70-556: The Ladbroke Grove rail crash (also known as the Paddington rail crash ) was a rail accident which occurred on 5 October 1999 at Ladbroke Grove in London , England, when a Thames Trains -operated passenger train passed a signal at danger , colliding almost head-on with a First Great Western -operated passenger train. With 31 people killed and 417 injured, it was one of the worst rail accidents in 20th-century British history. It
140-468: A proceed aspect. Since the introduction of TPWS, provision of new SPAD indicators has become less common. In the UK, incidents where a signal is passed at danger without authority are categorised according to principal cause. A SPAD is where the train proceeds beyond its authorised movement to an unauthorised movement. Other types are categorised as SPAR ("signal passed at red"). Prior to December 2012,
210-454: A basis for damages claims. Mr Gray was found guilty of the offence of manslaughter by reason of diminished responsibility , and detained in psychiatric care as a result. He then sued Thames Trains, along with Network Rail , seeking compensation for the loss of the earnings which he should have earned to date and might have subsequently have earned if he had not committed the offence and consequently been detained. The High Court initially, and
280-511: A follow-up audit in September 1999 found no evidence of any remedial action being taken. The failure to have signal sighting committees convened was persistent and serious. It was due ... to a combination of incompetent management 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. There had been over
350-550: A less than perfect training programme. The Class 165 unit had been fitted with an Automatic Warning System (AWS) which required the driver to acknowledge a warning every time he approached a signal not at green. If an Automatic Train Protection (ATP) system had been fitted and working it would have automatically applied brakes to prevent the train going beyond any signal at red. National adoption of ATP, British Rail's preferred train protection system, had been recommended after
420-571: A new body should be set up to manage Railway Group Standards. In 1996 ScotRail had initiated the creation of a confidential rail safety reporting system (later to become CIRAS) formed from an independent panel chiefly from Strathclyde University . Other TOCs expressed interest and others in Scotland voluntarily joined the system. Following the Ladbroke Grove rail crash, Deputy Prime Minister John Prescott mandated that all mainline rail in
490-419: A safe overlap if the signal was passed without authority. This effectively removes the chance of a side-impact collision as the train would be diverted in a parallel path to the approaching train. Prior to the introduction of TPWS in the UK, "SPAD indicators" were introduced at 'high risk' locations (for example: the entry to a single track section of line). Consisting of three red lamps, they are placed beyond
560-474: A signal at danger and continue until notified by network controllers, or a collision occurs, as in the Ladbroke Grove rail crash . The causes and prevention of SPADs is actively researched. Causes of SPADs are always multidimensional. Some of the causes of SPADs are: Automatic train protection (ATP) is an advanced form of train stop which can regulate the speed of trains in situations other than at
630-486: A signal set at danger. ATP can supervise speed restrictions and distance to danger points. It can also take into account individual train characteristics such as brake performance etc. Therefore ATP can determine when brakes should be applied in order to stop the train before passing a signal at danger. Presently, In the UK, only a small percentage of trains ( Great Western Railway and Chiltern Railways ) are fitted with this equipment. The driver's reminder appliance (DRA)
700-517: A slack and complacent regime, which was not alive to the potentially dire consequences of a SPAD or of the way in which signallers could take action to deal with such situations. The Health and Safety Executive 's HM Railway Inspectorate was also criticised for its inspection procedures. The then head of HSE told the Inquiry the HSE were concerned about, first, the length of time taken for the approval of
770-682: A specific train to pass a specific signal at danger, proceed with caution and travel at a speed that enables him to stop short of any obstruction, and then obey all other signals. If the signal is fitted with TPWS, the driver resets the Driver Reminder Appliance, pushes the TPWS Trainstop Override button in the cab, and proceeds cautiously through the section. If the train reaches the next signal without finding an obstruction, they must obey its aspect, at which point they can revert to normal working. If contact with
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#1732775783819840-452: A train had passed a signal at danger they should set signals to danger and immediately send a radio "emergency all stop" signal to the driver of the train by Cab Secure Radio (CSR) as soon as they realised that it had done so. In the event, only when the Thames train was 200 m (660 ft) past the signal did they start to send a radio "emergency all stop" signal (it is not clear whether
910-854: Is a valuable aid in studying rail (and other) accidents to help to prevent similar ones occurring in the future. Systematic investigation for over 150 years has led to the railways' excellent safety record (compared, for example, with road transport ). Ludwig von Stockert (1913) proposed a classification of accidents by their effects (consequences); e.g. -on-collisions , rear-end collisions , derailments . Schneider and Mase (1968) proposed an additional classification by causes; e.g. driver 's errors, signalmen 's errors, mechanical faults. Similar categorisations had been made by implication in previous books e.g. Rolt (1956), but Stockert's and Schneider/Mase's are more systematic and complete. With minor changes, they represent best knowledge. Other Signal passed at danger A signal passed at danger ( SPAD )
980-577: Is absent the further down the organisation one goes." Thames Trains inherited a driver training programme from British Rail, which had changed to the point where in February 1999, a concerned incoming training manager commissioned an external audit which reported The trainers did not appear to be following the training course syllabus and supporting notes as they considered these to be 'not fit for purpose' with inappropriate time allowances for some sessions. The traction and introduction to driving section of
1050-589: Is an event on a railway where a train passes a stop signal without authority. This is also known as running a red , in the United States as a stop signal overrun (SSO) and in Canada as passing a stop signal . SPAD is defined by Directive 2014/88/EU as any occasion when any part of a train proceeds beyond its authorised movement. Unauthorised movement means to pass: The name derives from red colour light signals and horizontal semaphore signals in
1120-458: Is an inhibiting switch located on the driver's desk of United Kingdom passenger trains designed specifically to prevent " starting away SPADs ". The driver is required to operate the DRA whenever the train is brought to a stand, either after passing a signal displaying caution or at a signal displaying danger. Once applied, the DRA displays a red light and prevents traction power from being taken until
1190-405: Is not universal; only those signals where the risk of collision is considered to be significant are fitted with it. At certain junctions, especially where if the signal protecting the junction was passed at danger a side collision is likely to result, then flank protection may be used. Derailers and/or facing points beyond the signal protecting the junction will be set in such a position to allow
1260-460: Is taken into account in the making of decisions about rail safety but did not align with the output of CBA (cost-benefits analysis). Any future ATP system will entail expenditure at levels many times higher than that indicated by any approach based upon CBA. Despite its cost, there appears to be a general consensus in favour of ATP . Both TPWS and ETCS would be mandatory and therefore their cost implications need not be considered by any body other than
1330-629: The Clapham Junction rail crash , but later abandoned because the safety benefits were considered not great enough to justify the cost. After a previous SPAD, Thames Trains had commissioned a cost–benefit analysis (CBA) study specific to the Paddington situation which came to the same conclusion. The Ladbroke Grove accident was felt to cast doubt on the wisdom of these decisions. However, the Cullen inquiry confirmed that CBA would not support
1400-659: The House of Lords on appeal, held in support of Thames Trains and Network Rail that: In so far as the claimant's claim relates to losses suffered after the commission of the act of manslaughter on 19 August 2001, that claim will not be entertained by the court and must be dismissed. Pam Warren wrote the book From Behind the Mask which narrates her experiences during the crash, her recovery, and how it has affected her life and relationships. Rail accident Classification of railway accidents , both in terms of cause and effect,
1470-663: The Rail Accident Investigation Branch , in addition to the Railway Inspectorate . Standards-setting, accident investigation and regulatory functions were from then on clearly separated, on the model of the aviation industry. On 5 April 2004, Thames Trains was fined a record £2 million after admitting violations of health and safety law in connection with the crash and ordered to pay £75,000 in legal costs. On 31 October 2006, Network Rail (the successor body to Railtrack, formed in
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#17327757838191540-405: The emergency braking system of a train, and magnets located in the center of the track. At each AWS site, a permanent magnet arms the system and an electromagnet connected to the green signal lamp disarms the system and a confirming chime is provided to the driver. If the receiver does not disarm within one second after arming, a warning tone sounds at the driver's desk and if it is not cancelled by
1610-502: The 06:03 First Great Western train from Cheltenham to Paddington. 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
1680-538: The DRA is manually cancelled by the driver. Whilst the ideal safety system would prevent a SPAD from occurring, most equipment in current use does not stop the train before it has passed the Danger signal. However, provided that the train stops within the designated overlap beyond that signal, a collision should not occur. On the London Underground (for example), mechanical train stops are fitted beside
1750-821: 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. 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. 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
1820-564: The UK come under the Confidential Incident Reporting & Analysis System (CIRAS) to involve every rail employee in the rail safety process. CIRAS now provides services to all rail workers and operating sectors throughout England, Scotland, Wales and the Republic of Ireland (ROI). The Railways Inspectorate had a responsibility for advising on and inspecting against matters affecting railway safety; they were also
1890-472: The UK government and the EU Commission. The inquiry noted evidence that railway safety statistics had not worsened after privatisation, nor had there been any evidence that however privatisation had been carried out it would have been detrimental to safety. Concerns were however expressed about how privatisation had been carried out: Beyond exhortations to do better, the Inquiry recommended changes in
1960-530: The United Kingdom, which are said to be at danger when they indicate that trains must stop (also known as the signal being on ). This terminology is not used in North America where not all red signals indicate stop. In the UK, a signal passed at red ( SPAR ) is used where a signal changes to red directly in front of a train, due to a fault or emergency, meaning it is impossible to stop before
2030-516: The adoption of TPWS (an upgrade of AWS, which could stop trains travelling at less than 70 mph within the overlap distance of a red signal delivering it assessed about 2 ⁄ 3 the safety benefits of ATP at much lower cost) by 2004 (advanced, a week after the crash, to 2003). The separate joint inquiry on the problem nationally noted that ATP and contrasting AWS introduced since about 1958 (and therefore TPWS) had continuing reliability problems and were obsolescent technology inconsistent with
2100-530: The adoption of ATP by Thames Trains. The signalling system on the approaches to Paddington did not incorporate ' flank protection ' (where the points beyond a stop signal are automatically set to direct the train away from the path which would cause a collision). This would have routed the train running past SN109 onto the Down Relief line. This should have been considered at the design stage. The reasons for not engineering flank protection were not known but it
2170-522: The approach to the signal, and will activate the train's emergency brake if it approaches faster than the 'trigger speed' when the signal is at danger . The 'Train Stop System' pair of loops is located at the signal, and will activate the emergency brake if the train passes over them at any speed when the signal is at danger . TPWS has proved to be an effective system in the UK, and has prevented several significant collisions. However, its deployment
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2240-504: The course has been extended and the six week route learning session is being used as additional practical handling. Indeed, Michael Hodder's 16 weeks' practical training had been given by a trainer who felt that "I was not there to teach ... the routes. I was totally to teach ... how to drive a Turbo"; the training manager was unaware of this. Details of signals which had been repeatedly passed at danger should have been supplied to trainers and passed on to trainees; no trainer had done so, and
2310-416: 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
2380-443: 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
2450-443: The distance which you can see to be clear". Failure to do this has caused the following collisions: Except where permissive working is in use, interlocking usually prevents a train from being signalled into a section that is already occupied. When operational needs require it, this can be overridden, and provided it is carried out in accordance with the rules this is a safe practice. However, failure to follow protocol can result in
2520-515: 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 130 mph (210 km/h) with
2590-409: The driver must obtain the signaller's authority to pass it at danger. Methods for contacting the signaller may include GSM-R cab radio, signal post telephone or mobile phone . The signaller can authorise a driver to pass a signal at danger when: The driver and signaller must come to a clear understanding, and ensure they agree about how it is to be done. In the UK the signaller tells the driver of
2660-399: The driver, the emergency brakes will be activated. A visual indication remains set to remind the driver that they have passed a restrictive signal aspect . On the UK mainline, TPWS consists of an on-board receiver/timer connected to the emergency braking system of a train, and radio frequency transmitter loops located on the track. The 'Overspeed Sensor System' pair of loops is located on
2730-479: The formal responsibilities for management and regulation of safety of UK rail transport ensued. 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 2 miles (3.2 km) to
2800-571: The impending standardisation EU-wide per the ETCS European Train Control System . In the year between Ladbroke Grove and the joint inquiry the rail industry (if not the general public) had become largely committed to the adoption of TPWS. Consequently, although the joint inquiry expressed considerable reservations about the effectiveness of TPWS it concurred with its adoption. The joint inquiry noted that public reaction to catastrophic rail accidents ... should be and
2870-512: The industry structure. Railtrack had not merely had responsibility for railways infrastructure, but also a lead responsibility for safety: for acceptance of the Safety Case of each TOC and for setting "Railway Group Standards" (system-wide standards on matters affecting safety). Since it also had commercial interests in these issues TOCs were unhappy with this: Cullen recommended that safety case acceptance should be directly by HSE in future, and
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2940-402: The network running, safety rules enable trains to pass signals that cannot be cleared to a proceed aspect. Provided that authority for the movement is obtained, a SPAD does not occur. There are two methods of obtaining that authority: Once the train has been brought to a stand at a signal which is at danger, the driver should attempt to contact the signaller. If the signal cannot be cleared then
3010-468: 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
3080-422: 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'
3150-506: The practical trainer quoted above was unaware that SN109 was a multi-SPAD signal. Testing of trainees was similarly unstructured and unstandardised, with no clear pass/fail criteria. Under the previous British Railways training regime, trainees would have spent far longer in training and once qualified, were not allowed to drive over the notoriously difficult approach to/from Paddington until they had at least two years' experience on less complex routes. Hodder had only qualified 13 days earlier; he
3220-406: The protecting stop signal and are normally unlit. If a driver passes the signal at 'danger', the top and bottom lamps flash red and the centre lamp, which has the word "STOP" written across the lens in black, is lit continuously. Whenever a SPAD indicator activates, all drivers who observe it are required to stop immediately, even if they can see that the signal pertaining to their own train is showing
3290-404: The rear car was undamaged, able to be used for spare parts. In a subsequent case arising out of a manslaughter committed by one of the victims of the crash, Kerrie Gray, who experienced post-traumatic stress disorder and went on to kill a pedestrian, legal issues were raised regarding the legal principle known as ex turpi causa non oritur actio , which holds that illegal actions cannot form
3360-503: The red signal. The inquiry noted that the lines out of and into Paddington were known to be prone to SPAD mishaps – hosting an unusual concentration of eight SPADs at signal SN109 in the preceding six years – and attempted to identify the underlying causes. Paddington approaches had been resignalled by British Rail in the early 1990s to allow bidirectional working . The number of signals and limited trackside space meant that most signals were in gantries over
3430-510: The signal at danger. However, Hodder was inexperienced, having qualified as a driver only two weeks before the crash. 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). The local signals were known to have caused other near misses – SN109 had been passed at danger on eight occasions in six years, but Hodder had no specific warning of this. Furthermore, 5 October 1999
3500-405: The signal was actually sent before the crash). Their understanding of the instructions was that they should wait to see if the driver stopped of his own accord before attempting to contact him; this interpretation was supported by their immediate manager. The signalmen had never been trained in the use of CSR, nor had they ever used it in response to a SPAD. The general picture which emerged was of
3570-435: The signal. The high inertia of trains, and the low adhesion between the wheels and track, means it takes a long distance for the train brakes to stop a train. SPADs are most commonly a small overrun of the signal (instead of a long overrun), because the driver has braked too late. The safety consequences for these types of SPADs may be minor. On the other hand, some SPADs involve the driver being unaware they have passed
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#17327757838193640-492: The signaller cannot be made then the driver must not move the train, unless it is standing at one of the following signals: After passing a signal at danger under their own authority, the driver must stop at the next signal (even if it is showing a proceed aspect) and inform the signaller of what they have done. Whenever a signal is passed at danger the driver is required to "proceed with caution, stop short of any obstructions, and drive at speed that will enable you to stop within
3710-456: The signalling scheme; secondly, the slow progress by Railtrack and the HMRI in bringing issues to a conclusion; and, thirdly, the inadequate risk analysis. Matters had not been followed up with more urgency. More could have been done to enforce health and safety legislation. She attributed these deficiencies to three causes: A fortnight before the crash the HSE had announced an intention to require
3780-571: The site, accessible from a supermarket car park, at 51°31′30″N 0°12′58″W / 51.5251°N 0.2160°W / 51.5251; -0.2160 . Heavy damage to power car 43011 saw it written off, officially withdrawn in November. After the completion of the inquiry it was cut up by Sims Metals in Crewe, Cheshire in June 2002. The Turbo unit was written off, the front two cars were scrapped;
3850-478: 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. The resignalling had been implemented ahead of formal HMRI approval; awaited at the time of the crash. 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: ... from
3920-446: The term "SPAD" applied to all such incidents, with a letter specifying cause. Some SPADs are defined as a; Signals form part of a complex system, and it is inevitable that faults may occur. They are designed to fail safe , so that when problems occur, the affected signal indicates danger (an example where this did not happen, known as a wrong-side failure , was the Clapham Junction rail crash due primarily to faulty wiring). To keep
3990-440: The time all the other gantry 8 signals westbound were also showing red. Local spacing between signals and points was designed to allow fast through-running by freight trains, such that gantry 8 was less than 100 metres (330 ft) west of a road bridge not at high level; 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,
4060-525: The track at signals to stop a train, should an S.P.A.D occur. Train stops are also installed on main line railways in places where tripcock equipped trains run in extensive tunnels, such as the on the Northern City Line where the Automatic warning system and Train Protection & Warning System are not fitted. On the UK mainline, AWS consists of an on-board receiver/timer connected to
4130-419: The tracks; the curvature of the lines meant that it was not always obvious which signal was for which track. Reflective line-identification signs had therefore been added but, the inquiry report noted, 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
4200-494: The usual investigating body for serious railway crashes. Cullen felt that there was "a strong argument for an investigating body which enjoys real and perceived independence" and therefore recommended that rail accident investigation should become the responsibility of a separate body. The recommendations of Lord Cullen's inquiry into the crash led to the creation in 2003 of the Rail Safety and Standards Board and in 2005 of
4270-516: The wake of a subsequent train crash at Hatfield ) pleaded guilty to charges under the Health and Safety at Work Act 1974 in relation to the accident. It was fined £4 million on 30 March 2007 and ordered to pay £225,000 in legal costs. Signal SN109 was brought back into service in February 2006. It and many other signals in the Paddington area are now single-lens type signals. A memorial garden and cenotaph has been created, partially overlooking
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#17327757838194340-510: 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
4410-597: 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. 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:
4480-406: 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. 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
4550-400: 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. 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. Poor signal placement meant that Hodder would have seen the reflection of
4620-412: Was ex-navy with no previous experience as a railway worker, but no special attention was paid to this in either training or testing. It must be concluded therefore that [the driver's] training was not adequate for the task for which he was being prepared. The very favourable comments made as to his progress by his various teachers have to be viewed against the background that his teachers were working with
4690-493: Was noted that the introduction of Automatic Train Protection (ATP) had been thought to be imminent at previous safety reviews. Flank protection would have increased the 'overlap' (the distance for which a train could run past the signal before fouling lines) at SN109; the desirability of doing so should have been considered by the risk assessment which had not taken place. The written instructions for Railtrack signalling centre staff at Slough were that as soon as they realised that
4760-619: 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. All new or altered signals or which had multiple SPADs 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
4830-618: 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, a few 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
4900-459: 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. The immediate cause of
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