Rail 412: It is time to inquire into the purpose of these inquiries

Lord Cullen’s Ladbroke Grove inquiry report is well-written and admirably detailed but has major omissions – and, argues CHRISTIAN WOLMAR, raises serious questions about the purpose of such high-profile investigations into railway accidents.

As the collection of thick accident reports on my bookshelf grows ever longer, it is time to question exactly what the process of these inquiries achieves.

When there is a railway accident, the politicians and safety authorities are quick to announce that there will be an inquiry. A suitably grey and respectable member of the upper classes – a Lord preferably, or failing that a Professor, but invariably male, middle-aged and a trifle self-important – is chosen. Hearings are held, time elapses while the report is written and then we get the ultimate cathartic experience as various hapless people and organisations are named and shamed in the final report. Politicians immediately endorse the report and say everything will be acted upon, the survivors and relatives have their five minutes of fame and the good lord goes back to his normal business.

Now don’t get me wrong. I do not belittle the awful experiences of those killed in the crash, the survivors, some maimed and scarred for life, and the relatives of those who died or were traumatised. They have suffered terribly and it is understandable the survivors and relatives feel that pushing for improvements in rail safety will make some sense of the tragedy.

It also needs to be said that, as the stories in our news pages show, this was a shameful accident for the rail industry. It is a searing indictment of the early years of privatisation, when the upheavals created by the structural changes seem to have led to railway managers taking their eye off the ball. Moreover, the lack of basic competence in the Railtrack Great Western Zone beggars belief. The failure to heed the warnings, to take action which had been recommended, to allocate responsibilities, to convene signal sighting meetings, to train signallers about how to deal with SPADs and many more mistakes are highlighted in graphic detail.

Thames Trains must take its share of the blame, too, with its appallingly incompetent driver training programme and its failure to learn from other incidents.

However, I want to return to the subject of these inquiries and the way they are conducted. Lord Cullen was remarkably defensive and even evasive at the press conference to launch his report. He kept on referring either to his report or his previous report or simply refused to engage in any wider issues. (Referring to his report was remarkably unhelpful since reporters had only been given a miserable 1/2-hour in which to read it, a shameful bit of news management by the Health & Safety Executive, which could easily have let people in for a couple of hours on the strict understanding they could not file any copy until afterwards.) That was frustrating for the media, particularly TV and radio who were not even given the opportunity for individual interviews afterwards.

The reason was clear. Cullen was trying to avoid offering any hostages to fortune which would give the tabloids the chance for even more over-the-top headlines the next morning. But that raises the issue of the validity of this process. The bald report inevitably leaves various questions unanswered or exposes assumptions made by the inquiry team. But, it seems, we are not allowed to question their thinking or the reasons behind certain assumptions.

So what exactly is this process for? In the old days, as my colleague Stanley Hall, the deeply knowledgeable author of a string of books on railway accidents, never tires of saying, the inspector would come along, hold hearings for a few days in a local village hall, and pronounce within a few weeks on the causes of the accident. The industry would take heed, remedying obvious faults, and, usually, the same sort of incident would not happen again.

What is the added value, then, of having a Cullen rather than an obscure major-general, as the inspectors used to be? Not a lot. There are many things on which one can take issue with the good lord. I have already done so with him and his co-author of the joint report into Ladbroke Grove and Southall (RAIL 407) about their recommendation on train protection systems published in March. This was a fundamentally flawed piece of work because it seemed to be based on the premise that the pockets of taxpayers were infinitely deep when it came to matters of rail safety.

While Cullen’s report is full of fascinating detail and commendably well-written, it too has major flaws and gaps. It takes us no nearer in the impossible task of ascertaining why exactly did driver Michael Hodder so fatefully blow that red light. It fails to consider properly the particular bugbear of this column, the reason for the failure to provide flank protection with the points located some 250 yards after the signal which, had they been set the other way, would have ensured that this was only yet another fortuitously harmless SPAD in the Paddington area.

Worst of all, Cullen seems to be bereft of all logic when he acquiesces in Thames’s decision not to install Automatic Train Protection on its trains (when neighbouring Chiltern, operating on a much less busy line but with a proper railwayman, Adrian Shooter, in charge, already had ATP). Cullen accepts the WS Atkins report which was commissioned when Thames took over the franchise on whether it should fit ATP. The report suggested that the costs outweighed the benefits by a ratio of three to one, even though he agrees that possibly some of the calculations were flawed and that insufficient account may have been taken of the implications of the unlikely event of there being a catastrophe.

The amounts were trivial. On WS Atkins’ rather exaggerated estimates of the costs, the price of fitting ATP would have been £8.2m. Yet, and this is breathtaking in its contradiction, Cullen-Uff merrily accepted that the European Train Control System had to be fitted on all high-speed lines at a cost of £2-3bn (Railtrack privately suggests this is already £3.6bn and rising), a scheme where the costs outweigh the benefits by something like 30 to one.

Cullen is a lawyer – in other words, an amateur – who after producing his second report presumably will have nothing else to do with the rail industry. Yet on his judgements, which he is unwilling to debate in public, will rest all kinds of vital decisions in the industry.

Of course, it is impossible to go back to the days when there were no lawyers at these hearings and there was co-operation from everyone within the industry who all worked for the same employer. However, when there is another accident – and there always will be one – hopefully ministers will think twice before announcing yet another extremely highprofile inquiry. The muted reaction of Stephen Byers to the Cullen report bodes well for the future.

Nor, however, should the process go completely in the opposite direction with everyone trying to hide behind closed doors. The Hatfield accident raises even more fundamental questions about the running of the rail industry than either Ladbroke Grove or Southall. The results of the internal industry inquiry must be made public and subject to scrutiny. If not, there will, rightly, be a public outcry.

The correct balance seems to have been achieved in the aviation industry where the Air Accident Investigation Branch publishes authoritative and full inquiry reports by professionals within a reasonable timescale. Witnesses are interviewed privately but the detailed nature of the reports ensures that all relevant issues are considered. Hopefully, this will be the route followed by Cullen in his part two inquiry report which is considering the management of safety within the industry and is due to be published later this year.

Tories sink to a new low

An added problem of these high-profile inquiries is the great long-term damage they do to the image of the rail industry. In the various TV and radio broadcasts I do on such occasions, I spend a lot of the time defending the industry against ridiculous perceptions of danger, heightened by the hysterical media.

For example, nearly three-quarters of respondents to a poll conducted in conjunction with a Sky TV phone-in on the day of the publication of the Cullen inquiry claimed not to feel safe on trains.

One woman phoned to say she had spent a whole London-Stoke journey clutching her daughter, totally terrified about the prospect of a train crash. “I would have taken the coach had there been one,” she said. Of course, that would have been far more dangerous.

The broadcast media seem to take the opportunity of these events to allow all kinds of irrational views to be put forward. On the Nicky Campbell show on Radio 5, a caller repeated that hardy perennial of concreting over rail tracks and replacing them with busways. I must have been a bit sharp in my rejection of the idea as Nicky Campbell thanked me rather ironically for ‘the Draconian way’ in which I had put down the caller. Then the BBC 10 O’Clock News gave airtime to a Ladbroke Grove survivor who said that since after the Concorde crash, they grounded the planes, “shouldn’t they ground all the trains?”. They already are, old chap.

Chris Leah, Railtrack’s Safety Director, manfully went round the studios pointing out rail was the safest form of land travel. Chris – a word of advice: say ‘travel’ rather than ‘land travel’. As I have pointed out before, the figures for rail accidents are unfair because they include all sorts of mishaps which happen to passengers, such as falling off platforms or drunk down station steps. Air safety statistics do not include people who fall down escalators at airports and therefore are unfairly weighted. Rail is, on that basis, much safer than air.

The situation is not helped by the intervention of the politicians. Bernard Jenkin, the Tory transport spokesman, issued a disgraceful press release which started: “There can be no price on a life.” It went on to argue that “there can never be justification to put commercial considerations ahead of safety”.

So, Bernard, trains should be fitted with three empty coaches at the front and back as buffer zones, and the interiors should be padded to withstand impacts of people flying around at 100mph? Come on, Bernard, you can do better than that.

Scroll to Top