'Slipshod' BR takes the blame for Clapham crash

London last December in which 35 people died and more than 100 were

injured. The inquiry concluded that British Rail had allowed working

practices and supervision to slip to unacceptable and dangerous

standards.

It is possible that criminal proceedings could follow the report.

Transport Secretary Mr Cecil Parkinson has instructed BR to deal

promptly with the findings of the Clapham Junction inquiry and report

within three months.

Sir Anthony Hidden, QC, the chairman of the inquiry into the disaster

and now a High Court Judge, makes 93 recommendations to British Rail,

the Government, and rescue services.

He wants changes to BR's ''safety culture'' and measures to ensure

that an accident can never again happen as a result of dangerous work

practices causing faulty signal wiring, the cause of the Clapham

disaster. The report concludes that the accident was caused by faulty

wiring carried out during a major modernisation programme.

The fault, which allowed a signal to remain at green when a train had

stopped just beyond it, should have been spotted during routine checks,

but the wiring was not checked, the report concludes.

The report identifies 11 signal engineers and managers who, it says,

must share the blame for the disaster. Nevertheless there was a

collective liability which lay with British Rail.

The 11 men connected with the signals department had made errors, some

worse and more numerous than others, but, the Judge declared: ''No one

is put in the dock.''

The most senior was Mr Clifford Hale, ''captain of the ship'' in BR

Southern Region's signals department until the day before the disaster,

who announced his resignation minutes after the report became public.

Sir Anthony was highly critical of British Rail for maintaining an out

of date, poorly trained, and poorly paid workforce working excessively

long hours at times.

Senior signal technician Mr Brian Hemingway was named as the man

responsible for the wiring errors. ''The direct cause of the Clapham

Junction accident was undoubtedly the wiring errors which were made by

Mr Hemmingway in his work in the Clapham Junction A relay room,'' Sir

Anthony said in his report. But he emphasised this was not a trial.

In his report, Sir Anthony says of Mr Hemingway: ''He was a man who

was methodical in his practices, whether good or bad, and among the bad

were his habits of failing to shorten wires and in particular to cut off

eyes and failing to secure such wires by tying them back out of harm's

way.'' Mr Hemingway, a father of four, worked regular long hours of

overtime, frequently putting in 60 plus hour to boost his basic pay of

#147 a week.

The report declares: ''He has never for one moment sought to evade his

responsibility for the appalling consequences of his errors. From first

to last he has sought to accept the burden of the consequences of his

mistakes and has not sought to blame other people or other factors.''

Sir Robert Reid, chairman of BR, accepted the findings in full and

declared steps had been taken to ensure that a Clapham disaster could

never be repeated. Nevertheless, he does not feel that he should himself

resign over the disaster and mismanagement criticisms highlighted in the

report.

BR's board said in a statement it had not examined all the

recommendations in detail, but had every confidence they were intended

to improve safety on the railways. ''In that spirit the board will now

be seeking the best ways to implement the findings,'' the statement

said.

Sir Robert told a news conference in London: ''I accept all the

inquiry's recommendations here and now. We have taken steps to ensure

that the circumstances that led to this tragedy can never be repeated on

British Railways.

''The BR board accepted responsibility on the day of the tragedy and

we have since done our utmost to meet our responsibility both to the

victims and their families and to rail travellers as a whole.''

The inquiry report said the Clapham triple-train disaster happened

because BR allowed working practices and supervision ''to slip to

unacceptable and dangerous standards''.

The report on last December's crash just south of the world's busiest

rail junction calls for radical overhaul of the ''historic character''

of the running of the railways.

Sir Anthony, although naming staff in the signals department who, he

says, must share the blame, points to the overall management

responsibility to make sure bad work practices are stamped out.

He identifies 16 areas ''where things went wrong'' and says these are

an ''indictment of the systems that were in operation before the Clapham

junction accident.''

Sir Anthony says in his report: ''The relevant errors include the

facts that working practices were permitted to slip to unacceptable and

dangerous standards. The quality of supervision was permitted to slip to

an equivalent degree so that those unacceptable and dangerous working

practices were allowed to continue.''

Among his main recommendations, Sir Anthony calls for speedy

implementation of the ''total quality management'' initiative BR has

adopted, to make sure poor working practices are stopped.

He wants BR to give priority to its plans to install cab radios in

trains, together with airline-style ''black boxes'' to help to determine

the causes of accidents. BR should speed up its plans for Automatic

Train Protection across a large area of the national network, he says.

He also wants more research into the ability of its carriages to

resist major damage in collisions, to protect passengers as much as

possible. The inquiry chairman says the drivers of the trains involved

acted correctly.

In the signals department, he calls for radical improvement in

recruitment, training and instructions, with changes to stop anyone

working excessive overtime.

The report accepts BR did not consciously decide to cut corners on

safety, but voices concern at the time taken to authorise spending on

safety-related projects.

Sir Anthony's recommendations to improve the response of emergency

services include local radio communication at the accident site,

high-visibility vests for all emergency workers, and telephone queueing

systems for casualty bureaux.

Sir Robert said that all BR staff members criticised in the report

would be subject to internal disciplinary procedures.

''All those heavily criticised have been moved to other jobs and the

former regional signalling and telecommunications engineer, described in

the report as the captain of the ship, indicated to me this afternoon

his intention to resign and take early retirement,'' Sir Robert said.

''I want to remind you that rail travel is still very safe. But when

something goes wrong as it did at Clapham the results can be tragic

beyond words.''

When asked if he had considered resigning himself, Sir Robert said

firmly: ''No, I have not.'' Sir Robert said Sir Anthony did not find

financial cut-backs were part of the problems at Clapham.

Parliament 6

INQUIRY'S SAFETY POINTS

THE inquiry lists 93 recommendations, of which the key findings are:

* Higher priority to the introduction of on-train data recorders

similar to an aircraft's ''black box'' to assist investigation of future

incidents;

* Priority plan to install cab radios in trains;

* Install voice recorders to provide a record of all radio messages;

* Speed up the introduction of a system which would automatically stop

drivers from passing a signal showing danger red;

* Ensure ''rigorous implementation'' of cutting back redundant wires,

insulating and securing them, so there is no risk of wires coming into

contact with working circuits;

* Introduce a ''national testing instruction'' with all speed;

* Ensure all staff understand and regularly re-read the departmental

instructions relevant to their posts;

* Ensure no individual is working excessive levels of overtime;

* Ensure that an organisational framework exists to prevent commercial

considerations of a business-led railway from compromising safety;

* Carry out by April 1991 research into the structural safety of

rolling stock.