Potters Bar Crash Inquest Results

[Poor Old Bruce]

I believe I am right in saying that the Southall collision was the first to occur under the new regime - certainly the first serious incident. Some of the initial insight investigation was abysmal with BTP officers, who hadn't got a clue what to look at or for, preventing access to areas of critical evidence by railway staff who knew exactly what to look for. By the time the right people were allowed in some of the evidence has degraded....

 

The process then got so tied up and hidebound in procedural and investigative boundary guarding that lessons learnt from Southall which could have been applied at Ladbroke Grove (and according to some people some of those lessons might even have averted it) simply did not emerge quickly enough.

The same applied at Hatfield where site access was denied for some time while BTP examined the (extremely remote) possibility of explosive devices when any experienced railway investigator could have told them in minutes (as I did about five hours after the event) that the rail had simply disintegrated. It was the following day before the investigation could really start, by which time rail fracture faces which had been fresh the day before were starting to go rusty.

 

Mention of Ladbroke grove still winds me up as a case where a simple rearrangement of co-acting points could have directed the DMU onto the Down Relief rather than the Up Main and would have led just to a set of points being run through rather than a 140 mph head-on collision. This may be considered by some to be an inflamatory comment but it is my opinion that (intentionally or otherwise) the signalling fraternity (the designers, not the operators I hasten to add) bamboozled the Public Inquiry into thinking that such point control was impossible without restricting train operation.

[Guest Max Stafford]

Tonight, rail passengers are being warned of more crashes and deaths on our railways.....Welcome to ITV News.

 

That's the problem in this country today. Everyone is accountable for their words and conduct except the runaway train that is the media. It's no secret that a little careful editing can give somebody's words an entirely different context than that in which they were presented.

 

It really does wind me up the way the media industry in this country abuses its unparallelled freedoms.

Time they were brought to heel in the way the rest of us are...

 

Dave.

[The Stationmaster]

 

Mention of Ladbroke grove still winds me up as a case where a simple rearrangement of co-acting points could have directed the DMU onto the Down Relief rather than the Up Main and would have led just to a set of points being run through rather than a 140 mph head-on collision. This may be considered by some to be an inflamatory comment but it is my opinion that (intentionally or otherwise) the signalling fraternity (the designers, not the operators I hasten to add) bamboozled the Public Inquiry into thinking that such point control was impossible without restricting train operation.

 

You're not the only one who gets wound up about it - for a variety of reasons; including a masterful 'P.R. style' job which directed media attention away from an area where some very serious questions needed to be asked to put the spotlight on another (where some equally serious questions were asked and which rapidly grabbed the headlines).

 

Mind you the Inquiry did have its amusing moments judging by the transcripts, especially when a certain traction engineer very innocently made one of the showboating legal eagles look a right ignoramus.

[coachmann]

It really does wind me up the way the media industry in this country abuses its unparallelled freedoms.

Time they were brought to heel in the way the rest of us are...

I feel in exactly the same way, although I suspect it's a case of.........give 'em enough rope and they'll hang themselves.

[Edwin_m]

I feel in exactly the same way, although I suspect it's a case of.........give 'em enough rope and they'll hang themselves.

 

More a case of "give 'em enough rope and they'll hang someone else".

[Edwin_m]

Mention of Ladbroke grove still winds me up as a case where a simple rearrangement of co-acting points could have directed the DMU onto the Down Relief rather than the Up Main and would have led just to a set of points being run through rather than a 140 mph head-on collision. This may be considered by some to be an inflamatory comment but it is my opinion that (intentionally or otherwise) the signalling fraternity (the designers, not the operators I hasten to add) bamboozled the Public Inquiry into thinking that such point control was impossible without restricting train operation.

 

I seem to remember that the excuse was the connection to the Down Relief being much nearer than that to the Up Main, so if a SPAD took place there was more length for the driver to stop before any potential collision. However this doesn't apply if the driver continued as if the signal was green, and of course running into a line for the same direction makes a collision both less likely and less severe than what actually happened.

 

The other issue with Ladbroke Grove is that the Thames train was going slowly enough to have been stopped by TPWS before reaching the point of collision. At the time the authorisation for TPWS fitting had been sitting on Prescott's desk for several months.

[The Stationmaster]

I seem to remember that the excuse was the connection to the Down Relief being much nearer than that to the Up Main, so if a SPAD took place there was more length for the driver to stop before any potential collision. However this doesn't apply if the driver continued as if the signal was green, and of course running into a line for the same direction makes a collision both less likely and less severe than what actually happened.

 

The other issue with Ladbroke Grove is that the Thames train was going slowly enough to have been stopped by TPWS before reaching the point of collision. At the time the authorisation for TPWS fitting had been sitting on Prescott's desk for several months.

 

I hope folk are happy with us widening this thread to include Ladbroke Grove (and possibly other incidents) but I think there are at least some common principles involved.

 

Your second point is one of those things where the new structure of investigation etc after Southall didn't exactly shine. Prescott might still have done the same had a propmpt report by an HMRI recommended widespread provision of TPWS - but the fact that he/his department delayed things would have been a lot clearer.

 

As far as the over-run distance etc is concerned the Turbo had a distance of more than half a mile, well over braking distance and then some, in which the Driver could realise he had got it wrong and should stop - he didn't. Previously an old-hand FGW Driver who had SPAD'd that signal did realise, and duly stopped. The difference in the actions of those two Drivers tells me something quite important, but it received far too little attention because inquiry eyes and minds had become focused elsewhere.

 

The lack of a 'safer' trapping method (i.e the one Bruce talked about above) is another area where, in my view, things were not properly brought out in the Inquiry. I put a lot of that down to the way in which the Inquiry itself was conducted because as soon as legal types are brought into what should essentially be an objective, fact finding, exercise they seem to think they should be carrying on in the same manner as they do at a trial. Add to that their clearly limited understanding of the subject and no amount of input from professionally experienced assessors is likely to clear the logjam.

 

If I had my way I would make it illegal for lawyers etc to speak at these inquiries unless they are a witness - they should stick to their 'watching brief' and no more.

[Poor Old Bruce]

The lack of a 'safer' trapping method (i.e the one Bruce talked about above) is another area where, in my view, things were not properly brought out in the Inquiry. I put a lot of that down to the way in which the Inquiry itself was conducted because as soon as legal types are brought into what should essentially be an objective, fact finding, exercise they seem to think they should be carrying on in the same manner as they do at a trial. Add to that their clearly limited understanding of the subject and no amount of input from professionally experienced assessors is likely to clear the logjam.

 

Not just the legal types SM, I don't remember what Lord Cullen's credentials were to chair the Ladbroke Grove Inquiry but my personal opinion is that he appeared to have insufficient railway knowledge to see through the smoke screens thrown up by various interested parties and was not given the necessary guidance by his own advisors.

 

Good to know (if that is the right choice of words) that I am not the only one with reservations.

 

Needless to say, I am not impressed with the Public Inquiry philosophy. While it may seem a good idea at face value, an Inquiry is given a remit to work to. Internal Railway Inquiries were given remits which included specific areas of concern and (at the bottom of the list) something like looking at other factor which may be relevant to the incident. It is then down to the Chair to follow that remit, whether the Ladbroke Grove Inquiry got to the botton of the list is a moot point.

[Guest Max Stafford]

It's sad that the focus of enquiries has become utterly warped in modern times. To me, the primary purpose of an enquiry is to ascertain what went wrong and what lessons can be learned to prevent a repetition.

 

Now it is all about apportioning blame and exacting revenge, largely motivated by the self-interest of a predatory and mercenary legal industry and those with political axes to grind under the guise of public interest...

 

Dave.

[Fat Controller]

Cullen may not have had the railway experience, but I believe he had previously chaired an Inquiry after another major industrial accident- I think it may have been Piper Alpha.

[Foulounoux]

It's sad that the focus of enquiries has become utterly warped in modern times. To me, the primary purpose of an enquiry is to ascertain what went wrong and what lessons can be learned to prevent a repetition.

 

Now it is all about apportioning blame and exacting revenge, largely motivated by the self-interest of a predatory and mercenary legal industry and those with political axes to grind under the guise of public interest...

 

Dave.

 

Agreed

 

Old times - Person responsible admits blame , everyone else has the view that as long as it doesn't happen again then lesson has been learnt inquests concentrate on causes and how to prevent in future

 

Mid times - person admits blame - lawyers all jump in and suggest the family sues

 

Now - No-one will admit blame for fear of repercussions, therefore the inquests come under pressure to point the finger and forget what they are there for which is to get to the root cause.

 

 

 

In my last job we operated a warehouse with FLT's and if someone had an incident we had a simple rule - admit/report it and we work together to find out why it happened after all it may not have been the operators fault, don't report it and then its the disciplinary route. That way we were able to concentrate on the causes rather than conduct witch hunts.

[Edwin_m]

Certainly Uff/Cullen were politely skeptical about the likely effectiveness of TPWS vs a full-blown ATP system - something where I had a small part in producing the safety studies. Subsequent events confirmed our prediction that TPWS would be about 60% effective in preventing casualties compared to ATP.

[jamie92208]

I agree wholeheartedly that the Full Public Enquiry route is not the way to go and only delays things and makes lawyers rich. They don't always understand the issues and because of the political pressure to fully inplement their findings they often end up saddling all of us which hugely inflated costs eg Hidden and signal tesing.

 

One factor about Ladbroke Grove has always puzzled me and I may ahve got my facts wrong. As I understand it the Thames Turbo was on a route that took it out along the fast lines. Before privatisation these services would probably have started from platforms 1 or 2 but after the great split up the Thames services were concentrated on the high numbered platforms while the service pattern was retained. this menat, i think, that there were two working an hour from platform 10, or thereabout, onto the fast lines that had to corss over at Ladbroke Grove. In my view this introduced extra risk into a system that the layout was not designed for. If privitisation had not split the serive operators for Paddington up that move would never have taken place.

 

 

Jamie

[The Stationmaster]

Not just the legal types SM, I don't remember what Lord Cullen's credentials were to chair the Ladbroke Grove Inquiry but my personal opinion is that he appeared to have insufficient railway knowledge to see through the smoke screens thrown up by various interested parties and was not given the necessary guidance by his own advisors.

 

Good to know (if that is the right choice of words) that I am not the only one with reservations.

 

Needless to say, I am not impressed with the Public Inquiry philosophy. While it may seem a good idea at face value, an Inquiry is given a remit to work to. Internal Railway Inquiries were given remits which included specific areas of concern and (at the bottom of the list) something like looking at other factor which may be relevant to the incident. It is then down to the Chair to follow that remit, whether the Ladbroke Grove Inquiry got to the botton of the list is a moot point.

 

 

Lord Cullen was assisted by assessors (one of whom I know quite well although I didn't realise at the time that he was acting as an assessor - in fact I only found out some years subsequently from someone else who had been unable to take up the role due to other commitments) but that doesn't answer things either in my view. The professionalism and 'detachment' of the 'old' Inspectors - with their military background and training plus the knowledge - has never been equalled since HMRI was grabbed by the HSE and even now under the ORR hasn't really recovered.

 

The old style Inquiries, taken by an Inspecting Officer, worked well and usually got to the heart of things but for various reasons they would have been difficult to carry on. What we have now is neither fish nor fowl and none too effective.

[The Stationmaster]

I agree wholeheartedly that the Full Public Enquiry route is not the way to go and only delays things and makes lawyers rich. They don't always understand the issues and because of the political pressure to fully inplement their findings they often end up saddling all of us which hugely inflated costs eg Hidden and signal tesing.

 

One factor about Ladbroke Grove has always puzzled me and I may ahve got my facts wrong. As I understand it the Thames Turbo was on a route that took it out along the fast lines. Before privatisation these services would probably have started from platforms 1 or 2 but after the great split up the Thames services were concentrated on the high numbered platforms while the service pattern was retained. this menat, i think, that there were two working an hour from platform 10, or thereabout, onto the fast lines that had to corss over at Ladbroke Grove. In my view this introduced extra risk into a system that the layout was not designed for. If privitisation had not split the serive operators for Paddington up that move would never have taken place.

 

 

Jamie

 

The question of 'trains crossing over' is always a complicated one and the basic, usually inescapable, fact is that they have to do it somewhere unless you happen to have a convenient return loop type of layout. Even then optimum use of line capacity is still likely to require trains to cross the path of others at some point in their journey.

 

The Turbo approached SN109 from Line 4 crossing to Line 3 more or less immediately in rear of a very poorly sited (but compliant with sighting time standards) signal, which happened also to have a very bad SPAD record. The alternative would have been to cross at Acton West - in the face of Up trains travelling faster than at Ladbroke Grove - or carry on on the Down relief Line losing time following something else.

 

The basic points which I think emerge are rather different in order from the way they came out of the Inquiry -

1. Was the signalling ideal (with good quality sighting and clearly visible aspect sequences) and was it being correctly operated?

2. Was the line and train equipped to the optimum level with equipment intended to eliminate or mitigate the effect of a SPAD?

3. Was the Thames Trains Driver adequately trained to the extent that he had proper road knowledge?

4. Was the Driver medically and environmentally fit to be in charge of a train?

5. In view of the signal's bad SPAD record what action had been and was being taken to improve that record?

6. Train design for accident survivability.

7. Could timetabling be changed in a way that mitigates risk whIle manitaining optimum use of capacity? (I put that last because effectively it was a new idea at the time).

 

I might have missed something but I think basically that's about it. Now compare it with the weight of the Inquiry's activities and the press reporting my No.5 became the biggy, No.1 became clouded in obfuscation and confusion while missing some very basic points and a huge red herring was dropped into the pond, No.2 was almost shoved under the carpet after an initial bit of froth where privytisation came into the question, No.3 was massively downplayed in relation to its importance until the time came for the fines, No.4 received only the most basic attention (correctly so as it happened), no.6 turned into a nonsense as a result of legal experts failing toi understand anything of what they were talking about, and No.7 was touted around as a bright new idea which the lesser mortals thought might be the answer to many of the problems (mind you an Australian network, some years later, paid me some fairly good money for devising a comparative risk assessment method for their running junctions etc . But having said that it is a very cpomplicated subject and such running junction crossings are virtually unavoidable - and that was somewhere which actually had a sort of return loop!).

 

[James]

Let's not forget Grayrigg which was a vertual repeat of the failure to maintain the points.

 

Was it?

 

Having spoken to a number of people about it, I'm not convinced they're the 'virtually' same.

[Edwin_m]

Both Grayrigg and Potters Bar were derailments caused by movement of the point under a train. This was due to failure of the stretcher bars and/or detachment of their bolts, which in turn suggests incorrect inspection or maintenance of those components.

 

The difference, as I pointed out somewhere further up this thread, is that at Potters Bar the underlying reason for the problems is still not fully understood with a suspicion remaining of sabotage. At Grayrigg, NR's own report makes it pretty clear that the local maintenance organisation was under-resourced for its increased workload so the checks were simply not done.

[James]

The difference, as I pointed out somewhere further up this thread, is that at Potters Bar the underlying reason for the problems is still not fully understood with a suspicion remaining of sabotage. At Grayrigg, NR's own report makes it pretty clear that the local maintenance organisation was under-resourced for its increased workload so the checks were simply not done.

 

That's kinda what I meant - I've spoken to people where on maintenance up around the time and they've spoken of huge under resourcing.

[The Stationmaster]

Both Grayrigg and Potters Bar were derailments caused by movement of the point under a train. This was due to failure of the stretcher bars and/or detachment of their bolts, which in turn suggests incorrect inspection or maintenance of those components.

 

The difference, as I pointed out somewhere further up this thread, is that at Potters Bar the underlying reason for the problems is still not fully understood with a suspicion remaining of sabotage. At Grayrigg, NR's own report makes it pretty clear that the local maintenance organisation was under-resourced for its increased workload so the checks were simply not done.

 

 

From what has been said inside the industry it would seem that the essential feature about Potters Bar is that, not to put too fine a point (sorry) on it, those charged with maintenance lacked the knowledge and experience to do the job correctly so didn't do it corectly.

 

The essential difference at Grayrigg was that according to evidence they didn't do it for the simpler reason that they didn't have the time (one version) or the inclination (the other version). However the other critical difference at Grayrigg was the fact that the points are badly sited in terms of maintainability and were being subjected to higher running speeds which led to greater pressure on the closed switch rail on the 6ft side. For some reason these latter factors, and the periodicity of regular visual inspection, seem to have got far less attention than the 'lack of maintenance'.

 

It also interesting to note that almost before they had arrived on site some 'investigators' had decided they were at 'another Potters Bar' whereas the course of derailment - from published pictures - was definitely something rather different with clear evidence of rail climbing on the high side rail.

 

Not far from where I used to live a new single lead running junction was laid in some years ago - prior to the PB derailment - using shallow pattern switches with the much maligned 'u' shaped brackets (which do seem to be a very poor design feature). I have taken a number of detail photos of it over the years and nowithstanding the fact that it has a 70mph turnout speed from , on one side, 100mph plus running lines (where trains are either under full power or beginning to brake hard) there has been no sign of component parts moving or nuts coming adrift etc.

 

It all inclines me to think that at Grayrigg there was more to it than has been acknowledged while at Potters Bar the most likely cause really was identified although I would also query the initial adjustment and fitting up of various components as the crossover went in during a period of fairly hasty 'campaign' relaying. The sabotage theory is just a load of obfuscation and red herring trailing and anyone whose been around a few incidents over the years will very quickly tell you why the nuts were found in a neat pile (similar story to those above about understanding the significant evidence).

[phil-b259]

Just a couple of points to raise

 

The layout at Ladbroke Grove was designed, approved and installed by BR, NOT under Railtrack. The layout was chosen because of the need to provide more capacity on the final approaches to Paddington to allow for the Heathrow Express project without major new civil engineering to widen the formation. This lead to the adoption of bi-directional signalling, however when designing the layout BR assumed that it would be fully fitted with the GWML ATP equipment then on trial making SPADS imposable and consequently it did not mater too much about the layout chosen. Then came privatisation and the ATP project was killed as well as making it extremely hard to get the badly sited signals moved or the layout changed (it would cost far too much as far as Railtrack was concerned) with tragic results.

 

With regard to potters bar, I recall shortly after it happened acording 'old hands' on the S&T, back in the day, it was custom and practice to loosen bolts and remove lock nuts in preparation for forthcoming p-way jobs, the aim being to speed up the job. This goes back to the days where technical staff would be expected to work until the job was done, however long it took, thus a culture of getting as much done beforehand grew up. To some of those 'old hands' therefore the suspicion was that the locking nuts had been removed in preparation for a forthcoming job that was subsequently forgotten about. Following the accident however no-body in their right mind would come forward and say anything for fear of prosecution so if there was any truth in the 'removed for a reason' we will never know.

[meple]

Was it?

 

Having spoken to a number of people about it, I'm not convinced they're the 'virtually' same.

 

 

I think so because fundamentally people who were charged with inspecting and maintaining the crossings did not do the job they were charged to do; whether that is through incompetence, lazysiness or bloody mindedness

 

What I also don't understand is how a design can be produced that is subject to dynamic/arbitrational loading that is reliant on lock nuts to retain its integrity.

 

 

[Poor Old Bruce]

The layout at Ladbroke Grove was designed, approved and installed by BR, NOT under Railtrack. The layout was chosen because of the need to provide more capacity on the final approaches to Paddington to allow for the Heathrow Express project without major new civil engineering to widen the formation. This lead to the adoption of bi-directional signalling, however when designing the layout BR assumed that it would be fully fitted with the GWML ATP equipment then on trial making SPADS imposable and consequently it did not mater too much about the layout chosen. Then came privatisation and the ATP project was killed as well as making it extremely hard to get the badly sited signals moved or the layout changed (it would cost far too much as far as Railtrack was concerned) with tragic results.

A valid point (ouch) Phil which most people forget.

 

As there seems to be a fair bit to be said about Laadbroke Grove, would it be worth starting a separate thread?

[James]

I think so because fundamentally people who were charged with inspecting and maintaining the crossings did not do the job they were charged to do; whether that is through incompetence, lazysiness or bloody mindedness

 

That doesn't fit with what I've heard and read about Grayrigg; iirc some staff were working in ways which could themselves at risk. I think this was one example relating to Grayrigg; areas where red zone was prohibitied, but staff working IWA in order to get the inspections covered. But of course, IWA means that any one following up may not know which leg had been inspected, or other similar issues.

 

Edited to make more sense...

[Ohmisterporter]

Can I say a big thank you to those of you who know the workings of the railways from first hand experience, you make reading topics like this fascinating to this outsider.

Can I also ask you to go easy on the acronyms? Some like ATP and TPWS are easy enough but what is IWA? No doubt it is me being thick as usual but I can't be the only thicko on RMWeb. Or can I?

 

Geoff.

[The Stationmaster]

That doesn't fit with what I've heard and read about Grayrigg; iirc some staff were working in ways which could themselves at risk. I think this was one example relating to Grayrigg; areas where red zone was prohibitied, but staff working IWA in order to get the inspections covered. But of IWA means that any one following up may not know which leg had been inspected, or other similar issues.

 

I don't doubt at all that Grayrigg was difficult to patrol - one look at a pic of the site confirms it.

 

And alas nowadays the investigative process is all rather different from the attitudes displayed here - following a massively more serious collision with a large death toll. http://www.britishpathe.com/record.php?id=30457