19.11.18
Clapham Junction disaster lessons are ‘fading’ from rail sector following London Waterloo collision last year
Errors made during the derailment of a London Waterloo train last year showed lessons learned from the 1988 Clapham Junction disaster were “fading” from the rail industry, the rail accident investigator has found.
The collision of the 05:42am train with a stationary engineering train on 15 August 2017 led to no injuries, however the derailment caused severe disruption, and the mistakes made were similar to those that led to the crash in 1988 that killed 35 people.
The RAIB report found that the passenger train last year was diverted away from its intended route by a set of incorrectly positioned points of track as a result of “uncontrolled wiring added to the signalling system.”
The uncontrolled wiring was originally added to deal with an issue discovered whilst testing signalling system modification, resulting in a problem where the test equipment design process did not allow for alterations to be made after the test equipment was designed.
The RAIB also noted that witness evidence showed that the functional tester—the staff member with the role of testing the equipment— had a “poor understanding” of how testing processes interacted with design and installation processes, and “did not fully consider” the potential consequences of adding the wiring.
Chief inspector of Rail Accidents Simon French said the mistakes made during the testing process was “concerning” that some of the industrial changes made during the Clapham Junction disaster were not reflected during their investigation last year.
The immediate cause of the 1988 disaster (found in an accident inquiry chaired by Anthony Hidden QC) was due to poor working practice by a signalling technician that caused an incorrect signal to be displayed to the train driver, who took a dangerous bend and collided with trains ahead.
“The disastrous collision at Clapham Junction on 12 December 1988, in which 35 people died and 415 were injured, was a turning point in the history of Britain’s railways,” said French.
“The immediate cause of the accident was poor working practice by a signalling technician, and the subsequent public inquiry into the accident highlighted serious deficiencies in the management of safety, particularly around the design, modification, testing and commissioning of signalling systems.”
French went on to say that some of the people involved in the signalling work connected with upgrading Waterloo station and its approach tracks “did not keep proper records” of temporary works or ensure that additional temporary wiring was shown on the design documents.
He added: “We are recommending that Network Rail takes action to develop and reinforce a positive safety culture within the signal engineering profession as a whole, by putting in place processes to educate present and future staff about how and why the standards have been developed, and why these things matter.
“It’s also important to give people the skills to recognise and deal with non-compliant behaviour, whether that behaviour is by themselves or their colleagues. I believe that this accident at Waterloo starkly demonstrates why the lessons of Clapham should never be forgotten.”
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Image credit: RAIB