The Clapham Junction Rail Disaster - Literature review Example

Clapham Junction Rail Disaster According to Anthony Hidden QC report (1989), Clapham Junction Rail accident was one of the worst accidents that ever occurred in London. The accident occurred during the morning rush hour in South London[CITATION les11 \p 525 \l 1033 ]. At the accident scene, three trains were involved in a collision that led to the death of 35 people and over 500 hundred people left injured. 65 people out of the 500 hundred sustained serious injuries. According to Anthony Hidden QC report (1989), the accident occurred as a result of the collision of two commuter trains which were both carrying about 1,300 passengers. This was followed by a third empty train which rammed into the wreckage causing more fatalities. The accident was taken seriously by the British Government as it exposed the major weaknesses in the rail transport system. Overview of the Clapham Junction Rail Accident Lorna and Chris (1996) said the Clapham Junction Rail accident occurred on 12th December 1988. On that day at 8:10 am, a crowded commuter train rammed onto the rear side of another commuter train that was standing on the southern side of Clapham Junction station. The events that led to the occurrence of the accident were that at 7:18 am; a first commuter train service from Basingstoke was standing on the fast lane. According to Lorna and Chris (1996), the second commuter train, the 6:14 am service from Poole was proceeding under clear signals on the up fast line and was behind Basingstoke commuter train. Since there was no signal indicating that the Basingstoke commuter train standing, the commuter trains from Poole proceeded normally and upon rounding a sharp curve found Basingstoke train standing. The driver tried to apply emergency brakes, but it was too late: consequently, an inevitable collision occurred. The force with which they collided was so immense that it forced the leading coach across to the right where it caught the 8:03 am empty Haslemere commuter train. As a result of the collisions, the occupants of the first three Poole train’s coaches incurred most serious injuries. Following the accident, the front third of the leading coach was severely damaged. The coach that was behind the leading coach also had its left-hand side ripped off. The Aftermath of the Clapham Junction Rail Accident Following the accident, Anthony Hidden QC report (1989) says the driver of Basingstoke commuter train which was standing just by the telephone made a call to the signalman. He informed the signalman of the terrible accident and also requested the signalman to alert the emergency services[ CITATION Rai11 \l 1033 ]. When they were alerted of the accident, the signalman responded instantly and switched all the signals to “danger” and also signalled the adjacent signal boxes that there was a problem with the line i.e. an obstruction. Unfortunately, the signalman was unable to control the automated signals and, as such, could only do little to control the fourth commuter train. The signalman then made a call to the station manager; reported the unfolding events and consequently requested the manager inform the emergency services of the same. When the accident occurred, the first witness was the pupils in the nearby school; Emanuel School. According to Gary, Ruth and Robert (2002), the students helped by taking some of the victims from the scene and giving them first aid after which they were rushed to St. George’s hospital. Being that the accident took place in London; the first people to make calls to the police were the members of the public. As a result of their selfless acts, the British Prime Minister, Margaret Thatcher, commended both the school and the public for their service in helping the victims. According to Gary, Ruth and Robert (2002), the Fire Brigades were the first emergency services to reach the sight of the accident. Standing at bridge that was above the rail, the station manager examined the wreckage carefully and ordered eight fire appliances to the station. In addition, the manager also requested for ambulances with a ready surgical team. Following his request Rob, Timothy and Peter (2011) say doctors were flown to the accident scene using the Metropolitan Police helicopter. However, rescue efforts were hampered due to the fact the railway was sandwiched with a metal fence at the top and a wall at the bottom side. In order for the rescue mission to be accomplished, the local authorities were forced to do away with the fence, and the trees that grew on the slope into which it cut the steps. Still in their rescue efforts, the Salvation Army organised a mobile canteen to serve the causalities. The mission was accomplished at around 15:45 when the last body was taken to hospital. Findings of the Anthony Hidden Inquiry An initial inquiry into the cause of the accident revealed that a wiring fault was responsible. In particular, the fault caused the signal not to indicate a red danger aspect in the event that a track circuit in front of the signal was occupied. The investigation showed that although new wiring had been done, the old wiring remained connected on one side. It was also loose and naked on the other end. According to the Anthony Hidden QC report (1989), an independent inquiry under the leadership of Antony Hidden QC for the department of transport found out that various interconnected issues that could have led to the accident. In the first instance, their investigation of the previous reports found out that in 1978, for example, a report done by British Rail Southern Region had recommended the replacement of the signalling equipment by 1986. Unfortunately, that report was only approved in the year 1984 after three signal failures were reported. Department of Transport (2006) says a re-signalling project was planned again; however, there was insufficient workforce. As such, some of the workers had to work for long hours with little or no rest. The investigation found out that installation and testing was done mostly over the weekends, and this proceeded for up to thirteen weeks. Prior to the Clapham junction rail disaster, the investigators found out that re-wiring of the signalling system had taken place within a few weeks before the accident. The fault, however, advanced the preceding day as a result of moving the equipment. The movement made the loose and naked wires and, as such, formed a fake feed to relay. Anthony Hidden QC report (1989) established that the signalling technician who was responsible for the work failed to; cut back the wires, insulate the wires and tie loose wires strongly. It was also established the particular technician’s work was not supervised or even inspected as the law requires. A critical mistake was failure to do a wire count which could have easily revealed that a wire still remained intact. In addition to this, inadequate training, assessment of the work was also not conducted effectively. The investigators also found out that failure by the re-wiring technicians to understand the consequences of signalling failure could have led to their negligence. Analysis of the findings of Anthony Hidden Enquiry Petri nets will be used to analyse the findings of the report. As per the report, the Clapham Junction accident was as a result of system “Failure” and operator “Error.” According to Lorna and Chris (1996), Petri nets provide an important way of analysing events that lead to an accident. In the case of Clapham Junction accident, the filled in circles in the Petri nets are representative of tokens. The circles usually “mark” places; on the other hand, the “empty” circles represent assertions regarding the status of the system. In the represented Petri net drawing, a place is located to show that Mr. Hemingway brought together a hardware “fault” by separating two wires linked to fuse R12-207[ CITATION Lor96 \l 1033 ]. In the event that all the places directed to a transition, as represented by the rectangles on the diagram, are labelled and then that transition will fire. In relation to the Clapham Junction accident, Lorna and Chris (1996) say the transition labelled “The five drivers preceding the collision train…” can fire. Consequently, all the places leading to output from this transition will then be marked. As a result, this will mark the place indicating that the five teamsters preceding the crash failed to report a beckoning failure[ CITATION Lor96 \l 1033 ]. Figure 1. The above figure represents the events that led to the Clapham accident (Lorna & Chris 1996). Recommendations from Anthony Hidden QC Inquiry There are quite a number of recommendations contained in the report, and they include the following. The investigation came up with the following recommendations regarding the Clapham Junction accident[ CITATION Tre08 \l 1033 ]. The Anthony Hidden inquiry proposed that emergency services to ensure that there is a smooth flow of information between them. This is especially when a major incident occurs and is reported to them by a dedicated phone line. A flawless movement of information, according to the inquiry will help in rescue efforts. The investigation team also proposed the need for regular testing of systems (Hidden, 1989). Other measures Hidden inquiry proposed about emergency services include regular simulation exercises on major incidents in order to test communication systems. In addition, the report proposed the introduction and availability of ambulance services at all times to assist in rescue efforts in case of major incidents. Moreover, the report recommended the provision of local radio and communications services by emergency services to facilitate communication between control units and experts on the accident scene. The Anthony Hidden inquiry also required ambulance services to provide aerials in hospitals to help in radiotelephone communications during emergency situations. The inquiry also made other recommendations such as the introduction of the Automatic Train Protection (ATP) system[ CITATION Ant89 \l 1033 ]. Differences brought as a result of recommendations Although compiling and publishing the report took a substantial amount time, not many changes were brought as a result of its recommendations. Part of the reason was that some of the recommendations were not implemented immediately. For example, the proposal to introduce Automated Train Protection was not acted on as fast as it needed. As a result of the failure to act, more accidents were witnessed including the accident at Southall in 1997, Ladbroke Groove in 2009 and the accident that occurred on 25th November 2005 at Esher. In Esher accident the Department of Transport (2006) says a train passed two success signals at danger; consequently overturning the first signal by a distance of about 1050 metres. Currently, however, ATP has been fitted on more or fewer lines even though not the entire network. For the recommendations especially touching on enhanced safety systems to come to fruition, must correct installation and proper maintenance. Automatic systems will be of great importance because unlike manually-operated signalling system; the automatic system will relay signals automatically as they are wired in at the design and construction stages. For as long as there will be no mistake in the design and construction, there will always be an assurance of getting correct decisions. Conclusion In conclusion, the Clapham rail accident was as a result of numerous trains colliding just at the southern part of Clapham. The accident occurred at 08:10 am December the year 1988. Involved in the accident was a jam-packed commuter train that collided into the rear side of a different train which had halted at a signal[ CITATION Ant89 \l 1033 ]. The crash also involved another unoccupied commuter train that was moving to the opposite way that packed up into the debris. As a result of the accident, 35 people died some while undergoing treatment, and many others sustained injuries. The collision occurred as a result of signal failure prompted by a wiring fault. Antony Hidden’s independent inquiry after conducting their investigations found out that the technician who installed the wires failed to follow proper procedures. In addition, there was negligence on the part of the supervisors as they failed to identify and correct the mistakes. Following the strictness with which the both the health culture and safety culture were handled by the British Rail, a series of recommendations were made in the report. This included ensuring independent inspection of any rail work system by the project manager. The report also recommended that the manager be highly involved in highly critical projects, for example, re-signaling work. References Department of Transport, 2006. “Rail Accident Report” [Online] Available at: http://www.raib.gov.uk/cms_resources.cfm?file=/070108_R252006_Part_1_Esher.pdf [Accessed 15th October, 2014] Gary J., Ruth E., & Robert C., 2002. Emergency Care: Principles and Practice. London: Cambridge University Press. CITATION les11 \p 525 \l 1033 : , (Hoel, et al., 2011, p. 525), CITATION Rai11 \l 1033 : , (Railway Accident Investigation Unit, 2011), CITATION Lor96 \l 1033 : , (Love & Johnson, 1996), CITATION Tre08 \l 1033 : , (Kletz, 2008), CITATION Ant89 \l 1033 : , (Hidden, 1989), Read More