Ladbroke Grove Rail Inquiry

Terms of Reference:

1. To inquire into, and draw lessons from, the accident near Paddington Station on 5.10.99, taking account of the findings of the HSEs investigations into immediate causes.

2. To consider general experience derived from relevant accidents on the railway since the Hidden Inquiry [into the 1988 Clapham Rail Crash], with a view to drawing conclusions about:

(a) factors which affect safety management

(b) the appropriateness of the current regulatory regime.

3. In the light of the above, to make recommendations for improving safety on the future railway.

Paras 1 and 2 of the terms of reference were dealt with in separate stages together with, on each occasion, para 3. This resulted in two reports being produced: the Part 1 Report and the Part 2 Report.

Chair: Lord Cullen

Panel Members: Professor Peter McKie and Mr Malcolm Southgate

Dates:

· Establishment: 8 October 1999, under s.14(2)(b) of the Health and Safety at Work Act 1974

· Hearings: Preliminary hearing for Part 1 on 21 December 1999; hearings from 10 May to 28 September 2000. Preliminary hearing for Part 2 on 30 March 2000. Hearings from 31 October to 20 December 2000.

· Report: June 2001

Link to website and or download report:

Part 1 report:

http://www.pixunlimited.co.uk/pdf/news/transport/ladbrokegrove.pdf

Part 2 report:

http://www.rail-reg.gov.uk/upload/pdf/incident-ladbrokegrove-lgri2.pdf

Description of the events which caused the public concern:

The rail crash at Ladbroke Grove junction between two trains operated by Thames Trains and First Great Western. There were 31 fatalities.

Litigation

Gray v. Thames Trains Ltd [2009] UKHL 33

On 5 April 2004, Thames Trains was fined a record £2,000,000 for violations of health and safety law in connection with this accident.

On 31 October 2006, Network Rail pleaded guilty to charges under the Health and Safety at Work Act 1974 in relation to the accident. They received a fine of £4 million on 30 March 2007, and were ordered to pay £225,000 in costs.

Summary of reports recommendations

The Part 1 Report made 89 detailed recommendations on the following issues:

· Support of the bereaved and injured

· Track and signalling changes

· Implementation of formal inquiry recommendations

· Signalling in Paddington area

· Driver management and training

· Safety auditing

· Signal sighting

· SPAD investigation

· Signallers instructions

· Signallers training and briefing

· Signallers working conditions

· IECC equipment

· Automatic controls

· Radio communications

· Preservation of data

· Crashworthiness

· Fire mitigation

· Passenger protection, evacuation and escape

· The implementation of recommendations

The Part 2 Report made 74 detailed recommendations on the following issues:

· Interfaces and the number of franchises

· Large scale projects and the case for system authorities

· Research and development

· The use of contractors

· The role of the trade unions

· Safety leadership within individual companies

· Communications

· Risk assessment

· Railway Group standards

· Safety cases

· The accreditation of suppliers and producers of services

· Licensing

· Railtrack and railway safety

· The safety regulator

· A rail industry safety body

· Accident investigation

· The implementation of recommendations

Any follow up bodies

The Southall and Ladbroke Grove Joint Inquiry into Train Protection Systems etc.

There were also related inquests into the deaths that occurred. In addition, the Health and Safety Executive carried out investigations and published a number of interim reports and a final report in December 2000. There was also a separate Formal Inquiry in accordance with the relevant Railway Group Standard, chaired by Mr R Bonham-Carter.