The unsafe track and signalling layout adopted by British Rail when the approaches to Paddington were remodelled in 1989-92 appears to be the root cause of the 210 km/h head-on collision that occurred at Ladbroke Grove on October 5 1999 (RG 11.99 p703). Lord Cullen’s report on the accident, published on June 19, confirms that the immediate cause was a Thames Trains DMU being driven past Signal SN109 at red and colliding virtually head-on with a Great Western High Speed Train. Both drivers and 29 passengers died. Several fires broke out, and some survivors were severely burned.

Thames Trains does not escape criticism for the training Driver Hodder received after being recruited into the industry in February 1999. But the company’s decision in 1998 not to fit its trains with the automatic train protection system being trialled on this route was ’reasonable’, Lord Cullen concluded.

When the Signal Passed at Danger (SPAD) alarm went off, the signaller at Slough failed to send an emergency stop message to Hodder by radio immediately, which might well have prevented the collision. Instead, he waited to see if the DMU would stop before fouling the Up Main track, as eight other drivers who had run by SN109 since 1993 had done. In fact, Hodder believed the signal was clear, and was accelerating.

Railtrack assumed responsibility for BR’s infrastructure on April 1 1994. In the ensuing five years there were numerous SPADs and other indications that drivers were having difficulty in reading signals between Ladbroke Grove and Paddington. The layout consisted of six reversible tracks with crossovers laid out for 145 km/h running to ensure a fast exit from the terminus.

In 1999, the relevant line speed was 100 km/h. Low overbridges obscured signals, and overhead electrification installed in 1995 for Heathrow Express had compounded signal sighting problems. As the line curved, drivers had to count across from left or right to identify the aspect applying to the track they were on (which frequently changed) while the lights appeared and disappeared behind various obstructions.

Several signals had poor SPAD records, and there was a sidelong collision at Royal Oak on November 10 1995. At SN109, a precursor to the subsequent fatal collision at Ladbroke Grove occurred on February 4 1998 when an HST (with the ATP not operational) stopped just short of colliding with a Heathrow Express in identical circumstances. Lord Cullen says ’there was a lamentable failure on the part of Railtrack to respond to recommendations of inquiries into [these] two serious incidents.’ While ’groups were formed to consider the problem ... this activity was so disjointed and ineffective that little was achieved.’

However, in 1998 Railtrack ’dispensed with the services of a significant number of senior Great Western Zone personnel or moved them on to other work.’ While the incoming Zone Director admitted that ’the culture of the place had gone seriously adrift over many years’, the flawed layout remained essentially unchanged when disaster struck a year later.