The second part of Lord Cullen's Report into the Ladbroke Grove train crash (1999), concerning the management of safety and the regulatory regime, was published on 20 September 2001. It was not within Lord Cullen's remit to consider the ownership of the railways. However he was able to consider the implications of privatisation. Two weeks after publication, Railtrack, responsible for the rail infrastructure, went into administration. Despite this turn of events the Report remains relevant to the railway's future.

The most important chapter of the Report is on the management and culture of safety. The crash itself involved a driver passing a red signal, known in railway jargon as a SPAD - signal passed at danger. The driver's SPAD at SNI09 was the ninth in just over five years. Lord Cullen in the first part of his Report declined to blame the driver for the crash. He viewed the driver's error as a consequence of management failures rather than a cause of the disaster.

In the Purley (1989) and Watford (1996) train crashes the drivers who passed red signals were prosecuted for manslaughter. In each case the signals in question had been passed on a number of occasions when red. Lord Cullen points out in the second part of the Report that the occurrence of multiple SPADs at a signal "is a clear example of what is effectively an unsafe condition" and failure to solve the problem "represents an acceptance of that unsafe condition".

Following the Purley and Watford incidents major changes were made to the signals involved. In the second part of the Report Lord Cullen develops many of his ideas about safety introduced in the first. Together both parts of the Report stand as a watershed for the industry in the approach to safety. Lord Cullen says the evidence he heard indicated that a high proportion of accidents, incidents and near misses followed unsafe actions resulting from underlying deficiencies in the management of safety. Lord Cullen says a key factor in the industry is the prevailing culture, of which safety culture in his view is an integral part. Recognising that the first priority for a successful safety culture is leadership, Lord Cullen. finds that the fragmentation of the industry made it difficult to provide leadership and for there to be united action on safety. He identifies the need for an industry body to take the leading role in the promotion of safety across the railway.

Lord Cullen writes that a key task for leadership is the communication of safety goals and objectives. He points out that for communication to be an effective instrument in the management of safety, it has to be a two-way process. It must involve the workforce and give them the sense that they are able to make a worthwhile contribution. The Report considers the Railway Group Standards and states that they represent a key element in the control of risk. However they do not exhaust what is required to meet the obligations imposed by health and safety legislation e.g. risk assessment pursuant to the Management of Health and Safety at Work Regulation 1999. The responsibility for setting and reviewing these Standards had been with Railtrack. Lord Cullen feels that such an arrangement is inappropriate and recommends an independent safety body to perform this role.

In addition to this new body, Lord Cullen recommends that the Rail Accident Investigation Body (RAIB) be established to investigate the causes of rail accidents -a role currently undertaken by HMRI (Her Majesty's Railway Inspectorate). The RAIB would investigate the causes of all serious accidents and near misses, while less serious incidents will be delegated to the rail industry for formal investigation. However the RAIB will not have powers to prosecute, which remain with the Police and the Health and Safety Executive (HSE).

Other recommendations include:

  • the HMRI to assess and approve the safety cases of the train operating companies (previously this function has been carried out by Railtrack)
  • a new central system of licensing of drivers and signalman to ensure they are competent and have sufficient knowledge of the rules and regulations covering rail safety
  • a new system of accreditation for contractors to be established to correct shortcomings in their training, preparation, control and supervision
  • a system for the accreditation of companies supplying safety critical products and services for use on the railways
  • the provision of additional resources for HMRI to carry out its duties.

 

The Report also considers the history and role of Railtrack. In Lord Cullen's opinion, prior to privatisation Railtrack was plainly accorded a dominant position. He says the evidence and arguments he heard satisfied him that it was not appropriate for a commercial organisation, as Railtrack became in 1996, to have the role which it possessed in relation to other commercial organisations, like the train operators. It is for this reason he believes it was not appropriate for Railtrack to have had the responsibilities for setting safety standards and assessing safety cases.

Lord Cullen highlights that when privatisation was being considered the HSE expected that "in the medium term" Railtrack would remain in the public sector. This observation is interesting in view of recent. events concerning the company.

In the first part of his Report, Lord Cullen found that there was a "lamentable failure on the part of Railtrack" to respond to recommendations of inquiries into two serious incidents in the Paddington area involving SPADs. However Railtrack did recognise there was a SPAD problem in the area and formed of a number of groups to deal with the problem. But Lord Cullen said little was achieved because they were so "disjointed and ineffective". He accused Railtrack of not dealing with the problem in a "prompt, proactive and effective manner". Lord Cullen quoted the comments of the Zone Director of Railtrack who said: "The culture of the place had gone seriously adrift over many years".

In addition to Lord Cullen's assessment of Railtrack there has been last year's crash at Hatfield (attributed to poor rail maintenance) and the spiralling costs of the West Coast Mainline's upgrade. Therefore, it is of little surprise that the Government felt that Railtrack's time was up and so forced it into administration.

The Government now proposes that Railtrack be replaced by a not-for-profit company, which it believes will need less intensive regulation enabling the existing regulatory structure to be streamlined. Lord Cullen's recommendations in relation to regulation clearly have to be viewed in light of the current position. Lord Cullen considered the role of the Rail Regulator and the Strategic Rail Authority. The Government is considering merging these two bodies but the train operating companies oppose this.

Simply changing the ownership of Railtrack will not solve the problems of the rail industry alone. The findings of both parts of Lord Cullen's Report and recommendations need careful consideration when planning its future.

Shortly after Railtrack was privatised, the company said it expected one day "to be able to offer other railways... the benefit of its experience". The advice must surely be that the model for privatisation adopted by the previous government was inappropriate, particularly from the point of view of safety, and has been, by anyone's standards, a failure.