meant that it was not always obvious which signal was for which track.Inquiry Report Vol 1 para 5.19 Reflective line-identification signs had therefore been added but, the inquiry report noted,Inquiry Report Vol 1 para 5.17 they were closer to the signal to the right hand side than to the signal for the line to which they related. However, misreading of which signal related to which track cannot have caused the fatal crash, because at the time all the other gantry 8 signals westbound were also showing red.Inquiry Report Vol 1 para 3.19 Local spacing between signals and points was designed to allow fast through-running by freight trains,Inquiry Report Vol 1 para 5.10 such that gantry 8 was less than west of a road bridge not at high level;Inquiry Report Vol 1 para 5.12 this compromised the distance from which the signal could be seen by drivers of trains leaving Paddington. To allow the higher ('proceed') aspects to be seen sooner, the standard signals (with the four aspects arranged vertically) were replaced with non-standard 'reverse L' signals, with the red aspect to the left of the lower yellow.Inquiry Report Vol 1 para 5.15 The resignalling had been implemented ahead of formal HMRI approval; awaited at the time of the crash.partly because HMRI did not want to take a view until prosecutions arising out of the Southall crash had been resolved: Inquiry Report vol 1, para 10.9
The line had been electrified to allow the new Heathrow Express service to operate from 1994 with overhead electrification equipment that further obstructed drivers' view of signals:Inquiry Report Vol 1 para 7.16
... from the outset there was not an adequate overall consideration of the difficulties which would face drivers, in particular in signal sighting, on which the safety of travellers critically depended. Secondly, when difficulties did emerge, there was not an adequate reconsideration of the scheme. There was a resistance to questioning what had already been done. Cost, delay and interference with the performance objectives underlay that resistance.
The red aspect of SN109 was particularly badly obscured by the overhead electrification equipment; it was last of all the gantry 8 signal aspects to become clearly visible to the driver of a Class 165 approaching from Paddington.Inquiry Report Vol 1 para 5.74
Problems with signal visibility management All new or altered signalsInquiry Report Vol 1 para 7.31 or which had multiple SPADsInquiry Report Vol 1 para 7.38 should have been reviewed for sighting issues by a 'signal sighting committee', but none had been held for signals around Paddington since Railtrack assumed responsibility for this in April 1994. An internal audit in March 1999 had reported this, but a follow-up audit in September 1999 found no evidence of any remedial action being taken.Inquiry Report Vol 1 para 7.42
The failure to have signal sighting committees convened was persistent and serious. It was due ... to a combination of incompetent managementthe Report speaks of 'a culture of apathy and lack of will to follow up promised actions' Inquiry Report Vol 1 para 7.41 and inadequate process, the latter consisting in the absence of a process at a higher level for identifying whether those who were responsible for convening such committees were or were not doing so.Inquiry Report Vol 1 para 7.45
There had been over the years a number of proposals or recommendations for the risk assessment of the signalling in the Paddington area; none of them was carried into effect.Inquiry Report Vol 1 para 7.47 Multiple SPADs at SN109 in August 1998 should have triggered a risk assessment; none took place. An inquiry into a February 1998 SPAD at SN109 had already recommended risk assessment of signalling on the Paddington–Ladbroke Grove bi-directional lines; this and many other inquiry recommendations had not been implemented:Inquiry Report Vol 1 para 7.96 the Railtrack employee with formal responsibility for action-tracking had been told his responsibility ended once someone accepted an action, and did not extend to checking that they had acted upon it.Inquiry Report Vol 1 para 7.103
'Disjointed and ineffective' SPAD reduction initiatives Between February 1998 and the accident there had been four separate groups set up with the aim of reducing SPADs; their existence, membership and functions overlapped.Inquiry Report Vol 1 para 7.107 A Railtrack manager told the inquiry how he struggled on his arrival in October 1998 to understand how "so many apparently good people could produce so little action": people had burdens that were too complex; they were not prioritising; people were "square pegs in round holes"; some were not competent; and, in summary, "the culture of the place had gone seriously adrift over many years". The chief executive of Railtrack spoke of a seemingly endemic culture of complacency and inaction, which he said reflected the culture of the old British Rail: "The culture is one in which decisions are delegated upwards. There has been little empowerment. People have tended to manage reactively, not proactively. The basic management discipline of 'plan-do-review' is absent the further down the organisation one goes."Inquiry Report Vol 1 para 7.115; whilst conversely the HSE blamed a move away from British Rail behaviours for their failure to regulate effectively; the evidence points to the Railtrack culture 'falling between two stools'
Problems with driver training