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).

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).

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).

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).

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).

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).

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).

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 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).

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).

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 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).

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).

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).

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 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).

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).

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).

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).

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).