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Tuesday, 19 June, 2001, 13:36 GMT 14:36 UK
Crash report blames 'lamentable' failures
Ladbroke Grove crash
The Ladbroke Grove crash killed 31 people
A report into the Ladbroke Grove train crash has blamed a "lamentable failure" by Railtrack to respond to safety warnings before the accident.

Lord Cullen's inquiry said the crash, in which 31 people died, could probably have been prevented if rail managers had properly appreciated the risks posed by trains going through red signals.

Thames Trains was strongly criticised for "incompetent management" and poor driver training.

Survivors and the bereaved have demanded an apology from Railtrack and called for prosecutions to be brought.

Main criticisms
Failure to respond to previous Spads
Thames Train driver inadequately trained
Poor sighting of Signal 109
Inadequate training of signallers
No emergency hammers on Thames Train

Thirty-one people lost their lives when a Thames Trains commuter service collided almost head-on with a Great Western express near London's Paddington station on 5 October 1999.

The Cullen report made 89 different recommendations to ensure such a disaster does not happen again.

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

There had been previous incidents of trains passing red lights at this signal, and Lord Cullen said there had been problems with its visibility.

'Incompetent management'

Lord Cullen said driver Michael Hodder, 31, who was killed in the crash, was only partly to blame - and Thames Trains bore much responsibility.

Mr Hodder, who had only just qualified as a driver, had received inadequate training and probably believed that he had "a proceed aspect", Lord Cullen said.

Lord Cullen
Lord Cullen will publish a second report into overall rail safety
"The safety culture in regard to training was slack and less than adequate," he said.

He accused the company of a "combination of incompetent management and inadequate procedures".

It had failed to take notice of difficulties drivers were having with the signalling around Paddington.

There was also "a dangerously complacent attitude to Spads (signals passed at danger) as being simply a matter of driver error".

Signals passed at red

Lord Cullen also accused Railtrack of failing to respond to previous incidents of Spads.

The problem of Spads in the Paddington area had led to the formation of a number of groups to consider what to do.

But Lord Cullen said: "This activity was so disjointed and ineffective that little was achieved."

Main recommendations
Improved safety information for passengers
Changes to signal sighting
Better communication between trains and signallers
Better training for drivers and signallers
High speed train improvements to withstand crashes
Computerised information system about casualties and survivors
Former Railtrack chief executive Gerald Corbett, who resigned late last year, was singled out for particular criticism.

Lord Cullen said he found it "extraordinary" that Mr Corbett had said in 1998 that Paddington was "the best protected major terminal station anywhere in the world".

"It demonstrated either a degree of complacency on the part of senior management or a desire to encourage an undeserved confidence in what Railtrack had actually achieved," Lord Cullen said.

Lord Cullen said the Health and Safety Executive's Railway Inspectorate, the railway safety watchdog, also could have done more.

He said it had suffered from "a lack of resources and a lack of vigour in pursuing issues."

The HSE acknowledged this, saying it would be taking a "firmer approach" in dealing with the railway industry in future.

'Blood on his hands'

Lord Cullen's major recommendations involved signalling, driver training and investigations into systems passed at danger.

But the 270-page report also called for improvements in the ability of trains to withstand an accident.

Former Railtrack chief executive Gerald Corbett
Gerald Corbett: Singled out for criticism
He commented on emergency evacuation procedures and safety information for passengers.

And he said experts should look at how to prevent diesel fireballs breaking out - two of these were endured by the Ladbroke Grove survivors.

Transport Secretary Stephen Byers said he had asked the HSC to ensure that the recommendations are acted upon.

He said "safety was paramount" and "at the heart" of government policies on the railways.

Chris Leah, Railtrack's Director of Safety and Environment, said much work had been done since the accident to make the railways "even safer".

Actions taken had already led to "real improvements in safety with signals passed at danger at an all-time low last year," he said.

But survivor Tony Knox said it was "time for Railtrack to say sorry" and accused Mr Corbett of having "blood on his hands".

Lord Cullen will publish a second report after this one examining the management of safety within the industry as a whole.

 WATCH/LISTEN
 ON THIS STORY
The BBC's Robert Hall
"A lot of Lord Cullen's findings haven't come as a surprise"
The BBC's Daniel Boettcher
"While the focus today is on technical aspects, this is ultimately about people"
Inquiry chairman Lord Cullen QC
"This appalling toll of death... cast a shadow over the safety record of the industry"
ASLEF representative Mick Blackburn
"It's our belief that the report doesn't go far enough"
Railtrack's director of safety Chris Leah
"There has been a major overhaul of the safety management systems"
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