Southall Rail Accident Inquiry Report - The Railways Archive

312 Pages·2006·5.14 MB·English

by  Garry Keenor

iealth 6 Safety
Commission
The Southall Rail Accident Inquiry Report
Professor John Uff QC FREng
-
2
Erratum
The Southali Rail Accident Inquiry Report iSBN 0 7176 1757 2
Annex 09 Passengers & Staff believed to have sustained injury as a result of the
accident
Include 'Stuttard, Janis, Mrs Coach H'
Delete ' Stothart, Chloe Helen, Miss Coach C'
MlSC 210
HSE BOOKS
0 Crown copyright 2000
Applications for reproduction should be made in writing to:
Copyright Unit, Her Majesty's Stationery Office,
St Clernents House, 2-16 Colegate, Nofwich NR3 1BQ
First published 2000
All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted
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LIST OF CONTENTS
Inquiry into Southall Railway Accident
Preface
Glossary
Report Summary
PART ONE THE ACCIDENT
Chapter l How the accident happened
Chapter 2 The emergency response
Chapter 3 The track and signals
Chapter 4 Why was the freight train crossing?
Chapter 5 Driver competence and training
Chapter 6 Why were the safety systems not working?
Chapter 7 Why the accident happened
PART TWO EVENTS SINCE SOUTJULL
Chapter 8 The Inquiry and delay to progress
Chapter 9 Reactions to Southall
Chapter 10 Ladbroke Grove and its aftermath
PART THREE WIDER SAFETY ISSUES
Chapter 11 Crashworthiness and means of escape
Chapter 12 Automatic Warning System (AWS)
Chapter 13 Automatic Train Protection (ATP)
Chapter 14 Railway Safety Issues
PART FOUR CONCLUSION
Chapter 15 Discussion and Conclusions
Chapter 16 Lessons to be learned
Chapter 17 Recommendations
ANNEXES
THIS Report follows an Inquiry held between September and December 1999
into the cause of a major rail accident which occurred on 19 September 1997 at
Southall, 9 miles west of Paddington. The trains involved were the Great Westem
Trains (GWT) 10:32 Swansea to Paddington High Speed Train and a freight train
operated by English Welsh and Scottish Railway (EWS), which was crossing the Up
Main line to enter Southall Yard. Seven people died as a result of the accident and a
further 139 people were injured, some severely. The Inquiry was set up within hours
and directed to sit in public. The terms of reference are as follows :
The purpose of the Inquiry is to determine why the accident happened,
and in particular to ascertain the cause or causes, to identify any lessons
which have relevance for those with responsibilities for securing railway
safety and to make recommendations.
The Inquiry proceedings began in December 1997 with a formal opening in
February 1998. The driver was charged with manslaughter in April 1998, but no
further progress could be made by the Inquiry pending decisions on criminal charges
being considered against GWT. This was not resolved until December 1998 when
manslaughter charges and charges under the Health and Safety at Work Act 1974
were brought against the driver and against the operating company. Criminal
proceedings took their course and were not finally resolved until July 1999. The
Inquiry proceedings then commenced at the earliest possible date. During the
proceedings, a further tragic accident occurred at Ladbroke Grove which has led to
the setting up of further Inquiries and to a review of the issues to be dealt with in the
present Inquiry.
The Southall collision was the first major accident to occur within the British
rail network since privatisation of the railway industry, which formally started with
the transfer of the railway infrastructure to Railtrack on 1 April 1994. The public sale
of Railtrack and letting of operating franchises followed. GWT had been set up as a
separate operating division before privatisation. The company acquired its franchise
on I February 1996 and had therefore been operating independently for some 19
months only, when the accident occurred. It would be wrong to see the Inquiry and
this Report as an inquiry into privatisation. Nevertheless, the new structure of the
industry has inevitably affected the events under consideration. At the same time it
will be seen that the new industry is still heavily influenced by procedures and
structures inherited from British Rail. It should be emphasised that the objective of
this Report is to set down the facts and to draw appropriate conclusions in accordance
with the Terms of Reference set by the Health and Safety Commission.
A large proportion of those who gave evidence at the Inquiry were railwaymen
and women, all experts in their respective fields. Most of this Report deals with
technical issues of varying complexity. While the Recommendations contained at the
end of this Report are addressed to the railway industry, the Report itself is intended
to be read by the travelling public who are entitled, through this Inquiry, to know how
the railway operated and precisely what went wrong so as to cause such a tragic
accident. The Inquiry heard witnesses and representations on behalf of a large
number of parties including passenger groups and representatives, Trades Unions, rail
operators, a rolling stock leasing company, an infrastructure maintenance company
and Railtrack. Also represented were the emergency services including ambulance,
fire and police services, and the Health and Safety Executive which includes HM
Railway Inspectorate. A full list of parties and their representatives is at Annex 1. A
full list of witnesses, including those whose statements were read to the Inquiry, is
included at Annex 2. A list of terms and abbreviations follows this Preface.
I extend my gratitude to the skilled and experienced Inquiry team with which I
was privileged to work. In order of their appointment, David Brewer took on the role
of Inquiry Secretariat before my own appointment and has organised the efficient
running of every aspect of the Inquiry throughout, including masterminding an
information database which has been appreciated by all the parties who have appeared
at the Inquiry. Major Anthony King OBE, himself a highly experienced Inspector of
Railways and Chairman of many Inquiries, was appointed Technical Assessor. His
tactful guidance on railway issues throughout the Inquiry has been invaluable.
Counsel to the Inquiry was Ian Burnett QC, who appeared with Richard Wilkinson.
Their capacity for mastering the huge volumes of documents generated by the Inquiry
proved to be as prodigious as the task and their contribution has been appreciated by
all. Last to be appointed to the team was Laurance O'Dea, Treasury Solicitor, who
took on the task of collating the written evidence and organising the attendance of 107
witnesses who were heard in person, many of whom appeared on several different
occasions. His success is measured by the fact that the Inquiry managed to achieve all
of its timetable objectives, despite the intervention of the Ladbroke Grove crash. A
list of Inquiry personnel is at Annex 3.
Finally, appreciation is due to David Brewer and to my secretary, Dorothy Dixson for
producing the Report.
Keating Chambers
10 Essex Street
Outer Temple John Uff QC FREng
London WC2R 3AA 3 1 January 2000
Glossary of Terms
AbbreviationITerm Definition
ACEC Suppliers of ATP equipment
AEA Technology Technical Consultants
ALARP As Low As Reasonably Practicable
Amey Rail Maintenance contractors
ARS Automatic Route Setting
ATC Angel Train Contracts
ATOC Association of Train Operating Companies
ATP Automatic Train Protection
Audit Procedural Check e.g. on Maintenance or Safety Provisions
AWS Automatic Warning System
AWS test box Equipment used to test AWS
BR British Rail
BRB British Rail Board
BRIMS British Rail Incident Monitoring System
BTP British Transport Police
CBA Cost Benefit Analysis
Country end Leading Power car on leaving Paddington
CPS Crown Prosecution Service
CIRAS Confidential Incident Reporting and Analysis System
CRUCC Central Rail User's Consultative Committee
DRI Driver Restructuring Initiative
Diagram Driver's route card
DM Driver Manager
DNV Technica Technical Consultants
DO0 Driver Only Operation
DRA Driver Reminder Appliance
DSM Driver Standards Manager
DSD Driver Safety Device
DVD Driver Vigilance Device
EQE Technical Consultants
EROS Emergency Restriction of Speed
EWS English Welsh and Scottish
FRAME Fault Reporting And Monitoring of Equipment Computer System
Group Standard Mandatory documents defining minimum requirements to ensure
system safety and safe interworking on Railtrack's infrastructure.
GWR Great Western Railway
GWT Great Western Train Company
HEX Heathrow Express
HMRI Her Majesty's Railway Inspectorate
HSC Health and Safety Commission
HSE Health and Safety Executive
HST High Speed Train
IECC Integrated Electronic Control Centre