Sunny Signals: The 1999 Ladbroke Grove (England) Train Collision

Background

Ladbroke Grove is the name of a road and its surrounding area in the Borough of Kensington and Chelsea in central London. Created in April 1965 the Borough is London’s smallest at just 12.13m²/4.7mi² and houses 156129 people as of 2019.

The location of Ladbroke Grove in Europe.

The borough and Ladbroke Grove are crossed by the Great Western Main Line, a 190km/118mi double- to quad-tracked electrified main line running from Bristol in the southwest of England to Paddington Station just east of Ladbroke Grove. Opened in its full expansion in June 1841 the line is mostly used for passenger trains at speeds of up to 201kph/125mph with the main operator, Great Western Railway (at the time called First Great Western), running everything from Intercity trains to regional commuter services on a network spanning over 270 stations.

The site of the accident seen from above today, Paddington Station lies a short distance beyond the right side of the frame.

The trains involved

Departing Paddington Station westbound was British Rail Class 165 number 165115 run by Thames Trains on a regional passenger service from Paddington Station to Great Bedwyn in southwest England. The Class 165, nicknamed “Networker Turbo” or “Thames Turbo”, is a three-car diesel multiple unit made by BREL York as part of their “Networker”-line between 1990 and 1992. The trains offer space for 262 seated and 91 standing passengers at an overall length of 68.54m/225ft. Each car holds a turbocharged 14l/850cubic inch inline six diesel engine putting out 261kw/350hp each, allowing the 111 metric ton trains to reach up to 145kph/90mph.

Thames Trains 165115, the train involved in the accident, photographed at an unknown point before the accident.

Travelling in the opposite direction was an Intercity 125 running a high speed service from Cheltenham in southwest England to Paddington Station. The Intercity 125 is a diesel powered high speed passenger train introduced into service in 1976. Despite appearing as a multiple unit the trains are not fixed combinations, instead each train consists of a British Rail Class 43 locomotive on either end of a row of Mark 3 passenger cars. The Class 43 is a four-axle high speed diesel locomotive purposely developed for the then-new Intercity service, evident in its asymmetrical design with a streamlined and a vertical end. Originally a small stripe on the vertical end also wore the same livery as the passenger cars, making the trains look more uniform. This was later extended to the whole locomotive’s livery matching the cars. Each Class 43 weights 70.25 metric tons at 17.79m/58ft in length and has a listed top speed of 200kph/125mph (giving the Intercity 125 its name) while 238kph/148mph have been reached in testing. At the time they were powered by a 79l/4800cubic inch Paxman V12 diesel engine producing 1680kW/2280hp at 1500rpm.

British Rail Class 43 Number 43011, the leading locomotive from the accident, photographed in 1993.

On the day of the accident the Intercity consisted of 8 first and second class Mark 3 passenger cars (called “coaches” in the UK). Introduced in 1975 each Mark 3 passenger car measures 23m/75.6ft in length and can carry 74 (second class) or 48 (first class) passengers at up to 200kph/125mph. The cars have an all-steel construction and weight 33.6 metric tons each with the exception of the buffet car (36 metric tons).

An Intercity 125 in First Great Western livery identical to the one involved in the accident, photographed in 2000.

The accident

On the 5th of October 1999 at approximately 8:05am a Thames Turbo Train (from here on referred to as the Turbo) departs platform 9 at Paddington station. It’s a sunny day, with the sun just rising behind the train as it pulls out of the station. It’s under the control of a 31 years old driver, who had received his certification only two weeks before the accident. The tracks immediately following Paddington station (which is a terminus station, meaning trains have to leave the same way they came) are in a six-track configuration with a number of points allowing trains to change between tracks depending on where they are headed or came from respectively. Nearly all the signals in the area between Paddington Station and the Ladbroke Grove overpass (approximately 3.2km/2mi of track) are mounted on overhead gantries spanning the width of all tracks, owing to the insufficient space to provide signaling for six tracks in two directions each. A few seconds after leaving the station the Turbo passes under gantry 6, being shown a single yellow. A yellow signal means to proceed at caution, usually a driver would expect the following signal to be red. Before the train would reach gantry 8 it had to pass through under a bridge, which obscured most of the gantry and its signals for a large part of the approach. The signal for the Turbo was red, it was meant to stop and let an incoming Intercity pass through before switching into the northern tracks.

Gantry 8 from the cab of a Turbo train, seen at a distance of 188m/617ft.
Gantry 8 at 168m/551ft, now the signals come into view behind the bridge.

At 8:08am the Turbo failed to stop for the red signal, running past underneath gantry 8 at 74kph/46mph and climbing. The points had already been set for the Turbo’s path after the scheduled wait, so now it was getting carried towards the main line to its right. On the main line the Intercity was approaching Paddington Station under green signals, still travelling at approximately 129kph/80mph. As the dispatcher in the control room saw the Turbo run the red signal he revoked the Intercity’s next green signal at 8:08:50am, turning it red the moment the train reached it, but it was too late to avoid the imminent catastrophe. At 8:09:15am the Turbo entered the path of the incoming Intercity at 82kph/51mph. Both drivers triggered an emergency stop, while survivors aboard the Intercity report feeling a moment of braking neither train shed any measurable speed.

At 8:09:24am the trains collide head-on at a combined speed of 209kph/130mph with the Intercity climbing the frame of and obliterating the leading car of the Turbo in an instant, killing both train’s drivers. The Intercity’s fiberglass nose cone was ripped apart and spread over a larger area, marking the point of collision as the heavy train continued to tear through the Turbo’s leading two cars. The wreckage of the Turbo ripped open the fuel tanks of the leading Class 43, engulfing it in flames as it shot out the top of the Turbo’s middle car. A surviving eyewitness further back in the Intercity later likened the sight he had of the crash to an airplane taking off in a ball of fire.

As the Class 43 veered off the tracks to the right it pulled the leading car (coach H) along, forcing it sideways before it was struck by the following cars and ripped off the locomotive. Behind it the remains of the Turbo’s middle car were pushed off the tracks to their right, rupturing the car’s fuel tank and further feeding the fire that engulfed the site. Meanwhile what was left of the Turbo’s leading car acted like a ramp, launching cars G, F and E of the Intercity into the air at various angles. As it came to a rest a fireball travelled through most of car H, fed by airborne fuel from the leading locomotive’s destroyed fuel tanks. Miss Warren, a survivor from coach H, later gave the following statement:

“I turned my head to the right and I saw a fireball. At this point I was still bracing myself in my seat… I tried to curl up when I saw the fireball coming. I twisted to my right and pulled my right leg up, trying to get into a foetal position and tried to pull the left leg up. I was unsuccessful in pulling my left leg up because it was trapped under the table which had fallen on to it. I clamped my hands over my face and pushed my right side of my head into the back of the seat. I don’t recall screaming but I might have done because I managed to burn the inside of my mouth and throat….I remember the fire hitting me. It got incredibly hot and I could hear my hair crackling. There was also a noise like gas igniting. It then went quiet. The heat had died down, so I took my hands away from my face… My right leg that I tried to pull up was actually stuck on the arm rest and was still on fire. I reached down with my right hand and patted my legs and put the flames out”

Aftermath

Miss Warren was among the survivors despite sitting in the Intercity’s worst-affected car, being pulled to safety and surviving with severe burns. In total 31 people died in the collision and fire (only one death is listed as being from the fire itself) while 417 people were injured, 227 of which severely (other sources list a total count of 523 injured passengers). 24 people died aboard the Turbo, 7 (including the burn-victim) aboard the Intercity.

The wreckage photographed a few minutes after the collision, car H of the intercity is engulfed in flames.

The first responders on site were local firefighters, arriving at the site by 8:13am. At the time an extensive fire burned across the wreckage, creating a dark column of smoke approximately 200m/656ft high. Car H was at full burn, it was clear that anyone who was still inside by that point was dead. The first firefighters scaled a fence adjacent to the tracks or entered the wreckage through a hole torn into it by the Intercity’s wreckage, accessing the stricken trains before their vehicles and most equipment reached the site and cut up the fence. Elsewhere, construction crews cut additional access openings into the fence to evacuate survivors. Going against protocol responders from the fire department, police department and the London Underground approached the remains of the Turbo train despite the destroyed overhead wires posing a potential risk, cutting open and peeling back the roof of the car and removing survivors from the smoke-filled area. The wires wouldn’t be grounded and secured until past 8:35am, and responders weren’t willing to wait that long while potential survivors might be dying a few feet away. Passengers in the rear car managed to evacuate the car largely on their own, as their car had remained structurally intact and had been thrown clear of most of the smoke and heat.

By 8:28 the collision was officially declared a major disaster, setting pre-planned procedures for a mass casualty event in motion and enabling further manpower and equipment to be involved in the rescue and recovery effort. At its height around 550 responders from various departments were involved in the operation, not counting off-site staff like medical personnel at surrounding hospitals. Fatally the only local medical evacuation helicopter was unavailable at the time, leaving ambulance crews to take even the worst-injured survivors to hospitals and burn-clinics. By 1pm the last survivors had been cut free and taken away from the site, at this point it was assumed that only victims were left to be recovered from the site.

A piece of the Turbo’s leading car where it had come to a rest leaning against car B of the Intercity.

With both drivers among the victims investigators lacked an important source of information, but still were under pressure to find out what had caused the second catastrophic train accident on the main line in just 2 years. It was deemed unlikely that a freshly certified driver would be distracted, not to mention pass a red signal on purpose, but the first theory, a malfunction showing a yellow or green signal when it should’ve been red, was quickly disproven also. Looking into the history of the site investigators found that SN109, the signal the Turbo train ran, had been run unauthorized on eight occasions in six years, much more than the usual rate. Backtracking the path of the Turbo was what brought the main theory literally to light, as investigators ran from Paddington station to the site of the accident in an identical train at a similar time and found that SN109 possessed a very poor sight line compared to the other gantrys or even its neighboring signals. There had been a campaign since 1998 to move the signal to a spot with better visibility, but so far with no success. Now the poor position was most likely a major contributor in the death of 31 people. Furthermore, at the time of the accident the sun was low and directly opposite the signal. Investigators found that the angle and intensity of the sunlight at the time of the accident likely made the yellow parts of the signal appear to be illuminated. In combination with the poor visibility and the driver’s inexperience they concluded that the most likely cause of the accident was the driver looking up and seeing a bright yellow signal, realizing neither that red was illuminated also nor that the illumination of the yellow bulb came from the sun in his back. It wouldn’t even have been negligence, he would’ve seen the (falsely) illuminated yellow section while the red bulbs were still obstructed. This obstruction was a consequence of the line’s electrification in 1994 for the Heathrow Airport Express, when a row of support poles for the overhead wires was installed between the southern and center pair of tracks along with the overhead wires themselves further obstructing upwards visibility. In fact, the red part of signal SN109 became the last part to become visible as the gantry was approached by a regional train from Paddington station.

An overview of the main wreckage looking westbound (in the direction the Intercity came from).

Looking into the Turbo driver’s training the investigation remarked two particularly poor areas, with very little time given to assessing and handling unclear situations as well as new drivers not being told about danger spots like signals being known to have been passed at danger a lot/being difficult to read (which would have included SN109). While driver error was declared to be the main cause of the accident partial blame was placed on the infrastructure too, mainly its safety-systems. Firstly, the paths were set up with no flank protection. On most modern railways the points behind a red signal can’t be set to direct a possible unauthorized train into the path/flank of another train. Allegedly a flank protection system was deemed unneeded because the introduction of an Automatic Train Control (ATP)-system was seen as being in the very near future. An ATP-system would have stopped the train automatically once the driver fails to react to a red signal, making it impossible to proceed past it. Nationwide adoption of ATP had been recommended after an accident that could’ve been avoided by it claimed 35 lives in 1988, but was abandoned because the Cost-Benefit-Analysis (CBA) said an ATP-system was too expensive in relation to its advantage. Thames trains had run another CBA on the topic after a previous incident of one of their trains running SN109 at red, coming to the same conclusion. A third CBA triggered by this crash came to the same result again. Introducing ATP would bring a clear improvement in safety, but it was just too expensive to justify the improvement brought by it.

The rear end of car H’s burned wreckage, where it was struck by the following car.

While there was no criminal investigation following the accident (as the person at fault had died) Thames Trains was fined 2 million British Pounds (2.35 million Euros/2.78 million USD) in 2004 for negligent violations of the health and safety law in connection with the accident while Network Rail (the owner of the British Rail Infrastructure) was fined 4 million British Pounds (4.7 million Euros/5.57 million USD) in 2007 for different violations of the same law. The signals in the area were changed after the accident, including SN109 in 2006, making them easier to read and changing their layout/type to avoid erroneous illumination.

While ATP was still deemed too expensive for a nationwide introduction the Intercity trains were fitted with TPWS, a cheaper system capable of stopping trains at up to 113kph/70mph, by 2003. By 2010 ETCS, a standardized European train control system similar to the proposed ATP, began its nationwide introduction in the UK. The system shows drivers the upcoming signal in the cab, technically making trackside signals redundant. While its main advantage is higher efficiency (the system can tell the driver which speed to pick to make it to the next signal as fast as possible without getting too close to the train in front) this also eliminates the risk of misread signals.

The leading and middle car of the Turbo Train, with the Intercity in the background.

The leading Class 43 was written off and scrapped once the investigation concluded, as were the remains of the leading two cars while the rear car, which only suffered minor damage, was kept as a parts donor. The Class 43-pulled Intercity 125 was retired from the Great Western’s fleet in 2019, being replaced with new class 802 multiple units. Most of the Class 43s will be headed to the scrapyard, while 7 are already in preservation by different owners. Similarly the Turbo trains have largely disappeared from the area, being moved to branch lines elsewhere except for peak hour supports, being replaced by electric Class 387 multiple units.

In 2016 Miss Warren returned to the site of the accident for an interview, talking about her memories of the event and her struggle with the physical and mental consequences of it. The interview also mentions a support group for relatives and survivors of the accident she founded, as well as noting that she eventually conquered her fears and managed to get on a train again a few years after the crash. She’s also since written a book about the process, “From Behind the Mask” (referring to the plastic protection mask she had to wear because of her burns).

After the accident a small memorial garden was created to the north of the site, with a stone pillar listing the names of the victims.

The memorial during an anniversary service in 2019.

Media

In 2005 the BBC aired a documentary-drama about the accident which was heavily criticized by viewers, with one review describing it as a “trashy piece of subjective storytelling”, complaining about a changed timeline and fabricated scenes harming the “documentary”-part of the piece’s intention.

In 2011 National Geographic’s “Seconds From Disaster”-series covered the accident in episode 3 of their fourth season, using the less common term “Paddington Train Collision”:

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Max S

Max S

Train crash reports and analysis, published weekly.

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