Reducing the risk

This month marks the tenth anniversary of the Ladbroke Grove rail crash. Anson Jack, RSSB’s Director of Policy, Research and Risk, runs through what’s changed for the better

The Ladbroke Grove rail crash happened at 08:11 hrs, 5 October 1999 and involved a collision between a Thames ‘Turbo’ train and a Great Western high speed train. 29 passengers and both train drivers lost their lives. The government set up three inquiries into the accident, train protection systems, and the arrangements for safety regulation.
The immediate cause of the disaster was identified as the driver of the Thames train, passing signal SN109 when it was showing a red aspect (technically known as a signal passed a danger or SPAD), 563 metres before the impact point. However, the public inquiry conducted over the next year by Lord Cullen identified many contributory factors, including Thames Trains’ driver training procedures. The driver had only qualified 13 days earlier, there was no documentary evidence of him being taught anything about the complexities of the route, and his Drivers’ Rules examination paper bore neither his signature nor had any ‘pass/fail’ ticks on it to indicate that any subjects had been discussed.
Also identified was Railtrack Great Western Zone, which Cullen said had not taken appropriate action following eight SPADs at signal SN109 in the preceding six years or taken sufficient action in response to complaints from train drivers about the visibility of various signals, particularly SN109.
While we remember the events at Ladbroke Grove ten years ago, and their tragic impact on many passengers, rail staff, and their families, it is a pertinent moment to reflect on what has changed since then, and how the industry’s safety performance has significantly moved forward.

Understand, analyse and manage
Nobody is complacent and the industry knows there are still risks to manage, but it has much greater knowledge and understanding of risk, increasingly smart technology and hardware, and the tools to monitor, research, analyse and manage those risks. Long-term developments will support this – for example, the introduction of dedicated High Speed lines such as HS1 between London St Pancras International and the Channel Tunnel, which have state-of-the-art signalling and protection built in.
The last ten years have seen greater recognition and appreciation by the industry of a systems-approach to the railway. While RSSB provides the industry with data, risk modelling, analysis and research to support safe decisions, the real improvements have come through the commitment of individual companies to safety, combined with sustained investment in modern equipment and infrastructure made possible through the long term funding from government.

Changes underway
Much has changed since Ladbroke Grove. The last decade has seen many changes in the structure and framework for safety in the railways. Ownership and responsibility for the national railway infrastructure transferred from Railtrack to Network Rail in 2002. An independent Rail Accident Investigation Branch was established in 2005, following the Railways and Transport Safety Act 2003, and its role defined by the Railways (Accident Investigation and Reporting) Regulations in 2005. The European Railway Agency was also created in 2005. The role of safety regulator was transferred from the Health and Safety Executive (HSE) to the Office of Rail Regulation (ORR) in 2006. RSSB was established in 2003.
Also in that time, the rail industry’s safety performance has progressively advanced to a point where the likelihood of a passenger being involved in a train accident is now at an historical low. Statistics firmly establish rail as the safest form of land transport in Britain whilst clearly identifying the remaining risk that needs to be managed. Although it’s important to recognise that the trends in risk reduction were happening well before 1999, at the same time, the figures demonstrate that the investment by industry and government in technology, training, research and their ongoing commitment to safety have paid off, and are continuing to pay off.
The risk to passengers from train accidents has reduced by more than 80 per cent – from an estimated 2.45 fatalities per 10 billion passenger kilometres in 2000 to 0.45 fatalities per 10 billion passenger kilometres in 2008. During the same period, passenger traffic has increased by about 25 per cent. Roughly half of the reduction in risk to passengers arises from reductions in the frequency of hazardous events, and the other half is from reductions in the consequences when they do happen. These figures take into account train-on-train collisions, derailments, and collisions with road vehicles on level crossings (where almost all of the risk is outside the industry’s direct control and down to motorists’ and pedestrians’ behaviour), and other types of accident.
The risk from signals passed at danger (SPADs) has reduced by more than 85 per cent since 2001 and there have been no fatalities as a result of a SPAD since 1999. In the last four years there has been one train accident in which one passenger lost their life (the derailment at Grayrigg in February 2007).
The headline changes that have contributed to improved safety are:

  • Improvements in rolling stock with superior crashworthiness that offer better protection to passengers in the rare event of an accident.
  • Installation of the Train Protection and Warning System (TPWS) alongside other initiatives such as improved training and competence management, monitoring, and better briefing support for drivers. This has meant that there are fewer trains passing red signals, and that there is far less potential for serious consequences – altogether a more than 85 per cent reduction in SPAD risk.
  • More comprehensive knowledge and understanding of the human factors  involved in train driving, signalling, and safety critical communication have been gained. RSSB’s research and technical experts have developed a range of cross-industry resources to manage issues such as in-cab ergonomics, risk-triggered commentary driving, situation awareness, fatigue, the effects of lifestyle on safety, and safety culture.
  • New legislation has introduced significant EU requirements relating to interoperability and safety management systems (SMS). The Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS) require all mainline transport undertakings to develop a formalised safety management system (SMS), which includes a demonstration of how they fulfil their duty to cooperate, and to obtain acceptance of it by the safety regulator for the railways, the Office of Rail Regulation (ORR). Modern safety management systems (SMS) introduced across the industry are supported by an industry safety risk model and information management system. RSSB facilitates a cross-industry national programme to support the development of SMS and share good practice.

RSSB supports the industry in managing system safety through an auditable trail from data collection, through to taking decisions affecting safety. This includes the collection, analysis and sharing of information about safety related events – including analysis through the Safety Management Information System (SMIS) and publications such as the Annual Safety Performance Report (ASPR). It also includes the development of the industry’s Safety Risk Model and a Precursor Indicator Model that looks specifically at the risk from train accidents, and the SPAD risk ranking methodology, which looks specifically at the risk from SPADs.
Industry performance
Building on this, there is also a cross-industry national programme on operational safety in the Operations Focus Group (OFG). This helps monitor industry performance in relation to operational safety, which includes issues such as SPADs, and recommends changes to priorities and strategies, which includes supporting effective campaigns like the ‘RED’ series – DVDs containing dramatised reconstructions of lessons learned out on the railway, used as part of more informed briefings between managers, drivers and signallers.
There is also the rail industry’s research and development (R&D) programme, which is funded by the Department for Transport and managed by RSSB. Research into railway operations has helped boost the industry’s knowledge base on key risk areas including SPADs, safety critical communications and abnormal and degraded working. Engineering research has investigated a wide range of options for improving the crashworthiness of rolling stock and increasing survivability – including the benefits of all-laminated glass to contain passengers. Research into management aspects of the railway have ensured high level safety decision making is grounded in an up-to-date understanding of risk, and helped inform modern approaches to competence management and workforce development.

For more information
A report summarising improvements in passenger and staff safety in train accidents will be published by RSSB during October, and will be available to download from the RSSB website –

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