THE PADDINGTON RAIL CRASH INQUIRY: THE BLUNDERS - CAREERING TO DISASTER.
PADDINGTON Paddington, London, England: see Westminster, City of. disaster survivor Pam Warren yesterday demanded the full truth about the tragic blunders that cost 31 lives.
Mrs Warren, 43, who wears a face mask Face mask
The simplest way of delivering a high level of oxygen to patients with ARDS or other low-oxygen conditions.
Mentioned in: Adult Respiratory Distress Syndrome over her burns, spoke out as it was revealed that the rookie rookie
a novice; often an athlete playing his first season as a member of a professional sports team. [Sports: Misc.]
See : Inexperience driver who caused the crash had a criminal record and should never have been at the controls.
Flaws in recruiting procedures meant Thames Trains Thames Trains was a British railway company franchised (from September 1996, following the privatisation of British Rail, until 31 March 2004) to run regional and suburban trains from London Paddington station to destinations in the home counties west of London, to Worcester, never knew about Michael Hodder's conviction for assault, the crash inquiry heard.
And, the London inquiry was told, Railtrack put profit before safety, ignoring repeated warnings which could have prevented last October's collision which left 31 dead and 250 injured in·jure
tr.v. in·jured, in·jur·ing, in·jures
1. To cause physical harm to; hurt.
2. To cause damage to; impair.
3. . It was revealed that:
-THAMES admitted three failings in Mr Hodder's training - including NO instruction on the risks of signal 109, which he passed at danger seconds before the crash;
-RAILTRACK were warned three times about the signal but failed to make track changes that would have prevented the disaster;
-SIGNALLING in the Paddington area was complex and hard to see, and drivers on the morning of the crash had experienced difficulty with the sun shining on east-facing signals.
Counsel to the inquiry, Robert Owen QC, said: "There would certainly appear to have been a conflict of issues of operational safety and commercial considerations."
Before Lord Cullen formally opened the hearings, Mrs Warren said: "I'm so angry with the decision of the Crown Prosecution Service
"I believe they should reconsider re·con·sid·er
v. re·con·sid·ered, re·con·sid·er·ing, re·con·sid·ers
1. To consider again, especially with intent to alter or modify a previous decision.
2. and wait until after the inquiry has finished before coming to a decision.
"We feel so strongly about it that we are going to have to consider some form of private prosecution."
Mrs Warren, 43, from Reading, Berks, was a first-class passenger on the Great Western Express which was engulfed in flames after the collision with a Thames train at Ladbroke Grove outside Paddington.
She suffered burns to her face, hands and back and wears a mask and gloves to prevent infection.
In an emotional news conference before the public inquiry began, she spoke of her sorrow for the bereaved be·reaved
Suffering the loss of a loved one: the bereaved family.
One or those bereaved: The bereaved has entered the church. .
"Our lives have been torn apart but they have lost loved ones loved ones npl → seres mpl queridos
loved ones npl → proches mpl et amis chers
loved ones love npl and will never see them again," she said.
"That's why the inquiry is so important - we have to get to the truth."
Thames driver Mr Hodder, 30, and Great Western driver Brian Cooper, 52, both died in the crash. Mr Cooper was cleared of any blame.
Mr Owen told the inquiry: "There seems to be little doubt that the immediate cause of the collision was that Driver Hodder passed SN109 at danger.
"It seems overwhelmingly improbable that Driver Hodder consciously drove past a red signal...up until that point he had been driving in an exemplary manner."
The QC said a fault on the track could have contributed to the disaster.
Mr Owen added: "It will be necessary to examine human factors which may have contributed to the error, in particular the degree to which Driver Hodder was handicapped by his lack of experience."
The inquiry heard that there had been eight previous incidents of "Signal Passed At Danger" (SPADs) before the crash, and Railtrack had been warned three times about the danger signal.
In a letter written in August 1998, Alison Forster, operations and safety director of First Great Western, reminded Railtrack of the eight SPAD incidents and told them: "I should be grateful if you would advise me, as a matter of urgency, what action you intend to take to mitigate mit·i·gate
To moderate in force or intensity.
miti·gation n. against this high risk signal."
On December 22 1998 she wrote: "It is clear from all the SPADS in the Paddington area that there is a serious problem with drivers misreading MISREADING, contracts. When a deed is read falsely to an illiterate or blind man, who is a party to it, such false reading amounts to a fraud, because the contract never had the assent of both parties. 5 Co. 19; 6 East, R. 309; Dane's Ab. c. 86, a, 3, Sec. 7; 2 John. R. 404; 12 John. R. signals.
"This has been known for some time and very little action has been taken by Railtrack to date."
In June last year, she wrote for a third time, saying: "I remain seriously concerned."
Mr Owen said that there had been other warnings from Colin Bray, Railtrack's signalling development engineer, who told his bosses: "I consider that it is our duty to try and reduce the number of SPADS now and that some radical changes may be necessary."
Mr Bray suggested that two of the tracks running into Paddington should be made one-way which would have made the head-on Paddington crash impossible.
But nothing was done.
Railtrack's operational planning manager, Mr Richard Cole, later complained of the financial implications of the one-way proposal.
Mr Owen went on: "The view of the operational planning department prevailed.
"Had it been adopted and implemented before October 5, the collision would have been prevented.
A few months before the tragedy, SN109 was identified in a rail safety report as one of 22 signals most frequently passed at danger.
The regulations required Railtrack to set up a "signal sighting committee".
But the QC said: "In fact no sighting committee was ever convened and the inquiry will want to know why."
Lack of vital safety equipment also played a major part in the crash, the inquiry heard.
Mr Owen said that if the Thames train had been fitted with ATP ATP: see adenosine triphosphate.
in full adenosine triphosphate
Organic compound, substrate in many enzyme-catalyzed reactions (see catalysis) in the cells of animals, plants, and microorganisms. (Automatic Train Protection Automatic Train Protection (ATP) in Great Britain refers to either of two implementations of a train protection system installed in some trains in order to help prevent collisions through a driver's failure to observe a signal or speed restriction. ) it would have slammed on the brakes as the train passed signal SN109 at red and "the collision would not have occurred".
The inquiry continues.