21 years ago today 31 people died and over 250 were injured when two trains collided at Ladbroke Grove. First and foremost our thoughts are with the many people who are still affected by the accident years later.
As well as being one of the worst train crashes in Britain over the last few decades, the tragedy came to symbolise systemic flaws in the running of the UK rail network. In particular, concerns were focused on Railtrack, who were at the time responsible for the UK rail infrastructure. Only two years earlier (and two miles away) seven people had died in a crash at Southall; and the Hatfield and Potters Bar crashes followed shortly afterwards.
The Cullen Inquiry found that many factors contributed to the Ladbroke Grove disaster, but principally highlighted:
- A lack of driver training; and
- A failure to act following numerous previous safety incidents at the signal where the crash occurred.
This failure to respond appropriately to previous incidents and near misses has been observed in many other disasters, from the loss of the Challenger Space Shuttle to the TalkTalk data breach of 2015. In fact, based on decades of observing how organisations in high-risk industries operate safely, Weick and Sutcliffe propose “Preoccupation with Failure” as the first of their five principles of “High Reliability Organisations” (HROs).
It was also widely reported following Ladbroke Grove that the culture within Railtrack accorded little weight to the views of engineers; and that the engineering function was not adequately resourced. This chimes with much of the commentary following the Deepwater Horizon explosion, about the hollowing out of BP’s engineering capability over a period of years preceding the incident. This point is also addressed in two of Weick and Sutcliffe’s principles of HROs: “Sensitivity to Operations” and “Deference to Expertise”.
The lasting legacy of Ladbroke Grove is the much safer rail network that we now enjoy. Sadly though, the broader lessons from researchers like Weick and Sutcliffe have not yet been universally adopted, as evidenced day by day in the Grenfell Tower inquiry.