A train collision at London Waterloo shows some of the lessons learned from a crash in which 35 people died have been forgotten, an investigation has found.
The incident at the UK’s busiest station has “certain similarities” with the 1988 Clapham Junction disaster, according to the Rail Accident Investigation Branch (RAIB).
A passenger service operated by South West Trains was leaving London Waterloo at around 5.42am on August 15 last year when it collided with a stationary engineering train and came off the tracks.
The 10-carriage passenger train was travelling at around 13mph. No injuries were reported but both trains were damaged and there was serious disruption to services until the middle of the following day.
The collision happened while major Network Rail engineering work was being carried out at London Waterloo to boost its capacity.
The RAIB found that the passenger train was diverted from its intended route because a set of points – movable sections of track which allow trains to transfer from one line to another – were incorrectly positioned due to “uncontrolled wiring” being added to the signalling system.
This occurred after a man employed to test the equipment failed to meet expected standards and “did not fully consider the potential consequences” of adding the wiring, the report stated.
An “underlying factor” in the collision was that Network Rail and its contractors had failed to address the “full requirements” of the staff responsible for the signalling work.
— RAIB (@raibgovuk) November 19, 2018
The RAIB found parallels with the Clapham Junction disaster in which three trains collided near the south London station on December 12 1988, killing 35 people and injuring 415 others.
An accident inquiry chaired by Anthony Hidden QC found the primary cause of the crash was incorrect wiring work, which led to a signal failure.
Several of the Hidden report’s recommendations to reform the way railway signalling is designed, installed and tested in the UK – such as through tighter control of procedures – were not followed in the London Waterloo incident, according to the RAIB.
The RAIB stated: “The major changes to signalling design, installation and testing processes triggered by the Clapham accident remain today, but the RAIB is concerned that the need for rigorous application is being forgotten as people with personal knowledge of this tragedy retire or move away from frontline jobs.
“This deep-seated, tacit knowledge is part of the corporate memory vital to achieve safety.
“Loss of this type of knowledge as previous generations leave the industry is a risk which must be addressed by organisations committed to achieving high levels of safety.”
The RAIB made three safety recommendations, one of which stated that Network Rail should improve the knowledge and attitudes needed for signal designers, installers and testers.