Rail 401: HSE ignores the interlocking causes of Ladbroke Grove

The Health & Safety Executive’s report on the Ladbroke Grove inquiry was supposed to be a factual document setting out what happened on October 5 1999. So why, asks CHRISTIAN WOLMAR, does it make so little mention of the track layout – and particularly the point interlocking, which played such a central part in the disaster?

Amid all the pre-Christmas chaos, the Health & Safety Executive slipped out its report on the Ladbroke Grove inquiry (RAIL 400). I’m not sure why it bothered to do so at this precise time because it is a factual report setting out what happened, rather than an analysis of the causes of the accident, and therefore most of it will be overtaken by the Cullen report due out later this year.

Even given the preliminary nature of the report, however, there is a very major omission which is troubling – there is no significant mention of the track layout and, in particular, the way that the points were interlocked, which has a serious bearing on the accident.

As with any major accident, the causes are, on investigation, complex and various. We all know the basic story now. Driver Michael Hodder took his Thames Class 165 Turbo DMU through a red light, and 700 yards later smashed headlong into a High Speed Train at an impact speed which the HSE now estimates to be 130mph.

The report examines all the obvious issues, such as signal sighting, driver training and the failure of the investigations of previous signals passed at danger (SPADs). There is even plenty of stuff about crashworthiness, which raises concerns that Cullen may well make a series of expensive recommendations on how to make trains more crash-resistant, when the real issue is that such high-speed accidents are incredibly rare and, instead, everything should be done to prevent them rather than trying to mitigate their effects.

How many drivers survive head-on car crashes at a speed of impact of 130mph? We would all have to be driving round in tanks to ensure survivability at such speeds.

So it’s even more worrying that the track layout is barely mentioned in the HSE’s factual report when clearly it played a key rôle in the disaster. The issue, as I wrote in the Independent on Sunday a few days after the crash, is that a key set of points was positioned in such a way as to have allowed the Thames train to head straight on to the Up line.

The set of points, 8059, is some 400 yards after the infamous signal SN109. The points, which lead back to the Down slow which the train had just left, were set against the Thames train on the basis that, had they been open, the train would have had less time to stop after a SPAD. The assumption was that a driver would eventually notice that he had gone through a signal at danger and therefore it was safer to give him the maximum length of track in which to slow down. But even though there had been a series of SPADs at that signal, one of which nearly resulted in a disaster, no one sat down and thought: what if the driver never realises that he has gone through a red light and merely continues travelling along the track?

If a proper risk assessment of this layout had been carried out, two scenarios would have been taken into account: if 8059 was set against a train that had gone through a signal at danger, then the consequences would be that it goes on to the Up line where there is a strong possibility of a very fast head-on collision; alternatively, if 8059 was open, then there would be a risk of a side-on or rear-end crash at much lower speeds.

And note that since the Thames train had just left that track, the most likely possibility in many cases would be that there would be no crash at all since the track was likely to be empty.

There is another question about this – was 8059 deliberately set against the Thames train or were they just left in the last position used by a train? The HSE provides no answer. Surely the HSE report should have considered why 8059 did not prove the saviour and consider whether there is an inherent flaw in the design. Thus making the overlap arbitrary and invalidating the standards and making the chances of a head-on collision after a SPAD at SN109 a lottery depending on the timetable.

Indeed, why is there no mention of any of this in the HSE report? Surely, a factual report should look at all the facts, including the layout of the track and the interlocking.

Is it because the HSE agreed the Paddington redesign to accommodate the Heathrow Express trains in 1995, just four years before the disaster? Its report says blandly that according to a report by WS Atkins, the layout conformed to existing signalling principles.

Even if this were the case, which some people within the industry dispute, the ‘factual’ report should surely question whether these principles are adequate given the resulting disaster. It is vital that Lord Cullen does not neglect this issue in his report.

Virtuous Virgin – but will it work?

Virgin’s offer to cut the price of tickets on its trains has all the hallmarks of being an off-the-cuff decision by Sir Richard Branson. That does not mean it is a mistake. Far from it. As this column has advocated several times, the railways must do something special to attract passengers back on to the network.

However, there are risks attached which a less impetuous fellow than Sir Richard might have considered. The half-price offer came just a couple of days after a leaked MORI report commissioned for Railtrack suggested it may take four or five years before passenger numbers return to post-Hatfield levels. I think that is unduly pessimistic. It was based on asking people their intentions, and respondents to surveys give very arbitrary answers about what they may or may not do in five years’ time.

However, the survey rightly identifies that the recovery will not be easy or straightforward. I suspect that Sir Richard heard of these findings and decided that he had to take action. He may also have been influenced by the fact that there had also just been considerable coverage of fares rises, even though both Virgin and GNER were canny enough not to impose any.

The timing of Virgin’s scheme is, therefore, something of a gamble. The main problem is whether the West Coast Main Line will be in a sufficiently good state to ensure that at least most people have a comfortable, as well as cheap, journey.

It is no good attracting people back on to the railways if they are going to suffer nightmare journeys yet again. GNER has clearly taken a more cautious approach, waiting until Easter to offer discounts, which has the added advantage that the scheme will be in place for a period when more people want to travel.

There are, too, the practical difficulties of ensuring that all Virgin’s customers can benefit. Undoubtedly, there will be tales in the ever-hostile media of people who may have been refused a half-price ticket because the fare is determined by another operator or the ticket clerk is not employed by Virgin.

Virgin’s plan also highlights the woeful failure of the industry to act in concert. The fact that most operators saw fit to increase their fares despite the terrible service which they had offered their passengers in the previous three months shows the extent to which most rail companies – and I suspect it is their corporate bus-company owners rather than the rail executives themselves – are only interested in maximising short-term profits rather than laying the foundations of long-term businesses.

Yes, of course higher fares give an immediate boost to income figures, but just how many more people will be put off rail travel for ever?

The rail companies have failed to realise that this is a battle for hearts and minds. The press coverage has at times been awful and unfair, but giving the media the opportunity for another week of anti-rail stories, just to put a few pence on average fares was hardly worth the trouble.

But the dozen or so executives who sit round the table at the Association of Train Operators took three years just to agree to use the term ‘National Rail’ so they are hardly likely to make any far-sighted decisions like scrapping fares rises until the railways are back to normal. One may well ask – if the worst ever crisis on the railways has not been sufficient to get them to work as a team, what would it take to do so?

With public support for a reorganisation and even possible renationalisation of the railways, they cannot afford to sit on their hands and do nothing.

This is a time to act together, putting aside their petty squabbles and think of the big picture. Otherwise, they may not have the opportunity to play with their train sets much longer.

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