Paddington crash signal criticised

Thirty-one people died in the collision

Signalling in the area of the fatal Paddington rail crash did not comply with relevant industry standards, according to a report published on Monday.

Signal 109, which was passed at red by a Thames train in the west London accident, was on a gantry which was of unusual design, said the Health and Safety Report.

When it was installed in 1994, procedures existed whereby unusual designs could be authorised.

But the Health and Safety Executive (HSE) report said: "No evidence was found that this process had been followed."

Steve Walker, the HSE's assistant chief inspector of railways, told a news conference after the publication of the report that the crash had been "the most serious high-speed collision we have had in the UK".

Thirty-one people died in the crash, involving a Thames Trains turbo service and a London-bound Great Western Express.

Beam alignment

The HSE report also stressed that signals needed to be aligned correctly to make them as easy to read as possible.

But beam alignment at signal 109, the three signals leading up to it and the signal which the Great Western train was approaching, was not in accordance with rail standards at the time of installation.

The signal layout is 'complex'

The victims of the Paddington crash included Michael Hodder, the driver of the Thames train.

The HSE report said there were "no indications that Mr Hodder deliberately set out to pass signal 109 at red".

It continued to say that "any acts or omissions by him were just one of a group of contributory factors".

Signal 109 had been "passed at danger" seven other times over the preceding five years, and was one of the top 22 most passed at danger signals.

Investigations into signals in the Paddington area, in particular signal 109, had found that "the complexity of the layout and signal gantries, the range of approaches and the obscuration of the signal aspects by overhead line equipment present an exceptionally difficult signal reading task".

Height limit

Inspectors also discovered that although the height of signal 109 met current safety requirements, other signals approaching it exceeded the height limit permitted by Railway Group Standards.

However, when the signals were designed and installed, no maximum height had been stipulated.

The report, which is part of the HSE's 14-month investigation into the crash, is not making any recommendations.

This will come when Lord Cullen produces his report following the public inquiry into the crash.

Closing statements at the inquiry are expected to be made on Wednesday 20 December.