Ladbroke Grove Disaster

The Ladbroke Grove rail crash was a rail acident which occurred on 5 October 1999 at Ladbroke Grove, London. With 31 people being killed and more than 520 injured, this remains the worst rail accident on the Great Western Main Line. This was the second major accident on the Great Western Main Line in just over two years, the first being the Southall rail crash of September 1997, a few miles west in England. Both crashes would have been prevented by an operational Automatic Train Protection (ATP) system, but wider fitting of this had been rejected on cost grounds. This severely damaged public confidence in the management and regulation of safety of Britain's privatized railway system. This crash is also known as the Paddington train crash.
*A public inquiry into the crash by Lord Cullen was held in 2000. Since both the Paddington and Southall crashes had reopened public debate on ATP a separate joint inquiry considering the issue in the light of both crashes was also held in 2000; it confirmed the rejection of ATP and the mandatory adoption of a cheaper and less effective system, but noted a mismatch between public opinion and cost-benefit analysis. The Cullen inquiry was carried out in 2 blocks of sittings, sandwiching the 'joint inquiry'; the first block dealt with the accident itself, the second block dealt with the management and regulation of UK railway safety; this had always been part of the inquiry terms of reference, but was given additional urgency by a further train crash at Hatfield in October 2000. Major changes in the formal responsibilities for management and regulation of safety of UK rail transport ensued.
The immediate cause of the disaster was identified as the Turbo train passing signal SN109 (located on an overhead gantry, with four other signals serving other tracks) at which it should have been held. It was established that the signal had been showing a red aspect, and the preceding signal SN 87 had been showing a single yellow which should have led the driver to be prepared for a red at SN109. Since the Thames Turbo driver, 31-year-old Michael Hodder, had been killed in the accident, it was not possible to establish why he had passed the signal at danger. However, Hodder was inexperienced, having qualified as a driver only two weeks before the crash. His driver training was found to be defective, whilst the signaling in the Paddington area was known to have caused problems SN109 had been passed at danger on eight occasions in six years, but Hodder had no specific warning of this. Furthermore, 5 October 1999 was a day of bright sunshine and at just past 8 o'clock the sun would have been low and behind Hodder, with low sunlight reflecting off yellow aspects. Poor signal placement meant that Hodder would have seen sunlit yellow aspects of SN109 at a point where his view of the red aspect of SN109 (but not of any other signal on the gantry) was still obstructed. The inquiry considered it more probable than not that the poor sighting of SN109, both in itself and in comparison with the other signals on and at gantry 8, allied to the effect of bright sunlight at a low angle, were factors which had led Hodder to believe that he had a proceed aspect. Since 1998 a campaign to have the signal SN109 properly sited had been running and the Bristol HST drivers were re-routed as not to pass this signal
The inquiry noted that the lines into Paddington were known to be prone to 'signal passed at danger' (SPAD) events - in particular there had been eight SPADs at signal SN109 in the preceding six years - and attempted to identify the underlying causes.
Paddington approaches had been resignalled by British Rail in the early 1990s to allow bidirectional working ; the number of signals and limited trackside space meant that most signals were in gantries over the tracks, the curvature of the lines meant that it was not always easy to work out which signal was for which track.