Cabinet Office UK Resilience

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Case Study

Topic

Inquiries
Coroner’s Inquests

Incident / Exercise

Incident: Ladbroke Grove Train Crash, 5 October 1999

Background and Context

The Ladbroke Grove Inquiry, which was conducted by Lord Cullen, arose out of the crash at Ladbroke Grove junction on 5 October 1999 between trains operated by Thames Trains and First Great Western. There were 31 fatalities.

How the Topic was Handled

The inquiry was conducted under section 14 of the Health and Safety at Work etc Act 1974. The inquiry had the following terms of reference:

1. To inquire into, and draw lessons from, the accident near Paddington Station on 5.10.99, taking account of the findings of the HSE ‘s [Health and Safety Executive] into immediate causes.
2. To general experience derived from relevant accidents on the railway since the Hidden inquiry [1988 Clapham Rail Crash], with a view to drawing conclusions about:
   • factors which affect safety management
   • the appropriateness of the current regulatory regime
3. In the light of the above, to make recommendations for improving safety on the future railway.

The inquiry complemented, rather than replaced, investigations by the Health and Safety Executive. Dr Knapman, the coroner for Inner West London, carried out an inquest into each fatality, into the time and place of death, and the medical cause of death. In accordance with section 17A of the Coroners Act 1988, each of the inquests was adjourned to await the outcome of the inquiry and then not resumed.

The costs of the inquest proceedings (much shorter than they would have been if there had been no public inquiry) were met by the local authorities with the coroner’s district (Westminster, Kensington and Chelsea, Wandsworth and Merton).

The inquiry heard witnesses and obtained documents (using powers under Regulation 7 of the Health and Safety Inquiries (Procedure) Regulations 1975) which was material evidence. The inquiry was held at Central Hall, Westminster. Evidence was taken from a total of 311 witnesses, either written or at the hearing.

The Inquiry reported in June 2001 and made 89 recommendations connected with railway safety.

Lessons Identified

None provided

Contacts for Further Information

Additional Documents

HSC: The Ladbroke Grove Rail Inquiry Report  [External website]