Ladbroke Grove Rail Inquiry

The system for the reception of information about missing persons, casualties and survivors should be computerised. It should be possible for information which has been received to be entered directly into the computer and for information from it to be provided, to the extent appropriate, to callers. There should be a set procedure for the returning of a call (para 4.119).

Computerisation should be extended to all police forces, so that the information collated by each is readily available to all others (para 4.120).

The police service, in co-operation with the emergency services, should use their best endeavours to ensure that common telephone numbers are issued for the use of members of the public who are seeking to give or obtain information about persons who have, or may have, been involved in a major incident (para 4.121).

The Railway Group should review emergency planning, including liaison with the emergency services, arrangements for the after-care of survivors and the provision of support and facilities for the bereaved and injured (para 4.122).

Where a material change to track or signalling or both is proposed, there should be an express consideration of all relevant safety issues by an analysis of the material factors, if necessary by means of a risk assessment. This should be done on a holistic basis at the design concept stage and repeated at defined stages up to and including full implementation (para 7.17).

Railtrack procedures, and the actions of management to enforce them, should be directed to ensuring that: (i) a recommendation which is accepted is implemented according to a defined timescale; (ii) the person to whom a recommendation is allocated for implementation is required to report periodically the action which has been taken, the state of progress and the reasons for any delay; (iii) the monitoring of the implementation of a recommendation is assigned to an identified individual whose duties are clearly defined, whether by job description, formal instruction, or training or a combination of these methods; (iv) the person to whom monitoring is assigned is required to ensure that the recommendation is implemented according to a defined timescale; (v) a recommendation should not be abandoned unless, exceptionally, this is shown to be fully justified to the person to whom monitoring is assigned; (vi) any management system to which the recommendation relates is altered to align it with the recommendation; (vii) the effectiveness of a recommendation is audited after its implementation; (viii) full records are kept of all recommendations and their state of progress; and (ix) there is a system for the central tracking of recommendations which are directed to Railtrack Line and those which, either immediately or thereafter, are directed to one or more of the Zones (para 7.106).

Consideration should be given to extending sub-para (ix) of Recommendation 6 to recommendations which are directed to one or more of the TOCs and others (para 7.106).

Railtrack should ensure that the risk assessments and any consequent actions required under Group Standard GK/RT 0078 in respect of the signals in the Paddington area are carried out as soon as possible (para 7.125).

Railtrack should conduct a safety examination of the layout over 0-2 miles from Paddington Station so as to satisfy the HMRI, if necessary by a risk assessment and additional measures, that it is safe for operation at current speeds and to current traffic arrangements. Such a safety examination should be repeated before the implementation of any change which is or may constitute, in the opinion of the HMRI, a material change of circumstances (para 7.126).

No change should be made in the direction of running on line 3 or in the current speed limits on any of the lines out to two miles six chains from Paddington Station unless and until the following have been done to the satisfaction of the HMRI, namely: (i) a risk assessment has demonstrated that the change can be implemented in safety, and, if this can be achieved only if certain measures are taken, what these measures are; and (ii) such measures have been implemented and shown to be effective. The risk assessment should take account of the following possible measures, inter alia: (i) the conversion of four-aspect to three-aspect signals; (ii) the addition of flank protection at SN109 and elsewhere if appropriate; (iii) the installation of standard, simple, non-distracting and consistent means of line identification; (iv) the alteration of the height, configuration and mounting of signals; and (v) the installation of an additional gantry to the east of Portobello Bridge for carrying Down signals previously carried on gantry 8. The risk assessment should be carried out by persons independent of Railtrack and in accordance with usual standards and the best available methods. It should take account of human factors which may affect the actions of drivers and signallers, and any risks which the carrying out of any of these measures might create (paras 7.127 and 7.128).

Signallers and drivers should jointly attend away days and other training processes to develop their mutual understanding (para 9.28).

Thames Trains should increase the frequency of the briefing of drivers with a view to ensuring that each driver has a face to face meeting with his or her driver standards manager at least monthly, if not more often, and safety should be the first item on the agenda of these meetings (para 9.29).

The adoption by TOCs of the teaching and practice of defensive driving is endorsed (para 9.39).

TOCs should review the effectiveness of the systems in place to deliver the required level of driver competence at least once every three years, and should retest the driver against the revised systems at the same frequency (para 9.49).

The ATOC study on the central licensing of drivers should be progressed expeditiously (para 9.50).

ATOC should consider the application of NVQs to the driver licensing scheme presently under their consideration (para 9.52).

The development of a culture within the industry in which information is communicated without fear of recrimination, and blame is attached only where this is justified, is commended (para 9.60).

Thames Trains and other TOCs should ensure that their driver training and testing programmes adequately reflect the need for specific, relevant and validated criteria. Drivers should be tested against these criteria, and a definite pass standard should be established. Consideration should be given as to how often drivers should repeat key steps in their training before submitting themselves for testing (para 9.64).

Further research should be carried out to develop the understanding of human factors as they relate to train driving (para 9.66).

The safety audit process should be strengthened, and the quality of communication during the process should be improved (para 9.44).

An organisation the activities of which are being audited should disclose all material and relevant information to the auditor in regard to the area of the activity which is being audited (para 9.46).

The standard on signal sighting should require that explicit consideration is to be given to the readability of a signal. It should be made clear that the fact that a signal complies with a minimum requirement is not of itself to be taken as meaning that it is adequate (para 11.13).

The standard on signal sighting should deal explicitly with the additional time required for the reading of certain signals, including (but not necessarily limited to) those mounted on gantries (para 11.13).

Human factors experts should be involved in the revision of the standard on signal sighting (para 11.13).

The reference to “very short duration” in the standard on signal sighting should be clarified (para 11.14).

Areas where ambiguity in the meaning of “very short duration” may have caused, or may still cause, problems should be identified. There should be a retrospective review of all locations where this may be the case, so that appropriate action may be taken (para 11.14).

The expression “overhead line equipment” in the Group Standard on signal sighting should be clarified by the statement that it refers only to wires and droppers (para 11.16).

The standard on signal sighting should define acceptable limits to the temporary obscuration of a signal, subject to the overriding right of a signal sighting committee to determine whether the nature and extent of the interruption in the individual case is such that the sighting is unacceptable (para 11.16).

The standard on signal sighting should explicitly define the cab sight lines within which signals must be positioned by reference to the envelop governing the position of the driver’s eye which is specified for each particular rolling stock (para 11.17).

The report by W S Atkins “Initial Study of Signal Sighting Practice on Railtrack Infrastructure”, Issue 1, 6 March 2000, is commended (para 11.19).

Railtrack, in consultation with the TOCs, should examine the availability of signal sighters to meet the expected workload and take all necessary steps to ensure that there is an adequate supply of trained signal sighters and an adequate range of skills (para 11.20).

It should form part of Railtrack’s safety management system that it is the responsibility of senior Zone operating and signal engineering management to decide whether the recommendations of a signal sighting committee under the Group Standard on SPADs are to be implemented and, if not, what alternative measures are to be taken, and, in either event, that the relevant measures are implemented (para 11.22).

The Group Standard on SPADs and its associated documentation should be reviewed to ensure that there is no presumption that driver error is the sole or principal cause, or that any part played by the infrastructure is only a contributory factor (para 11.27).

The use of the word “disregard” in the Group Standard on SPADs and its associated documentation should be reconsidered (para 11.29).

Persons who investigate, and make recommendations as a consequence of, SPADs should be trained in the identification of human factors and in root cause analysis. Their competence in these areas should be formally recorded, and renewed by refresher courses. The analysis of SPAD data should be specifically directed to eliciting the part played by human factors and assessing the significance of the hazards against which the signals which have been passed at Danger were intended to afford protection (para 11.31).

The instructions for signallers as to their response to a SPAD should be: (a) clarified; and (b) set out in a single set of instructions, while if there are matters which are specific to a particular area they should be covered by separate local instructions (para 12.9).

The instructions for signallers should state explicitly that the signaller is expected, in the event of a SPAD, to make an assessment and to take action immediately (para 12.10).

The instructions for signallers should provide a set of options, including the use of the CSR (where it is available) either to send an emergency stop message to a particular train or a general stop message. This range of options should be supported by full and regularly repeated briefing as to the type of circumstances in which each option is or may be appropriate (para 12.11).

Railtrack should institute a system whereby all signallers in the signal box (or centre) are briefed by their line manager following a SPAD in their area, and there is appropriate dissemination of information which may be of assistance to signallers elsewhere (para 12.13).

Railtrack should ensure that the reports which are made to the Zone about a SPAD should include a report by the signaller as to the actions taken by him or her and the reasons for such actions (para 12.13).

The use of simulators in providing fully effective training of signallers in dealing with emergencies is endorsed (para 12.15).

Railtrack and the TOCs should take steps to ensure that signallers and drivers obtain a full appreciation of the nature and demands of each other’s work (para 12.16).

Railtrack should review the work done by signallers to identify all non-essential tasks and eliminate them from the work which is performed by them while they are in charge of a workstation (para 12.17).

A supervisor should be employed on a continual basis to ensure that the workstations are operated in the most effective way (para 12.17).

Signallers should take the opportunity from time to time to practise the controlling of train movements (para 12.18).

Railtrack management should set out the criteria for allowing signallers, in exceptional circumstances, to exceed the maximum of 72 hours of work per week, and ensure that these criteria are, and continue to be, correctly applied (para 12.19).

There should be a unique alarm for SPADs, which should sound until it is turned off (para 12.21).

The speed with which signallers can take action to move points in an emergency should be improved (para 12.22).

There should be a study of the possibility of the automatic replacement of a signal to Danger where a SPAD has occurred and the layout is such that there is a significant danger of collision (para 12.27).

Subject to satisfactory risk assessment, an arrangement should be made whereby, when a train which is fitted with the CSR passes a signal at Danger, an audible warning automatically sounds in the cab (para 12.28).

There should be a national system of direct radio communication between trains and signallers (para 12.29).

Signallers, managers and maintenance staff working at IECCs should be instructed as to the need to preserve CSR data disks in the event of a SPAD taking place (para 12.30).

The enhancement of the cabs on HSTs to improve driver protection along with energy absorption and compatibility with other vehicles, and the enhancement of measures for the retention of bogies on the coaches of HSTs, should be considered, subject to an assessment of feasibility, costs and benefits, with a view to possible retro-fitting (para 13.4).

The current standard for crashworthiness in respect of new vehicles should be reviewed in the light of the crash at Ladbroke Grove with respect to the objectives referred to in Recommendation 53 (para 13.4).

In the case of Turbos, the enhancement of end pillar weld connections, the possible enhancement of crashworthiness by weakening the ends and strengthening the saloon of the cars, and the fitting of shear-out couplers and anti-overriding devices should be considered, subject to an assessment of feasibility, costs and benefits, with a view to possible retro-fitting (para 13.5).

The current standard for crashworthiness should be reviewed, in the light of the crash at Ladbroke Grove, in order to ensure that there are adequate measures for safeguarding survival space (para 13.5).

In the case of new vehicles constructed of aluminium, consideration should be given to: (i) the use of alternatives to fusion welding; (ii) the use of improved grades of aluminium which are less susceptible to fusion weld weakening; and (iii) the further development of analytical techniques (para 13.9).

The revision of the Group Standard for crashworthiness should be pursued with particular reference to: (i) the design requirements for more realistic scenarios; (ii) high speed accidents; and (iii) dynamic verification testing (para 13.17).

The enhancement of the security of seating in Turbos and of tables in HSTs should be considered, subject to an assessment of feasibility, costs and benefits, with a view to possible retro-fitting (para 13.19).

Comprehensive market research in regard to safety related measures should be carried out in order to take account of the views of informed passengers (para 13.20).

The following measures should be considered with a view to enhancing protection against fire: (i) a review of Group Standards in respect of improved crash resistance of fuel tanks; (ii) consideration of the feasibility of reducing fuel inventories and of utilising smaller fuel tanks; (iii) in respect of frontal impacts, consideration of the repositioning of fuel tanks away from the leading ends of trains from behind bogies wherever this is practicable; (iv) avoidance of placing fuel tanks in exposed and vulnerable locations; (v) examination of the use of additives to reduce the propensity of a fuel to atomise; (vi) the employment within fuel tanks of internal flexible linings or a honeycomb construction; (vii) consideration of the most appropriate material for fuel tanks; and (viii) recognition of the need for supporting theoretical and experimental work in respect of the foregoing (para 13.27).

The scope of Schedule 1 to the Railway (Safety Case) Regulations 2000 should be extended so as to include explicitly the arrangements which the duty holder has established in regard to facilities, instructions and signs for the escape of persons in an emergency (para 14.3).

The provisions in the schedule as to evacuation and escape should be supported by adequate guidance from the HSE (para 14.3).

The code of practice on public information on train safety and emergencies should be kept up to date (para 14.6).

So far as is feasible, the safety information issued to passengers and the means by which they can be evacuated or escape from a train should be standardised (para 14.8).

A system should be established for the collection of human factors information pertinent to issues of passenger safety following rail accidents (para 14.8).

Passengers should be given general safety advice both before and after they have boarded their train (para 14.14).

Expert assistance should be obtained on the advice which should be given to passengers as to what to do in the event of there being a known threat of serious danger to them in remaining on board (para 14.14).

The provision on board of explanatory information about the emergency facilities of individual trains is endorsed (para 14.14).

The use of on-board announcements to draw attention to safety information is endorsed (para 14.16).

The requirement for emergency signs to be luminous should be made retrospective (para 14.18).

So far as is feasible, emergency signs on all trains should be capable of being understood by passengers without the necessity to read text (para 14.19).

There should be research with the aim of arriving at a system of signage which is common to all trains in Great Britain (para 14.20).

Research should be carried out into the means of safeguarding emergency lighting systems from disablement by the forces involved in sudden deceleration (para 14.21).

The provision of “snap wands” should be considered as a supplementary means of providing lighting in an emergency (para 14.22).

In the case of every coach (on any train) which has internal doors which slide in the same direction one of the following should be carried out by 31 December 2003: (i) the coach should be fitted instead with opposite- handed internal doors; (ii) the coach should be fitted instead with double leaf internal doors; or (iii) a panel in the door should be rendered removable so as to enable passengers to pass through. The above is subject to the proviso that if the HMRI are satisfied, on application by the TOC concerned, that it is not practicable for that change to be achieved within this period, they may grant a deferment for an appropriate period in which the work is to be done (para 14.28).

The staff-only doors on all trains should have an override device to enable them to be used by passengers in an emergency (para 14.29).

Signage primarily in the form of pictograms similar to those used on aircraft, and depicting the correct operation of emergency door mechanisms, should be developed. The signage should conform to current human factors standards on signage and be displayed prominently adjacent to each door and beside the door release mechanisms, as well as within the carriage. The mechanisms should be provided with artificial illumination to highlight their location at all times, with a back-up power supply in case of an emergency (para 14.34).

The daily routine check of every train should include confirming that all ladders can readily be used. A mechanism to enable ladders to be released quickly should be devised and fitted (para 14.35).

There should be a thorough review of the adequacy of the number of, and signage relating to, emergency hammers. This should include the provision of means of illuminating the location of hammers in an emergency, with a back-up power supply in case of emergency (para 14.46).

There should be research into the feasibility of, and risks associated with, removable windows, the adequacy of windows as a means of emergency egress, the number of dedicated windows which are necessary and the provision as to the maximum distance between each passenger and a bodyside door or emergency exit (para 14.46).

Tests should be carried out into the practicability of building emergency hammers into the passenger alarm system so that they could be released only after an alarm has been activated (para 14.50).

The incorporation of escape hatches in existing carriages should be the subject of feasibility and risk assessment and the provision of escape hatches in new carriages should likewise be considered (para 14.54).

All members of the on-board train staff (including persons working under contract) should be persons who have been trained in train evacuation and protection (para 14.62).

The possibility of installing on driver-only trains a telephone by which passengers can communicate with the signaller in the event of the driver being killed or incapacitated should be studied (para 14.65).

The feasibility of a “roaming” communication system for train staff should be examined (para 14.68).

The possibility of remote broadcasting from outside the train, where it is not already available, should be investigated (para 14.68).

The availability on trains carrying passengers of the items of emergency equipment mentioned in the standard on emergency and safety equipment should be unrestricted (para 14.74).

A review of compliance with the above recommendations should be conducted on behalf of the HSC within six months of publication of this report, and further reviews should be put in hand as necessary thereafter. The HSC should publish the outcome of such reviews (para 15.7).