Reports & recommendations
93 recommendations, each with the government response on the record. Filter by government response or delivery status.
Reports (1)
| Title | Volume | Publication Date | Recommendations | Links |
|---|---|---|---|---|
| Hidden Inquiry — Final Report | - | 07 Nov 1989 | 93 |
Recommendations (93)
BR to rigorously implement cutting, insulating, securing redundant wires before commissioning
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.
Establish national responsibility for updating and creating new installation standards
BR at national level shall be responsible for updating and creating new standards of installation.
Enforce tighter control on Design Office procedures for accurate working drawings
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.
Urgently ensure and document independent wire counts during testing procedures
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.
Identify single individual responsible for overall charge of all testing
BR shall ensure that one individual is always identified as the person in overall charge of testing.
Ensure a comprehensive testing plan is drawn up for every commissioning
BR shall ensure that a testing plan is drawn up for every commissioning.
Require BR to include sufficient, qualified staff in all testing plans
BR shall ensure that sufficient numbers of suitably qualified staff are included in the testing plan.
Require BR to provide and monitor full documentation for proper testing
BR shall ensure that full documentation is provided and later monitored in order that proper testing is carried out.
Introduce national testing instruction with workforce explanation, monitoring, and auditing
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 to audit resources and authority for national signal testing instruction implementation
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.
Ensure independence of testing and commissioning engineers from new works staff
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.
Establish effective systems for personal distribution of departmental instructions to all employees
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.
Require staff to understand, re-read, and biennially confirm understanding of instructions
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.
Provide necessary technical training for all staff to ensure safe practices
BR shall give technical training as necessary to ensure that efficient and safe practices are carried out by all technical staff.
Provide mandatory refresher courses for installers at least every five years
BR shall provide refresher courses for installers at intervals of not more than five years.
Urgently progress and monitor training, certification, and refresher courses for testers
BR shall urgently progress and monitor training and certification of testers. Refresher courses shall be evolved.
Regularly review the structure and content of all training courses
BR shall ensure that the structure and content of courses are regularly reviewed.
Monitor staff overtime to prevent individuals working excessive levels
BR shall ensure that overtime is monitored so that no individual is working excessive levels of overtime.
Introduce scheduled hours for Signals and Telecommunications weekend work with unions
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.
Monitor and forecast skilled S&T staff to ensure safe recruitment and retention
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.
Consider recruiting staff at assistant technician level and above
BR, in reviewing recruitment and retention levels, shall also consider recruiting staff at levels at and above assistant technician.
Provide clear job descriptions for all staff grades and posts
BR shall provide all grades with job descriptions for their particular post so that staff know what is expected of them
Extend simplified annual appraisal system to include senior technician level
The annual appraisal system, albeit in a simplified form, shall be extended to senior technician level.
Establish continuous system to identify employees who would benefit from additional training
BR shall ensure that there is an effective system in place on a continuous basis to identify which employees would benefit from additional training.
Introduce system for reporting, classifying, and monitoring all WSFs to Board level
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.
Thoroughly investigate unprotected WSFs with danger potential to learn wider lessons
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.
Report unprotected WSFs as "dangerous occurrences" to the Railway Inspectorate
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 to seek legislative effect for recommendation 27
Government shall seek to give legislative effect to recommendation 27.
Person in overall charge of new works to nominate a Project Manager
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)
Project Manager responsible for the whole project within budget and timescale
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)
Require external work to be contractual, specified by Project Manager
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.
Establish direct reporting line for Testing Engineer to overall scheme charge
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.
Provide necessary training resources for wider management down to supervisor level
BR shall make available necessary training resources for wider management training down to supervisor level.
Require future reorganisations to be properly planned, resourced, and timely implemented
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.
Implement improved procedures to prevent unallocated staff during reorganisations
BR shall implement improved procedures to replace the cumbersome arrangements on reorganisations which allow staff to be displaced and to remain unallocated.
Continue implementing Total Quality Management Initiative and BS5750 quality systems
BR shall continue to press ahead with its Total Quality Management Initiative and the application of British Standard BS5750: Quality systems.
Urgently implement the Board's existing quality plan within S&T Departments
S&T Departments shall implement the Board's existing quality plan with the greatest urgency.
Urgently use outside consultants to review safety management and communication issues
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.
Urgently introduce independent monitoring and auditing for all safety-related work
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.
Prioritise introduction of on-train data recorders for incident investigation assistance
BR shall give a higher priority to the introduction of on-train data recorders to assist investigation of any future incident.
Utilise on-train data recorder information for systematic safety monitoring procedures
BR shall consider the use of information from on-train data recorders as part of a systematic safety monitoring procedure.
Report 6-monthly to Railway Inspectorate on accident follow-up and recommendations
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.
Prioritise installation of driver-signalman radio communication on all traction units
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.
Install voice recorders to provide a record of all radio messages
BR shall instal voice recorders for the purpose of providing a record of all radio messages relayed.
Government allocate sufficient radio frequencies for important safety communication functions
Government, in discussion with BR, shall allocate a sufficient number of frequencies for this important safety function
Fully implement Automatic Train Protection within five years, prioritising busy lines
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.
Report 6-monthly to Railway Inspectorate on Automatic Train Protection implementation progress
BR shall report at 6 monthly intervals to the Railway Inspectorate on its progress in implementing ATP.
Study appraisal procedures for safety elements in railway investment proposals
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.
Develop system for allocating project priority to prevent safety compromise
BR shall develop an adequate system of allocating priority to projects to ensure that safety standards are not compromised by delay.
Establish organisational framework to prevent commercial considerations compromising railway safety
BR shall ensure that the organisational framework exists to prevent commercial considerations of a business-led railway from compromising safety.
Emphasise signalling irregularity definitions and reportable situations during driver training
BR shall ensure that during driver training the definition of a signalling irregularity and situations which are reportable are given greater emphasis.
Provide appropriate feedback to drivers reporting signalling irregularities on outcomes
BR shall ensure that drivers, reporting on signalling irregularities, are given appropriate feedback on the outcome.
Eliminate re-use of insulation tape and ensure secure insulation methods
BR shall ensure that the practice of the re-use of insulation tape is eliminated and the method of insulation is secure.
Complete research programme into structural integrity of rolling stock by April 1991
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.
Discuss research conclusions with Inspectorate to agree structural changes for rolling stock
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.
Extend research to include dynamic testing for improved passenger furniture design
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.
Seek economic dynamic modelling methods for coach collision resistance research
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.
Expand involvement in European studies on passenger stock performance and collision resistance
BR shall continue and expand its involvement in collaborative European railway studies of performance of passenger stock, including collision resistance.
Amend Road and Rail Traffic Act 1933 to include rolling stock approval
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.
Achieve and regularly review overall train loading criteria with Department of Transport
BR shall ensure that overall train loading criteria are achieved. The Department of Transport and BR shall keep the criteria under review.
Improve inter-service communication for major incident declarations via dedicated lines
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.
Conduct regular major incident exercises to test emergency communication systems
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.
Review ambulance procedures to provide early major incident warnings to hospitals
Ambulance services shall review procedures to ensure that the designated and supporting hospitals are given a major incident warning as early as possible.
Ensure emergency alert lines receive incoming calls only and are tested weekly
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.
Implement training for Medical Incident Officers in radio communications usage
The LAS shall implement its proposal to train prospective Medical Incident Officers in the use of radio communications.
Require hospitals to provide Medical Incident Officer training for relevant staff
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.
Require emergency services to provide local radio communication at accident sites
Emergency services shall provide local radio communication at the accident site to facilitate liaison between the control units and experts on site.
Require Ambulance Service to provide hospital aerials for emergency radio communication
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.
Require all emergency services to provide and ensure personnel wear protective clothing
All emergency services shall ensure that personnel are provided with and wear protective clothing, including protective headgear.
Require services to provide coloured high-visibility vests for personnel identification
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.
Require ambulance staff qualified in intubation to wear 'Millar trained' badges
Ambulance services shall require staff properly qualified in intubation and infusion to wear "Millar trained" badges prominently displayed, including on protective clothing.
Require police casualty bureaux to be equipped with telephone queuing systems
Police forces shall arrange that all casualty bureaux be equipped with a telephone queuing system with a recorded message.
ACPO to establish system for extending simultaneous casualty bureau call handling
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.
Require emergency services to recognise Civil Police primacy in non-fire accidents
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.
Require police forces to adopt Metropolitan Police arrangements for bereaved relatives
Police Forces shall study and follow the excellent arrangements made by the Metropolitan Police for the bereaved and relatives of the seriously injured.
Require BR and emergency services to maintain joint planning with table-top exercises
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.
Require medical personnel to report to ambulance forward control unit on site
The ambulance service and designated hospitals shall require that all medical personnel report to the forward control unit of the ambulance service on site.
Require each service to maintain up-to-date staff lists within inner cordon
Each service shall additionally maintain on site an up-to-date list of staff within the inner cordon in case evacuation is necessary.
Department of Health to review Circular 71, clarifying Major Incident declaration terms
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.
Department of Health to review BASICS' role and funding in emergency planning
In revising the Circular the Department of Health shall consider the role of BASICS in emergency planning and review BASICS' funding arrangements.
BR to equip signal boxes with direct lines and emergency dialling systems
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 to review and test communication systems with emergency services weekly
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 to ensure proper training and clear instructions for new communication systems
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.
Rectify high-priority deficiencies in railway communication systems and signal-post telephones
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.
Install public address systems in all new and older trains for passenger communication
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.
Produce updated accident procedure manual and provide staff with appropriate training
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.
Develop and regularly exercise effective emergency plans for all station staff
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.
Introduce emergency signal override in signal boxes and update immobilised train procedures
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.
Examine introducing short-circuiting bars with positive clamp on running rail
BR shall examine the possibility of introducing short-circuiting bars which achieve a positive clamp on the running rail.
Detail evidence recording and preservation procedures within the accident procedure manual
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.
Ensure fault finding teams are accompanied by police and photographer for 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.
Promptly update Rule Book and Books of Instruction incorporating report observations
The Rule Book and Books of Instruction of a similar status shall be promptly updated and observations made in this Report taken into account.
Adequately staff and resource the Railway Inspectorate for increased responsibilities
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.