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Sir Anthony Hidden QC 's inquiry into Clapham introduced us to accident inquiry by wall-to-wall Queen's Counsells. At the time, and subsequently, experienced railway managers highlighted the malign influence of the legal profession in transforming what had previously been a collaborative search for the causes of an accident into a confrontational blame process.
Part 1 of the Ladbroke Grove Rail Inquiry, which ended its hearings on 20 July, more than justified these misgivings, with 24 counsel, including eight QCs, representing the Inquiry itself plus 12 other companies and organisations. As a result, the tone of the inquiry was full of m'learned friendery, when what was needed was incisive professional analysis of the causes of an accident in an industry once categorised as heavy engineering in public.
Reading the transcripts one can see these well trained first class minds confirming the ability of top quality counsel to grasp complex briefs. But there are limits.
For example, much time was spent on the minutiae of crashworthiness. But when the best that the latest computer aided design can provide in a Diesel Multiple Unit front end is 3 megaJoules (MJ) and the kinetic energy in the collision between the Great Western IC125 and the Thames Turbo was over 400MJ, the issue was largely academic compared with the key questions, what happened, how did it happen and what preventative measures should be taking
Similarly, on the last day of the inquiry you had a technical expert carrying out back of the envelope calculations using Newton 's laws of motion to recapitulate how long the signalman had to tell the Thames Train to stop under different braking rates. There are several organisations that the Inquiry could have commissioned to produced a dynamic simulation of the paths of the two trains involved in the accident, with signal spacings, gradients and brake characteristics, in which parameters could be changed and any required scenario played out.
As for the revelation, also on the last day, that Thames Trains had trained its drivers to use the Driver's Reminder Appliance (DRA) on the move at yellow signals. Why did this not emerge earlier from analysis of the Thames Turbo's On Train Monitoring & Recording (OTMR) ‘black box'? Why, when viewing a cab video taking in a Turbo, did not one of the experts note this use of DRA which Thames had, apparently unilaterally, made mandatory for its drivers
Then there were the legal representatives for those associated with or affected by the accident, but not involved in its cause. Yes, Aslef is expected to support its members, - but at the expense of two Counsel including a QC? Yes, survivors and the bereaved have feelings of grief and anger that others cannot even guess at, but an accident inquiry is not the place for such understandable desire for retribution to be worked out – much though the media feeds off these emotions. And, given that there was to be no prosecution, why did the British Transport Police need a QC?
From the start Railtrack was seen to be in the dock. And when you have been cross examined aggressively, as Railtrack was, by those seemingly more concerned with making points rather than elucidating fact, the temptation to answer in kind is understandable. Thus in his closing speech Railtrack's lead Counsel focused on the DRA issue and in the newspaper headlines, Railtrack was quoted as ‘blaming' the dead Thames Trains driver.
Attributing blame make may you feel better, may help achieve the counselling industry calls ‘closure' but it does not move railway safety forward. Sadly, fallibility is the human condition. The history of transport safety echoes to stable doors being shut before any more horses may bolt. The trouble today is that because of this progress the public assumes that total safety has been achieved – exacerbating the reaction when things go wrong. It hasn't and probably never will be. Lord Cullen's key role then is to ensure that more stable doors are closed.
Two preliminary conclusions can be drawn from this public inquiry. It may be a minor detail, but there is much to be said for the new law in one American state will allows organisations to apologise without prejudicing any subsequent legal action. In retrospect there is no doubt that Sir Bob Reid's donning of the white sheet of contrition after Clapham greatly helped the healing process.
Second, and most important, we must have an independent accident investigation body for the railways – and soon. Apart from the anomaly of the Railway Inspectorate being both a safety approvals body and accident investigator, the Ladbroke Grove Inquiry has shown that wall to wall QCs – who by their training and culture can only attack and defend, are no substitute for the sort of dispassionate technical proficiency displayed by the Air Accident Investigation Board for example.
Ladbroke Grove was a tragically simple accident which sprang from a number of latent wrong decisions throughout our industry coming together at once to make an active error fatal. Whether it was training, signal sighting or track layout risk assessment, the industry failed.
If we reject the blame culture of the Inquiry, then we also reject excuses and buck passing. Ladbroke Grove has shown that accident investigation by show trial gets in the way of the simple truth; in Part 2 of their now joint inquiry, Professor Uff and Lord Cullen should reflect on their respective accident inquiries and from their unique experience propose the way forward.