The "immediate cause" of the Paddington rail disaster, in which at least 40 people are feared dead, appears to be that the Thames train driver passed a red signal about 700 metres before the collision point, the Health and Safety Executive's interim report on the crash revealed yesterday.
The accident "would have been prevented by the installation and correct operation of a Train Protection Warning System (TPWS)", on SN109, the signal that was passed by the Thames driver, and immediate safety improvements on Britain's railways have been ordered.
Publication of the report came as the first of 11 victims of the crash were named, including both drivers and one of Dr Mo Mowlam's senior advisers, at an inquest which was opened and adjourned in London. The report said analysis of data tapes suggested the signalling equipment outside Paddington "is unlikely to have been at fault", which lends weight to the theory that the driver of the Thames train crossed into the path of the high-speed Great Western train in error.
Stressing that his findings were interim, the chief inspector of railways, Mr Vick Coleman, said the reasons why the Thames train driver passed SN109 at red "are likely to be complex" and further investigation could reveal systems failure caused the crash and/or any action or omission by the driver "was only one factor". While the final report will take some time to complete, Mr Coleman said his investigation had already established that the Automatic Train Protection (ATP) system, which was fitted as part of a pilot scheme, was switched off in the leading cab of the Great Western train. However, on the evidence gathered so far, it was unlikely to have had any bearing on the cause of the accident.
The Automatic Warning System (AWS) system was switched on in the leading cab, but the report said: "We cannot tell whether it was operational at this stage, neither is the result likely to have any bearing on the accident."
Diesel fuel was spilled over a wide area after the crash, the report said, after three fuel tanks on the Thames train and the forward tanks on the Great Western train ruptured. The ensuing fire was "wholly unprecedented", and its cause would be thoroughly investigated.
Ordering immediate improvements in safety, the HSE banned the use of SN109, which has been at the centre of eight incidents since 1993. Furthermore, all train operators must re-brief their drivers on "signals passed at danger" and review driver training, competence assessment and driver monitoring arrangements to ensure all drivers are competent to perform their duties.
Railtrack, which owns the rail infrastructure, has been ordered to install additional controls at 22 signals involved in the largest number of "signals passed at danger" incidents, or to devise another way of securing an equivalent or higher standard of safety in those signalling areas. The controls must be in place by November 6th.
The full HSE report will focus on three key questions:
Why the accident happened;
What immediate action needs to be taken to prevent another accident;
Is enforcement action, including prosecution, justified?
Piecing together the likely sequence of events leading up to the crash, Mr Alan Cooksey, deputy chief inspector of railways, said a signaller in the Slough area near Reading observed the progress of the trains on his visual display unit. Shortly before the crash he realised the Thames train had passed SN109 at red and was heading towards the Great Western train, which was authorised to proceed on a green light. He immediately changed the signal controlling the fast track to red, but the Great Western train was travelling at speed and the collision occurred almost simultaneously.
The full text of the British Health and Safety Executive's interim report into the Ladbroke Grove Junction (Paddington) train accident can be read on The Irish Times on the Web (www.ireland.com).