The lessons of Ladbroke Grove

01 October 2019

Simon Weller, ASLEF's Assistant General Secretary, reflects on the long shadows cast by the rail crash at Ladbroke Grove twenty years ago.


On 5 October 1999 a tragic collision took place two miles out from Paddington at Ladbroke Grove. The collision, and ensuing fire, claimed the lives of 31 people, including the two drivers – Brian Cooper (Paddington) and Michael Hodder (Paddington). It was a collision that was not only tragic but also avoidable – and it became a turning point in the way drivers were trained and managed in the newly-privatised industry, amongst other things.


Many lessons were learned but also, at a distance of 20 years, it seems many of the recommendations have been forgotten.


The simple facts are as follows: a Thames Trains Class 165 turbo driven by Michael Hodder left Paddington at 08:06 bound for Bedwyn in Wiltshire. At 08:08:25 the turbo, travelling at 41mph, passed signal SN109 at danger after passing the previous signal, SN107, at single yellow. The state of the points was such that the turbo was inevitably carried towards the up main line. 


Meanwhile, a First Great Western HST was approaching the up main on green signals. Shortly before the crash a signaller at Slough power box, who had been monitoring the progress of both trains, put signal SN102 back to red in the face of the HST. Both drivers applied their brakes but this had no significant effect on the impact which took place at a speed of about 130mph. Both drivers were killed.


The impact was virtually head-on. The HST absorbed the crash energy well but several bogies became detached. The turbo suffered a considerable degree of destruction and failure. The initial impact was followed by a number of fires caused by the dispersal and ignition of some 690 litres of diesel from the turbo exacerbated by 4,000 litres from the HST. The most horrific fire was the one that engulfed coach H of the HST.


A public inquiry, led by Lord Cullen, was set up in 2000 to determine the cause of the accident and what action should be taken. He made several findings of fact, and 89 distinct recommendations, in part one of his report. Part two dealt specifically with industry regulation.


The immediate cause was identified as the turbo passing SN109 at danger but Cullen determined that there were a number of factors that led to that. These included the visibility and positioning of the signal – which was an unusual reverse L shape and not compliant with then current signal sighting requirements – and the poor quality training that the newly-qualified Michael Hodder had received. He had only worked 20 turns as a driver prior to the crash. The lack of knowledge of many drivers of the risk the multi-SPAD SN109 posed; it had been the subject of eight SPADs in the previous six years and the train operators had demanded action from Railtrack.


The cause was one thing, the consequences another. The lack of flank protection in the relatively new track layout and signalling system – which was only seven years old – meant the opposing trains were routed into a head-on situation rather than away from each other in the event of a SPAD. The design and construction of the fuel tanks were identified as a problem; as was emergency information and escape provision for passengers; and the rules and working environment for the signallers.


Following the Southall collision in 1997, when eight people were killed, and other serious incidents that had resulted in collisions but no deaths, SPADs had moved up the agenda. However, the response had been patchy and inconsistent and pretty much left down to local driver management teams.


One of Lord Cullen's recommendations was that SPADs were to be investigated with 'no presumption that driver error is the sole or principal cause'. SPAD prevention was now a priority.


Signal sighting standards were to be tightened up and ambiguity removed from regulations. Sighting standards must explicitly define the cab sight lines by referencing the driver's eye line and be specified for each type of rolling stock.


Briefing cycles for drivers and signallers were to be introduced with joint driver and signaller 'away days to develop their mutual understanding'. Whatever happened to those?


And while not specifically referenced in the recommendations, driver competency management came to the fore, with a consistent approach across the TOCs. This shake-up in driver management was a direct result of the Ladbroke Grove collision.


Driver training was massively overhauled; developing into a more consistent and professional approach – a departure from the ad hoc DIY approach practiced by some TOCs. Defensive driving techniques, which were in their infancy at the time, became the norm.


The ASLEF archives show our robust responses and how these had already been ASLEF policy prior to the collision.


Our demands for the introduction of Automatic Train Protection were palmed off to a further inquiry and a cost-benefit analysis of ATP versus other systems. It came as no surprise that private industry, Railtrack, and the TOCs ultimately went with the cheaper TPWS system.


There was more to come in part two of Lord Cullen's report – a wholesale change in the railways regulatory makeup. The Health and Safety Executive came in for criticism as it had a confused role as both standards-maker and investigator – trying to both poacher and gamekeeper.


Following Cullen's recommendations the then Labour government split the rail responsibilities between the Rail Regulator (later to be the Office of Rail and Road) and the Rail Safety and Standards Board with the independent Rail Accident Investigation Board to investigate incidents, establishing the facts of the case, and assessing and evaluating causes, but not apportioning blame or establishing liability.


The Ladbroke Grove collision had far-reaching effects on us, as drivers, and on the regulation of our industry, dragging the woolly private model into the 21st century. But even those changes were not enough to prevent the Hatfield collision the following year, in October 2000. That stripped bare the complacency, nay corruption, at the heart of the privatised railway in Britain.


This article originally appeared in the October 2019 issue of the ASLEF Journal.


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