Clapham Junction Inquiry

BR shall ensure that there is rigorous implementation of the practice of cutting back redundant wires, insulating, and securing them, so that there is no risk of wires coming into contact with working circuitry. Cutting back must be done before commissioning.

BR at national level shall be responsible for updating and creating new standards of installation.

BR shall enforce tighter control on Design Office procedures for the production, issue and amendment of documents to ensure that all working drawings are complete and are an accurate representation of the system to be worked on and of the work to be done to that system.

BR shall urgently ensure that an independent wire count is carried out as a matter of practice during testing. It shall be the responsibility of the person in overall charge of testing to ensure and to document that an independent wire count has been done. This function may be delegated to works staff who did not do the work.

BR shall ensure that one individual is always identified as the person in overall charge of testing.

BR shall ensure that a testing plan is drawn up for every commissioning.

BR shall ensure that sufficient numbers of suitably qualified staff are included in the testing plan.

BR shall ensure that full documentation is provided and later monitored in order that proper testing is carried out.

BR shall introduce a national testing instruction with all speed. Such introduction shall be accompanied by a full explanation to the workforce, including workshops or seminars as necessary. Implementation must be monitored and audited.

BR shall ensure through its system of audit that the necessary resources and authority are available to Regional Signal Engineers to implement the national testing instruction.

BR shall ensure that the Testing & Commissioning Engineer must be independent of the line of command between Area Signalling Engineer and new works staff, but able to call on new works staff to assist him in his testing duties.

BR shall ensure that there are effective systems for distributing Departmental Instructions on a personal basis to all relevant employees and that provision is made for the situation where an employee moves to a new post.

BR shall ensure, as a matter of practice, that all staff understand and regularly re-read the Departmental Instructions relevant to their posts. In addition, every two years, those staff involved in an annual appraisal interview, shall sign a statement to the effect that such Instructions have been recently read and understood.

BR shall give technical training as necessary to ensure that efficient and safe practices are carried out by all technical staff.

BR shall provide refresher courses for installers at intervals of not more than five years.

BR shall urgently progress and monitor training and certification of testers. Refresher courses shall be evolved.

BR shall ensure that the structure and content of courses are regularly reviewed.

BR shall ensure that overtime is monitored so that no individual is working excessive levels of overtime.

BR, in conjunction with the Unions, shall introduce the concept of scheduled hours within the Signals and Telecommunications Department in order to make better provision for work which has to be carried out at weekends.

BR shall monitor and forecast wastage and recruitment of skilled S&T staff and take urgent steps to ensure that sufficient numbers of skilled staff are retained and recruited to match work requirements safely.

BR, in reviewing recruitment and retention levels, shall also consider recruiting staff at levels at and above assistant technician.

BR shall provide all grades with job descriptions for their particular post so that staff know what is expected of them

The annual appraisal system, albeit in a simplified form, shall be extended to senior technician level.

BR shall ensure that there is an effective system in place on a continuous basis to identify which employees would benefit from additional training.

BR shall introduce, within S&T Departments, a system of reporting and reviewing all WSFs and shall ensure that they are classified according to potential for danger, and that they are monitored up to and including Board level.

BR shall ensure that any unprotected WSF with potential for danger shall be thoroughly investigated with a view to learning and acting upon wider lessons.

Unprotected WSFs shall be reportable to the Railway Inspectorate as a "dangerous occurrence" and reported on by the Chief Inspecting Officer in his annual report.

Government shall seek to give legislative effect to recommendation 27.

BR shall ensure that new works schemes in future shall have one clearly identified person in overall charge of all aspects of the project who would nominate a Project Manager from within his chain of command. For predominantly signalling schemes that individual would, in the present BR structure, report to the Regional S&T Engineer. (Paragraphs 12.28 - 12.34)

The Project Manager nominated in 29 above shall be responsible for the execution within budget and timescale of the whole project from the original estimate preparation to the project completion. He shall report to the person in overall charge as necessary for approval. (Paragraphs 12.28 - 12.34)

BR shall ensure that where work is required from areas outside the command of the person in overall charge, that work should be carried out on a contractual basis to a specification provided by the Project Manager.

BR shall ensure that the Testing Engineer shall be ultimately responsible to the person in overall charge of the scheme, but not through the Project Manager.

BR shall make available necessary training resources for wider management training down to supervisor level.

BR shall require that any future reorganisation shall be properly planned, effectively resourced and implemented to an agreed timetable which takes account of all relevant problems.

BR shall implement improved procedures to replace the cumbersome arrangements on reorganisations which allow staff to be displaced and to remain unallocated.

BR shall continue to press ahead with its Total Quality Management Initiative and the application of British Standard BS5750: Quality systems.

S&T Departments shall implement the Board's existing quality plan with the greatest urgency.

The Court endorses the use of outside consultants to review safety management issues within BR and recommends that the consultants proceed with their programme with the greatest urgency looking particularly at problems of communication up and down the organisation.

BR shall introduce monitoring and independent auditing systems in all safety-related aspects of work, in particular the S&T Departments, with the greatest urgency, in advance of Total Quality Management as an aid to good management.

BR shall give a higher priority to the introduction of on-train data recorders to assist investigation of any future incident.

BR shall consider the use of information from on-train data recorders as part of a systematic safety monitoring procedure.

BR shall report at 6 monthly intervals to the Railway Inspectorate on its follow-up to the Clapham Junction accident and implementation of its own and this Report's recommendations.

BR shall implement as a priority its programme to install a system of radio communication between driver and signalman on all traction units. The introduction of this system shall be in addition to signal-post telephones and not automatically entail their removal.

BR shall instal voice recorders for the purpose of providing a record of all radio messages relayed.

Government, in discussion with BR, shall allocate a sufficient number of frequencies for this important safety function

The Court welcomes BR's commitment to introduce Automatic Train Protection on a large percentage of its network, but is concerned at the timetable proposed. After the specific type of ATP system has been selected, ATP shall be fully implemented within 5 years, with a high priority given to densely trafficked lines.

BR shall report at 6 monthly intervals to the Railway Inspectorate on its progress in implementing ATP.

The Department of Transport and BRB shall make a thorough study of appraisal procedure for safety elements of investment proposals so that the cost-effectiveness of safe operation of the railway occupies its proper place in a business-led operation.

BR shall develop an adequate system of allocating priority to projects to ensure that safety standards are not compromised by delay.

BR shall ensure that the organisational framework exists to prevent commercial considerations of a business-led railway from compromising safety.

BR shall ensure that during driver training the definition of a signalling irregularity and situations which are reportable are given greater emphasis.

BR shall ensure that drivers, reporting on signalling irregularities, are given appropriate feedback on the outcome.

BR shall ensure that the practice of the re-use of insulation tape is eliminated and the method of insulation is secure.

BR shall carry out its stated programme of research into the structural integrity of its rolling stock within its planned timescale of completion by April 1991.

On completion of the programme BR shall discuss its conclusions with the Railway Inspectorate and obtain their agreement to the structural changes necessary to strengthen all relevant rolling stock with a subsequent life span of eight years and over.

BR shall extend its programme of research to include dynamic testing or full-scale simulations of collision retardations in order to improve the design of internal furniture under conditions of passenger impact.

BR shall, as an alternative to full-scale testing, seek economic and practical methods of dynamic modelling during development stages when researching the structural resistance of coaches to collision conditions.

BR shall continue and expand its involvement in collaborative European railway studies of performance of passenger stock, including collision resistance.

Government shall seek to amend S.41 of the Road and Rail Traffic Act 1933 to clarify what work has to be approved by the Secretary of State after inspection, if necessary, and to include rolling stock within the terms of the statute.

BR shall ensure that overall train loading criteria are achieved. The Department of Transport and BR shall keep the criteria under review.

The Emergency Services shall improve communication between them to ensure, in particular, that the declaration of a Major Incident by any service is immediately passed by a dedicated phone line to all other services and acted on by them . Systems shall be checked daily and logged.

Emergency services shall carry out exercises simulating a Major Incident on a regular basis to test specifically their communication systems in the light of the shortcomings identified in Chapter 5.

Ambulance services shall review procedures to ensure that the designated and supporting hospitals are given a major incident warning as early as possible.

Hospitals shall ensure that emergency alert telephone lines receive incoming calls only and are tested weekly. Switchboard operators shall be fully trained in their use and procedure.

The LAS shall implement its proposal to train prospective Medical Incident Officers in the use of radio communications.

Hospitals shall provide training in the duties of Medical Incident Officer for staff who could be called upon to act as such in the event of an accident.

Emergency services shall provide local radio communication at the accident site to facilitate liaison between the control units and experts on site.

The Ambulance Service shall provide aerials at all designated hospitals for radio telephone communication in an emergency. The transmittedreceiver should be provided on declaration of a Major Incident.

All emergency services shall ensure that personnel are provided with and wear protective clothing, including protective headgear.

All emergency services, hospitals, BR and local authorities shall provide their personnel with coloured high visibility vests with the name of the service printed on it. Each service shall be easily identified by the colour of its emergency clothing.

Ambulance services shall require staff properly qualified in intubation and infusion to wear "Millar trained" badges prominently displayed, including on protective clothing.

Police forces shall arrange that all casualty bureaux be equipped with a telephone queuing system with a recorded message.

The Association of Chief Police Officers shall continue their efforts to establish an effective system for extending the number of calls which can be dealt with simultaneously by a casualty bureau.

The emergency services shall recognise the primacy of the Civil Police authority in accidents of this kind where there is no fire. This recognition does not preclude delegation to the LFB of control at trackside.

Police Forces shall study and follow the excellent arrangements made by the Metropolitan Police for the bereaved and relatives of the seriously injured.

In the exercise of command and control at accident sites BR and the emergency services shall maintain their policy of joint planning supported by table-top exercises.

The ambulance service and designated hospitals shall require that all medical personnel report to the forward control unit of the ambulance service on site.

Each service shall additionally maintain on site an up-to-date list of staff within the inner cordon in case evacuation is necessary.

The Department of Health shall review DHSS Circular 71 in consultation with emergency and medical services to reflect all lessons learned but in particular in relation to procedures for declaring a Major Incident. The Department of Health shall specifically require that the terms used to warn hospitals of a possible Major Incident, and subsequently to declare an actual Major Incident are sufficiently distinct to prevent any confusion between the two. The terms used shall exclude any colour.

In revising the Circular the Department of Health shall consider the role of BASICS in emergency planning and review BASICS' funding arrangements.

BR shall complete its programme of equipping major signal boxes with direct lines to the appropriate electrical control and equipping other signal boxes with priority emergency dialling systems. Those direct lines and emergency dialling systems shall be logged and tested daily. The purpose of this programme shall be to ensure that: (i) the signalman is able to take full responsibility for ensuring that the area surrounding the accident site is electrically isolated; (ii) the action is confirmed to the signalman, the emergency services, and the BR officials at site; and (iii) the boundaries of isolation are similarly confirmed.

BR shall review its communication systems with the emergency services to ensure that efficient methods exist to provide and disseminate early information requiring immediate action. In the course of the review BR shall look particularly at communication between signal boxes and the emergency services. Systems shall be tested weekly and logged.

BR shall ensure that those likely to use such systems in recommendations 81 and 82 above shall be properly trained in their use. Instructions in the use of these systems must be clearly drafted, prominently displayed and regularly checked for relevance and accuracy.

BR shall ensure that efficient arrangements exist to rectify as a matter of high priority any deficiencies in the communication systems involved in recommendations 81 and 82 and in signal-post telephones.

BR shall extend its programme of installing public address systems in all new trains and those with a life of over 5 years to allow the driver and/or guard to speak to passengers.

BR shall produce an up-to-date manual on Accident Procedure to replace such incomplete and out-of-date documents as the Southern Region Accident Procedure booklet of November 1984. BR shall ensure that all staff are given appropriate training in such procedures.

BR shall ensure that each area manager, station manager and all senior station staff have an effective emergency plan for their area that is understood by all their staff and is the subject of regular exercises.

BR shall introduce into all signal boxes the facility to switch all automatic signals to red in an emergency, and BR shall review and update where necessary its procedures to protect rail traffic in the vicinity of immobilised trains.

BR shall examine the possibility of introducing short-circuiting bars which achieve a positive clamp on the running rail.

BR shall set out in its manual on Accident Procedure the procedures that should be followed to ensure the proper recording and preservation of evidence.

BR fault finding teams shall report to the Railway Incident Officer who, in consultation with the Police Incident Officer, shall ensure, in all but the most exceptional circumstances, that the team is accompanied by a police officer and a photographer to provide for the proper recording and retention of evidence.

The Rule Book and Books of Instruction of a similar status shall be promptly updated and observations made in this Report taken into account.

Government shall ensure that the Railway Inspectorate is adequately staffed and resourced to match the increased responsibilities incurred as a result of recommendations made in this Report.