Southall Rail Accident Inquiry

All parties in the rail industry should co-operate in the collection of evidence to support reliable research into human behaviour studies relating to driver performance. Railtrack should co-ordinate this work and TOCs incorporate the results into training programmes (paras 1.25, 7.16, 16.2).

Evidence should include that to be provided by CIRAS and from On-Train Data Recorders used to monitor driver behaviour. ASLEF in particular should give their full support to such an initiative (paras 14.23, 14.25, 15.15, 16.3).

Simulators should be introduced for driver training and for the observance of driver behaviour (para 16.3).

Driver training should include driving in abnormal situations permitted by the Rules and specifically driving with AWS isolated to the extent so permitted, including the use of simulators (para 16.4).

Testing of driver competence and knowledge of Rules should be extended to cover application of the Rules to practical situations, including all abnormal driving situations permitted by the Rules (para 16.4).

Drivers should be encouraged to report all actual or suspected faults, whether through formal fault reporting procedures or through CIRAS (paras 14.26, 16.4).

Railtrack together with ATOC should establish a national qualification and accreditation system for drivers including centrally held records to be available to the current employer (paras 5.5, 16.5).

Railtrack and ATOC should monitor the transfer of drivers between operators and the numbers of drivers trained by each TOC and consider whether there are any safety implications involved (paras 5.5, 16.5).

Current Rules governing drivers’ permitted daily and weekly working hours should be reviewed in the light of current research into human behaviour (para 5.9).

Railtrack must ensure that Rules and Group Standards applicable to operators, including drivers, are clear and unambiguous. In particular, Railtrack should urgently complete the review of operating Rules to ensure they are workable in the privatised, fragmented industry (para 16.6).

The use of more than one document (whether Rules, Group Standards or otherwise) to cover a single operational issue should be avoided, save where proper reasons exist for use of multiple sources (para 15.9).

All train-borne safety equipment should be clearly designated as to whether or not it is vital to the continued running of the train (para 15.11).

AWS is to be regarded as vital to the continued running of the train (para 15.11).

Clear procedures for steps to be taken on failure of any train-borne safety equipment should apply nationally, subject only to such company variation as is fully justified (para 15.11).

All parties must emphasise the need to comply with the Rule Book and must not condone departures (para 7.9).

Railtrack and TOCs must impress on drivers and other staff the need to use formal fault reporting procedures where the Rules so provide, and that the duty to report a fault must be performed personally and the report delivered to the person or body identified in the Rules, and not to any other person or body (paras 7.9, 16.11).

Fault reporting procedures should be reviewed and made as simple and convenient to use as practically possible. They should include provision for an acknowledgement and an explanation if relevant (para 16.11).

Failure to provide forms, defect repair books or other means of reporting faults should be regarded as a disciplinary offence (para 16.11).

Appropriate procedures for receiving and making an automatic record of verbal reports should exist in all control centres, similar to the facilities installed by GWT in 1998 (Para 9.14).

Level and quality of training for information controllers should be reviewed (para 9.15).

Controllers’ posts in Railtrack and TOCs should be designated as “safety-critical” as defined in the Railways (Safety Critical Works) Regulations 1994 (para 9.15).

Fault data bases (including RAVERS) should ensure that repeat faults are logged and that a 28 day history of defects is available to managers and maintenance staff (para 16.9).

Databases should be programmed to determine and highlight statistically significant trends in faults reported and to display such information to managers and maintenance staff (para 16.9).

GWT should maintain full records of competencies for all maintenance staff as required by job descriptions and safety responsibility statements (paras 6.8, 15.6).

GWT should regularly monitor the workload of all maintenance staff (para 15.6).

A current and detailed list of items required to be inspected for each examination should be prepared for and used by maintenance teams (paras 6.8, 15.6).

Documentation for the A-Exam should require ATP reset and self-test (para 6.8).

Maintenance staff should be provided with a flow-chart to show the derivation of all sources of repair work, to include RAVERS (with check on repeat items) and appropriate structure for Request, Repair Book and Maintenance Control items (para 15.16).

Maintenance procedures should require checking of the history of reported defects, including repeat faults, and the taking of appropriate action (paras 6.14, 15.6).

An improved AWS test box, capable of detecting faults not revealed by the magnet test, should be provided as standard issue at all maintenance depots (paras 6.11, 9.22, 15.6).

Efforts should be concentrated on ensuring that AWS and other train-borne safety equipment does not fail in service through preventable causes. This should include regular replacements of equipment, maintenance of full service records and provision for full traceability of repairable parts and components (para 15.8).

Contractual ownership and other rights in AWS equipment must be clarified and defined (paras 15.7, 16.21).

ATOC and Railtrack should monitor the supply of new AWS parts and components to ensure continued availability on an indefinite basis, including the introduction of improved components (para 15.7).

Railtrack should ensure that the alignment and sighting of signals is confirmed at the time of commissioning, both from the signal and from the track, and appropriate records made, including photographs (paras 3.16, 16.14).

Railtrack should ensure that checks on alignment and sighting of signals are made at least annually, and at a greater frequency to be determined on the basis of errors found (paras 3.16, 16.14).

Railtrack should review all maintenance contracts to ensure that all parties are aware of what checks are included and which excluded (paras 3.16, 16.14).

Railtrack should ensure that any further proposed change of regulation policy is preceded by a risk assessment (para 4.6, 16.15).

There should be a review of Condition H11 of the Track Access Conditions which should make clear that no regulating decision is to be made on the basis of protecting commercial interests. Safety and security must be paramount considerations (paras 4.13, 7.6, 16.16).

Railtrack should review their Level 1 Policy Statement in the light of any amendment to Condition H11 (para 6.16).

More Level 2 and 3 Policy Statements should be introduced having due regard to any relevant risk analysis (para 6.16).

Railtrack should review the operation of ARS to consider whether more green signals should be booked ahead of higher speed trains, and generally whether the speed and length of trains is adequately taken into account (para 16.16).

Any further review of LRM should take into account Dr Murphy’s risk analysis (para 16.16).

HMRI should keep under long-term review the effect of speed on numbers of casualties in rail accidents (para 11.7).

A review should be carried out by ATOC, with input from all interested bodies, on the ways in which internal safety features may be modified and standardised to provide the best practicable means of emergency exit under accident conditions, including vehicles lying on their side, to include the provision of emergency lighting and standardised public announcements (paras 11.11, 11.12, 11.13).

The review should consider dates and means for the introduction of identified improvements to existing stock (para 11.2, 15.16).

A single body should be empowered to specify common standards for safety features in the interior of passenger vehicles and to identify and approve types of vehicles and/or operators to which particular standards are to apply (paras 11.6, 16.18).

The design of coaches should be such that internal doors can be easily opened in a crash situation, in darkness and irrespective of the attitude of the vehicle; and that hammers intended for breaking windows can be easily located in the same conditions (paras 11.11, 11.12).

Safety briefings or other appropriate means of communicating safety information to passengers should be adopted, including pointing out safety notices to passengers. ATOC should monitor the methods adopted by TOCs and issue guidance documents after a suitable trial period, including recommendations for different types of journey (para 11.13).

A design study and risk assessment should be carried out to determine whether freight wagons could be designed with less aggressive features without detriment to their primary function (para 11.14).

Consideration should be given to the most appropriate form of coupling for freight trains, to minimise damage in the event of collision, including a risk assessment (para 11.15).

No recommendation is made concerning crumple zones in passenger carriages, save that the matter should be given attention by the Ladbroke Grove Inquiry (para 11.4).

Train crews should be given improved training and briefing on emergency actions, including a practical evacuation (para 11.11).

Standards for evacuation of passengers should be proved by practical exercises using typical groups of passengers and train crew, and repeated on a regular basis to be approved by HMRI (para 11.11).

Consideration should be given to modification to the design of OHL structures to improve their response to accidents, if achievable without detriment to their primary role (para 11.16).

All trains should be fitted with data recorders. All data recorders should record speed, time/location, brake application and AWS cancellation, and should be simple and speedy to download (para 14.23).

Consideration should be given to developing a cheaper form of data recorder for retrospective fitment where this will allow earlier fitting (para 14.24).

Steps should be taken to put in place means to resolve inter-company issues relating to research and development at all levels. Specifically, the following issues must be addressed (paras 15.13, 16.21).

Rights (including ownership) and obligations in all equipment added to vehicles, together with lineside equipment upon which its operation depends, must be defined in legally enforceable terms (paras 15.7, 15.13, 16.21).

The above recommendation to include review of Safety Cases and franchising arrangements and consideration of action by the Rail Regulator (para 16.22).

Consideration should also be given, for the purpose of the above recommendations, to enlarging or re-organising existing inter-company groups, including considering whether the Railway Group should include ROSCOs and component suppliers (para 16.20).

S&SD together with HMRI and other bodies having responsibility for accepting or approving new equipment or stock should review their procedures with a view to reducing delay and introducing fast-track procedures where possible (para 15.7).

There should be a review of progress on implementing the Recommendations of the DTp Review Committee Report (chaired by Sir David Davies) published in September 1996 (para 14.31).

One or more System Authorities should be created to oversee the specific development of any new project on the railways and to oversee continuation of work on existing projects, including AWS and ATP (paras 15.13, 16.13, 16.18).

Future R&D must be the subject of rigorous programming, cost-projections and funding arrangements, including reliable contingencies. R&D funding must be on a cross-industry basis, irrespective of whether individual TOCs decide to fit new technology (para 16.22).

Development of ATP should be managed and funded in future through a System Authority having broad industry representation and support (para 15.13).

ATP should be maintained in a fully operational state on Great Western lines currently fitted, until replaced by an equally effective train protection system (para 15.14).

GWT and Railtrack should consider extensions to the present coverage of ATP (para 15.14).

GWT, Railtrack and HMRI should consider whether trains with AWS isolated can run normal services where ATP is fitted and operational (para 15.10).

All parties in the industry must ensure that paper-based procedures do not become divorced from reality. This should include senior managers maintaining a direct knowledge of the situation in railway workplaces (para 16.25).

Paper-based audits should be backed up by unplanned inspections and other direct observation of the work under review (para 16.26).

Steps should be taken to ensure that all risk assessments are rigorous and that those initiating risk assessments are appropriately qualified and informed. Steps include giving attention to HSE Guidance Notes covering risk assessment, which should accordingly be kept under review (paras 15.21, 16.26).

Consultation procedures and times involved in revision of Group Standards or the introduction of new Group Standards, should be reviewed by the Inquiry to be held into safety procedures (para 16.8).

The technical investigation of serious rail accidents should be controlled by HMRI save in exceptional cases of suspected crime which is unconnected with the running of the railway (para 15.23).

HMRI should ensure that a single, thorough and definitive technical investigation is carried out, to include the recording of all appropriate factual data, the collection of physical evidence from the scene of the accident and decisions as to handing the site back to the rail companies (paras 2.19, 7.3, 15.24).

Standing contracts for the provision of consulting services by recognised railway experts should be amended to make provision for HMRI to require any appropriate individual to provide expert services for the immediate accident investigation, including the services of any appropriate laboratory or testing house (para 15.23).

HMRI should decide, irrespective of any ongoing criminal investigation, what data or information is to be passed on to rail companies for rapid action (para 15.24).

The primary forum for deciding upon appropriate recommendations following an accident should be the Rail Industry Inquiry (RII). Procedures for holding such an inquiry at the earliest possible date should be strengthened, and should include the presentation by HMRI of their investigation (para 15.26).

Procedure for conducting a RII should be reviewed. This should include ensuring that the RII panel is independent of all parties having an interest in the accident (paras 9.33, 15.25, 16.26).

Consideration should be given to whether procedures can be adapted to make any RII accessible to the public, save where the needs of confidentiality otherwise require (para 15.28).

Nothing should be permitted to delay the opening of a RII nor the completion of their Report and Recommendations (para 15.28).

Consideration should be given to whether an additional independent accident investigation body should be created, to take over the accident investigation functions of HMRI under Recommendation 73 (para 15.23).

Existing protocols between Railtrack, BTP and HMRI should be reviewed in the light of the above Recommendations (para 15.24).

Any subsequent Inquiry directed under the Health and Safety at Work Act, 1974 should involve all parties in the rail industry who may have an interest in Recommendations to be made, through the involvement of representative groups including ATOC (para 15.27).

Passenger representation at such inquiries should not be limited to those involved in the immediate accident. Consideration should be given to enlarging the role of CRUCC and the provision of appropriate funding for their full participation in Inquiries (para 15.27).

Responses to the S&SD paper “The Future of Accident Investigation in the Railway Industry” should be taken into consideration in applying the foregoing Recommendations (para 15.29).

Steps should be taken to upgrade the role of Rail Incident Officer and to ensure that the person so designated has sufficient authority and standing for the task in hand, bearing in mind the tensions that can develop in the early stages of an accident response (para 2.15).

Consideration should be given to means of speeding up the process of earthing and isolation of traction current following an accident on an electrified section of line (para 2.15).

Routes for evacuation away from an accident should take into account the need to avoid distressing scenes (para 2.11).

Further consideration should be given to the sensitive handling of persons rescued from accidents including whether they should be sent onward by train (para 2.14).

More effective means of liaising with hospital and casualty gathering areas should be considered (para 2.14).

Identification of victims should be speeded up and information released to relatives at the earliest possible time (para 2.24).

Casualty bureaux procedures should be reviewed in order to ensure that they remain open for as long as required and that adequate telephone facilities are available (para 2.24).

Post-accident de-briefing procedures should be reviewed to ensure that combined de-briefings are held between all involved Railway Industry and Emergency Services groups (paras 2.25, 16.28).