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Tuesday, 19 June, 2001, 11:29 GMT 12:29 UK
Ladbroke Grove inquiry at a glance
The train crash was the worst in a decade
The main findings of Lord Cullen's report into the mistakes leading up to the Ladbroke Grove rail crash on 5 October 1999 published on Tuesday. There are 89 recommendations for improvements in his 270-page report.

  • Railtrack failed to respond to earlier Spads -instances of signals passed at danger in the Paddington area.

    Confusion resulted from too many groups dealing with similar issues.

    There were Spads at Royal Oak in London on 10 November 1995, and at signal 109 on 4 February 1998.

  • Thames Trains criticised for "gaps" in driving training.

    The primary cause of the crash was the failure of the Thames Trains driver Michael Hodder to stop at a red signal as he left London.

    Mr Hodder, 31, was killed in the crash. He had qualified only 13 days before and had received inadequate training.

  • Difficulties in reading train signals.

    Poor sighting of signal 109 and bright sunlight at a low angle contributed to Mr Hodder's belief that he could proceed.

    Mr Hodder had not been informed properly about the type of signal in place at Ladbroke.

    Problems with signal sighting had been accentuated by incompetent management.

  • Signaller training criticised.

    Signallers inadequately instructed and trained in how to react to a SPAD.

    A Slough control centre signaller tried to prevent the collision.

    But there was a failure to realise the importance of communication between the signaller and driver.

  • The Railway Inspectorate could have done more but did not due to "a lack of resources and a lack of vigour in pursuing issues."

  • Thames Trains' removal of all in-carriage emergency hammers before the crash "compromised the safety of passengers".

  • After the accident there was no organised evacuation of passengers.

    Great Western passengers had difficulty in knowing how to open the external doors, and where to find and how to use hammers to break windows.

    Main recommendations

    Lord Cullen made 89 recommendations. They included:

  • Better training and management of drivers.

  • Improved safety information for passengers.

  • Emergency lighting, operation of internal and external doors and escapes through windows on trains.

  • Revision of signal sighting.

  • Better investigation into SPADS.

  • National system of radio communication between trains and signallers.

  • Improvement to high speed train and turbo train crash-worthiness.

  • Computerised information system about missing persons, casualties and survivors.

  • Railtrack should conduct a safety examination of the signalling layout at Paddington to satisfy the Railway Inspectorate that it was safe for operation at current speed limits and to current traffic arrangements.

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