Accidents that should never have happened

Early one October morning an express slammed obliquely into the side of another train.¹ By all precautions they should not have been sharing the same piece of track, and 20 seconds earlier or later they would not have collided. The ensuing fire consumed the bodies of many passengers and injured many more, and for days no one was sure exactly how many perished.² The subsequent inquiry was full of discussion about human error, blame, fire prevention, and automatic train protection.³

This was not last week outside Paddington, when two commuter trains collided and burst into flames, but October 1928, when the Derby to Bristol mail train of London, Midland and Scottish Railways struck a Great Western goods train at Charfield, Gloucestershire. In December 1928 the official inquiry into the Charfield crash called for the “eventual” installation of automatic train control, which could have stopped the train: 71 years later we are still waiting for it to be implemented.

The memorial in Charfield churchyard bears the name of Philip Jenkins, probably the first person to be the subject of an inquest under section 18 of the 1926 Coroners Act, one held where no body has been found. The fire at Charfield was so intense that only Mr Jenkins’s crepe rubber shoe sole was left for identification.⁴ The coroner’s medical expert was Dr Walshman Ward, a local general practitioner, and it was his forensic skills that identified the remains of two children among the incinerated dead. Despite suggestions put to him that one of these bodies may have been that of Mr Jenkins, he defended his opinion, though the children remain unclaimed and unidentified to this day.

Colonel J W Pringle headed the inquiry and blamed the mail train driver, Ernest Aldington, for passing signals at danger. The testimony of both Aldington and his fireman was that the signals were clear. Pringle recommended installation of automatic train control to protect the train against any human error. The question of the rail companies perhaps being at fault never arose. Aldington was committed for trial for manslaughter by the coroner’s injury, but in view of the magistrate’s contrary finding that Aldington had no case to answer,⁵ the crown offered no evidence at his trial and he was formally acquitted in February 1929.⁶

In view of the recent allegations concerning the failure of Great Western Trains to ensure the use of its existing automatic train protection system, which might have prevented the 1996 Southall railway disaster,⁷ it is ironic that it was the company’s ancestor, Great Western Railways, which first introduced such protection, even before the first world war.⁸ The system did two things: a ramp on the track a quarter mile before a signal at “danger” would physically lift a shoe on the locomotive, tripping the brake vacuum valve to activate the brakes and sounding a warning siren in the cab.* Only if an electric current was running to the ramp, and was collected by the shoe, would the brake valve stay closed and an “all clear” bell sound to allow the driver to continue. Although Great Western Railways progressively installed the system on all its lines and trains the company had no influence over others, which chose not to follow suit.

In 1915 fire after a collision at Quintinshill led to Britain’s worst ever casualty toll in a railway incident: 227 dead and almost 200 injured. Two signalmen changing shifts allowed a fast, heavily laden troop train to enter a section of line already occupied by a stationary local train. Worse still, an express from London was also accepted, which then ploughed into the wreckage, spilling hot coals on to the ruptured gas pipes of the coaches. The conflagration consumed many of the victims without trace. The signalmen were convicted of manslaughter and jailed, but, as Kitchenside points out in his account of the tragedy, “the technology that could have prevented the accident, in the form of track circuits, was by then available to the railway owners...had they been willing to pay for it.”⁹

Since the 1930s, when gas lighting was phased out, major fires after railway accidents have usually been confined to those involving fuel tankers, as happened at Eccles in 1984 and in the Pennine Summit tunnel in the same year.⁸,¹⁰ A fire in a sleeper train between Tiverton and Taunton in 1978 caused 12 deaths and 15 casualties owing to carbon monoxide poisoning, but until this month any casualties from fire have been light. We may have become too complacent about the risk of fire, even within the emergency services.¹¹

The collision at Ladbroke Grove, just outside Paddington Station, on 5 October¹² bears many similarities in layout to that at Southall, on the same section of track three years earlier.⁷ However, the Southall incident happened at a much higher closing speed, did not result in a fire, and was associated with a lower injury and fatality rate. The engineering and design failures which removed the protection from fire in the most recent incident will need as much scrutiny as the cause of the collision itself. The recent disaster belongs to the first third of the twentieth century, not the last year of it.

Any tendency for blame to be directed towards individuals will inevitably deflect attention from the basic economic issues which have always dogged railway safety. Many countries, including France, Germany, and Japan have successful high speed railway systems with fully automatic train protection, and despite occasional derailments they maintain a good safety record. The excuse that the technology is difficult to apply to existing British networks wears thin, considering that some of these overseas systems have been in place for nearly forty years.⁹

Earlier this month Coupland reviewed the duties of health professionals in reporting the medical consequences of weapon technology.¹³ We have the same duty to report on behalf of the public the preventable injuries caused by disasters and to “call time” when the lessons of the past are being ignored.

Personal view p 1079