Rush hour and an express train is leaving the capital bound for Oxford.
At 70 miles an hour, the train violently derails, jackknifing carriages and leaving the loco on its side.
10 die, but why?
Join us this week to find out.
Hello and welcome back to Signals to danger.
Welcome to episode twelve, all festivities are now suspended for the year and business as usual has returned!
As ever, thanks to everyone for listening, sharing and liking, please continue, it’s lovely to have you here so please keep coming back. If you haven’t come to hang out with us on social media, you can follow the podcast on twitter at @signalstodanger, or me personally at @danielfoxrail.
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The last thing I would really like to say this week is to thank you all, most wholeheartdly. I received an email from my hosting service this week, telling me that the podcast has hit 7 and a half thousand total downloads. That’s phenomonal. I genuinly wrote the first episode on great heck for myself, to see if the podcast would work as a concept, and expecting to have maybe 50 downloads over a couple of months. The response I’ve received has been far in excess of that and for this I cannot thank you enough. To call it humbling would be a great understatement.
No RAIB or industry news this time round so let’s get straight into the episode.
The light was poor in the bottom of the cutting, but for those climbing from the derailed carriages the picture quickly became clear. The express train that had been travelling at 70 miles an hour minutes before, now lay strewn across all four tracks of the great western mainline, and the locomotive lay on it’s side ahead of the wreckage.
The year, is 1973, and for this episode, we’ve come to Ealing.
This is Signals to Danger, A podcast where we look at major rail disasters which have occurred in the UK, explain what happened, how the investigation was carried out, and how each of these accidents shaped the industry going forwards.
I’m Dan, I’m work within the rail industry in my day to day life but today I’ll be the one taking you through this podcast.
This time out, we’ve gone back to 1973. As ever, let’s start with contextualising the year!
In january the Open university awarded it’s first degrees. The organisation would continue on to revolutionise distance learning over the next 48 years in what seems to have been the perfect preperation for 2020.
In yet another crucial moment for music, (in my humble opinion), British Prog band Pink Floyd released Dark Side of the Moon, the forth best selling album of all time, and not without reason!
March saw the explosion of several IRA bombs in London, and July saw the release of Live and Let die, the first Bond film to feature Sir Roger Moore.
In a testament to the ongoing troubles, a futher 6 IRA bombs were set off in London and Manchester in September. And the year continued to tick onwards, until we reached September.
At 17:29 on the 19th December 1973, 1A82 pulled out of the platforms at London’s paddington station. It wasn’t particularly a good start, the service was the 17:18 departure. But at least it was on it’s way.
Alpha 82 was an express passenger service, booked to travel out of the capital, along the great western mainline and then on up to the city of Oxford.
In previous episodes we’ve come across a few “main lines” so far, and they tend to have names which describe the way they run. East coast and West Coast are fairly self explanatory, and the midland main line is the one that runs up to the midlands. As such, it would follow that the great western mainline runs, well, west.
The 118 mile line leaves the capital and heads westbound, through Reading, Didcot, Swindon and on to Bristol’s Temple Meads station. Since 1841 the tracks of the GWML have carried commuters, shoppers, lovers, holiday makers and businessmen into the capital and back again. The line formed the original route of the Great Western Railway, one of the original railway companies, which then became one of the fabled big four, covering the south west of the country. In 1948, when the big four were grouped into British Railways, the line was folded into the amalgamated western region, where it remained until the time of this accident.
By the 1890s the line had been quad tracked as far as didcot, and meant that the busy lines out of the capital could see two lines in each direction, but unlike some other locations we’ve looked at, the lines here weren’t called fast and slow. There were the Up and Down Main, and the Up and down relief. These were paired in twos, with the main lines to the south of the relief. And of course Up, was heading to the east, to London.
1A82 was, as I said earlier, an express service carrying passengers away from the capital. Eleven carriages carried approximately 650 people out onto the mainline. This would have meant that at least 28 people would have needed to stand, as the seated capactity was only 622, but what else could be expected from a Wednesday rush hour service.
At the head of the train was found a powerful locomotive, designed to run up and down this line at speed. D1007 was a class 52 Diesel-Hydraulic loco, featuring two 1350hp Maybach engines, one powering each of it’s six wheeled bogies. These locomtives were known as the Westerns officially, because each of their two word names started with “western”. 74 of the westerns were built, but this one, was Western Talisman.
Diesel – hydraulic means that the power of the engines was transferred to the bogies via an hydraulic transmission, and not via an electical generator and traction motor, as found on a diesel electric loco.
Designed to haul trains at 90 miles an hour, Westerns were a regular sight whipping up and down the great western main line. Not least because of their fairly distinctive appearence. The front end was almost a slab with a slight crease in the centre, sloping out towards the buffers a small amount and featuring a very large headcode display, above this were two large windows, filling the width of the loco, with a curved upper edge in line with the roof of the loco. The sides of the locomotive turned inwards with a distinctive sharp angle to the roof, and below the bodyside were access doors for various peices of equipment.
When I say they looked distinctive I mean it, if you do a quick google search for a british rail class 52, I think you’ll probably know what I’m talking about.
Moving back to the 19th December, Western Talisman pulled slowly out of Paddington station, it’s twin engines, pushing out nearly 3000 horse power, drawing 11 carriages, and 650 commuters out over the complex trackwork of the station approach.
Driver Owen sat at the controls of Western Talisman as the train started along the line. He dutifully increased the speed as they continued along the line. Passed Old Oak Common Depot and Aton, continuing along and powering up. Around 10 minutes after departing, they approached Ealing broadway station, 6 miles from the platforms at paddington.
Owen believed his speed as he whipped through the platforms at Ealing to have been around 70miles an hour. He noticed nothing unusual until he felt a lurch as they were passing under the bridge at the western end of the Station.
At the time he assumed that it was a bad rail joint and, as he should do, he decided to report it when he stopped at Reading. Drivers are trained to report “rough rides” when they experience it. Bumps and lurches could indicate problems. Quite often defects can manifest as smaller bumps, sways or knocks, and these might be noticable to those who drove trains over the lines daily before a maintainance crew might spot any visible issues.
Becuse of this, crews have long been trained to report a rough ride, so that it can be investigated in case of a fault. Driver Owen suspected that the lurch might have been the tell tale sign of a bad rail joint, so he made a decision to report the sensation when he arrived at Reading, his next stop.
However, he wouldn’t ever get the opportunity, as the locomotive passed over the next AWS ramp, for the clear signal ahead here was a sudden thumping from the rear end of the loco. It was felt by Owen as if the rear end of the 110 tonne piece of machinery had bounced up in the air.
The unsusal bouncing sensation was all too quickly replaced by the fact that the loco rolled over, onto it’s right hand side, and started to slide along the tracks until it came to a rest.
Sadly the damage and destuction didn’t end with just the locomotive, Western Talisman lay on the gravel between the up and down main, obstucting both lines, Immediately behind it lay the leading carriage of the train. All of its wheels had been derailed, and it’s buffers had become locked with that of the loco, but mercifully, it had remained upright with some damage.
The second however, had swung around to the right hand side. It too had ended up on it’s right hand side, obstructing all four of the lines at Ealing, the windows now forming the ceiling and floor.
The next 4 coaches remained upright but had these zigzagged into a tight mass across all the lines too. The trailing ends of the third and fifth vehicles and the leading ends of the fourth and sixth had locked together. On the down side of the cutting, the vehicle ends had partially embedded into the earth.
despite the proven strength of the Mk I coaches used in this train the forces involved in a 70 mile an hour crash meant that there was a considerable amount of serious body damage in this area.
Indeed, it was here that most of the casualties occurred. This was only amplified when a cast-steel bogie from the trailing end of the third coach was forced through the body side into compartments at the leading end of the fourth coach.
The rear five coaches remained upright, coupled together and more or less in line. They sustained only minor or superficial damage, most of the energy of the train having been absorbed by the jacknifing of the front half of the train.
As the carriages of the train had become strewn over the bottom of the cutting, the wreckage had triggered the track circuits of all of four lines. This caused warning to sound in the signal box at Old Oak Common, and the supervisor responsible for the panel couldn’t help notice that something had gone terribly wrong. When he saw the track circuit indications for all lines in the area showing occupied with the associated signals at Red he deduced that a derailment must have occurred occurred. He contacted the emergency services immediately, ensured the lines were fully protected and the rescue operation could begin. The Police arrived at 17.44, the first ambulance at 17.46 and the Fire Brigade at 17.48. A team of doctors and nurses from two local hospitals arrived by 18.25.
Sadly though, despite the best efforts of all involved, the disaster at Ealing left 10 people dead, and a futher 94 injured.
It’s clear that this accident would require a thourough investgation, 10 lives had been lost and 94 others injured. The human cost needed explaining.
On top of this, you can add damage to the infrastructure, 580ft of track of the Down main line was destroyed and 320 feet of the up Main with it. All of the signalling and telecommunications cables on the down side of the line had been severed.
You can then add into this the fact that all 4 tracks of the great western main line caused extensive disruption to train services in the south and west of the country. During the blockage most main line services were terminated at or started from Reading and a shuttle service was run between Paddington and Reading by way of a diversionry route, until the Up and Down Relief lines were reopened to traffic the following evening. 20th December. This got some traffic moving, with the relief lines able to accommodate a limited service, however with Christmas, the Up and Down Main lines were not reopened to traffic until the evening of 28th December.
An investigation, headed up by the Railway Inspectorate begn almost immediately, and as we have done in every episode, we’ll start this section by listing the main questions which needed answering.
Firstly, as it has been in every episode which has dealt with a derailment, was, what had led to the Oxford Express being derailed at 70 miles an hour, 10 minutes into it’s Journey?
Secondly, had any safety systems which could have prevented the accident failed?
And thirdly, what could be done in the future, to prevent the disaster happening again.
Discussing the first point, the reason the express derailed, we can start by going back to the criteria we’ve used in the past.
The reasons derailments tend to occur are, as we’ve experienced before, are excessive curvature, broken rails, defective pointwork or an outside influence.
Just to the West of Ealing Broadway Station, the great Western Main Line features a series of curves, but these are very gentle, sweeping curves, in fact you could say it was almost straight. This was reflected by the maximum permissable speed in the area. In this area it was 90 miles an hour, indicative of the low risk posed by the track layout, amongst other factors.
So that’s out of the equation.
Inspections of the permanent way, the track iteself, after the accident, certainly yeilded some evidence of damage to the track. I said I said earlier, some 900 feet of track was in need of replacement across the main lines.
However, when the investigations were completed, investigators were able to ascertain that the extensive damage was the result of vehicles running derailed and pulling rails, sleepers and ballast out of it’s correct positions, the dynamic forces invoved in the accident had spread and broken rails, but this was an affect of the accident, and not the cause of it.
So, that brings us to the next reason, pointwork.
Sometimes we can discount this straight away, where there isn’t any junction in the vicinity of the accident. But this wasn’t the case. 210 yards in advance of where Western Talisman came to rest you could find 807A points. Considering the proximity to the site of an accident, it’s fairly guarenteed that the points would come under scrutiny.
Previously we’ve talked of points, and the fact that they can be divided into facing, or trailing points. As a quick refesh, if you imagine the letter Y, on a trailing point you would be travelling from one of the upper arms on to the trunk. On facing points, you’re facing the direction of the seperating track, so from the trunk to the arms. Facing points have an inherint risk which trailing doesn’t, if they’re set incorrectly a train can suddenly find itself vearing off the expected course sharply, a sure fire route to disaster.
In fact for many years, some companies only used trailing points wherever possible, to mitigate the risks I’ve just described. Over time, the safety of points imprived and designs developed to the point where their use became widespread. 807A, was the facing set of points at the start of a crossover from the Down Main, across the Up Main and onto the Down Relief lines. If a new weakness had been found in these designs, it was crucial the investigators discovered it before a repeat occurance elsewhere.
The investigation learned that the section of line had been inspected by a patrol on the morning of the accident, with nothing untoward having been reported, no notable faults logged, and no reason to have concern over the integrity of 807A.
Points allow a train to change direction by virtue of switch rails. These are two moveable pieces of track, which when operated by a motor, or lever, move from the normal position, where trains continue straight on, to the reverse, where these rails are now diverting a train off on the alternative route.
When investigators assessed the points at Ealing, what they found gave them a fairly reasonable sign as to the instagating event of the accident.
The switch rails of the crossover found to sit almost in the reverse position, close enough to it that the wheels of any passing vehicle would have been diverted over to the crossover, and on to the down relief.
The Oxford express was only ever booked to continue on the main line, so this certainly didn’t make sense when compared to the booked timetable and route of the train. Had the train been intended to make this crossover to the relief lines, the speed would have needed to be reduced to a safer level, the crew would have been aware, and corresponding signals would have needed to be set correctly, ensuring that no conflicting movements would have taken place.
By this point it was clear that the derailment had been initiated by the facing points haveing been set into an almost reverse position, what needed to be asked next was why this condition had existed.
The signalling systems, operated from Old Oak Common Signal box, a few miles away, showed that the route had been set correctly, and that the train had been running under clear signals. The orientation of the switch blades down on the ground didn’t tally with the settings the signaller had created.
The reason for this was clear to investigators on the ground. Attached to the switch rails, via a system of rods, was a point motor. This motor reacted on the nstructions of the signaller in the box so far away, and it moved the rails into the correct position. Not only that, as an extra safety system, the motor also had a facing point rock, designed to hold the rails in the correct position.
So, what had gone wrong?
The smoking gun, as it were, was the condition of the point machine at the facing end of No. 807 points. It was clear that the motor, which was located on the side of the Down Main line, had been almost completely destroyed by an impact, which appeared to have been concentrated at the point where the rods emerged from the housing of the machine. This was at 2 feet outside the rail and 6 inches below it.
In the report, The damage to the point machine, was described as simply, extreme. Rods, and slides which connected the switch rails was buckled. Other rods and slodes connected to the trackwork was similarly ruined.
In fact these rods were bent to such an extent that the switch blades had been dragged across from the normal almost into the reverse position. The force transmitted back into the main drive rod had broken the throwbar where it was connected to the drive mechanism of the machine and the cast iron case of the machine was broken in several places and its lid had been thrown clear of the box altogether.
It was obvious by this point that the broken points motor and damaged rodding was to blame for the reverse setting of the points and the subsequent derailment.
But, to answer to question fully, we must step down yet another level, and discover what caused the damage itself.
The damage was significant, so the impact which caused it must have been so as well. Had it been the result of an outside force, or had it too somehow occurred in the course of the accident?
The clue to this comes from the testimony of the the signaller at old oak common. At the same time as he noticed track circuits showing ocppied by the wreckage, he also saw warning lights flash on the indicators for the points themselves. This means the likelyhood was, by far, that the damage was caused in the course of the accident as well.
The answer came in the testimony of an A. E. Holder, A Traction Inspector for british rail. Immediately following the accident, he came down to the scene. As he walked along the tracks, he came to the points, and inspected the condition. He then walked a little further to where there was a policemanguarding a battered steel object. He did not recognise it at the time. Though he turned it over and saw that it was blue. He then walked further to the locomotive.
As I said earlier, it lay on it’s right hand side 200 yards ahead of the points. The right hand side was heavily damaged , but the left, lay almost pristine facing the night sky. When Holder reached the locomotive, he climbed atop it.
When he did, he noticed the the door to the fouth battery compartment on the predominantly undamaged right hand side of the class 52 was missing. He realised where it was, at the feet of a policeman, nearly 200 yards further east.
While circumstantial evidence clearly pointed out that the most likely chain of events was that the door of the compartment caused the damage to the rodding and motor, it’s never been the modus operandi of the inspectorate to settle for circumstantial.
Measurements were taken of the door, and where it could theortetically drop to were it not restrained by it’s hinged stays or locks, and this tallied almost perfectly with the impact point on thr lineside equipment.
This was further reinforced by sampls of paint taken from the door, and paint that had been transferred onto the point equipment. Microscopically compared, the paint was a match, showing the same several layers. All ambiguity was removed. The leading bogie of Western Talisman had passed over the points, an open battery door had destroyed the motor, buckled the rods and dragged the switch rails across. The second bogie was then dramatically derailed by the points, along with the carriages which followed. And thus, the chain of events which led to the deaths of ten had begun.
The second point the investigation needed to answer was wether or not there were any failed safety systems, and straight away we can say yes to one of them.
A few months ago, when we discussed the derailment at Morpeth, we discussed the loading gauges present on the UK rail network. In that case, it was to illustrate the compact nature of the sleeper stock.
Not to repeat myself, but the brief version is that the loading guage is the two dimensional template which shows what space a train can fill based on lineside obstacles, is, to say the least, restrictive.
If you were to mount a cut out of this shape on a piece of track, all stock for that particular line would need to be able to pass through it without contacting it,
In fact, in the days of old, a regular sight in goods yards was a peice of kit not a milion miles away from this. Dubbed a loading gauge, this was normally a post at the side of the track, with an arm hanging out over it. From this arm, hung an arch, representative of the maximum loading gauge of the line.
This kit was used far more frequently where freight was manually loaded into wagons and onto flatbeds, by the 70s most freight travelled on standardised wagons, with a known gauge and passenger stock was built to a standardised gauge.
Locos and wagons were all classified with a “route availability”, a code which told BR exactly what lines they were able to operate on based on their profile.
Vehicles built within the gauge should have been safe from impacting structures on the side of the line, and conversly, new kit that was put next to the line was purposefully place outside of the gauge to keep it safe from trains.
All of this means that no part of Western Talisman, or any of it’s 12 carriages, should have damaged the points equipment at Ealing.
But it clearly did. The next step was to understand how this took place.
The next thing to note, is that the loading gauge only needs to be adhered to while out and about. Many vehicles have access hatches and doors which sit outside of gauge when they’re open.
These hatches are needed to allow maintainance to take place, giving free access to areas that otherwise would have been challenging to get at. One such example would be the battery doors on the class 52 Westerns.
For preheating, starting, and the operation of controls and auxiliaries these locomotives carry a large battery comprising 16 separate units. These units were stored below the level of the frame of the loco, in storage between the two sets of bogies.
At each side of the loco were 4 hatches, behind each was two of these battery units. The doors themselves opened downwards, and were held in place by two steel stays. This was so that when the hatch was open, it almost formed a table for the units to be pulled out onto and worked upon.
In this open configuration, the doors themselves sat around 12 inches outside of the gauge template for this loco and route. So it was important that they were kept shut while the vehicle was out and about.
For this reason the 80 pound doors were secured by two locks, at the upper edge. These were of a carriage key type that could be found almost everywhere on the network, a square peg placed in the hole on the outside of the door could rotate a bar on the inside, latching the door shut.
This mechanical solution was simple, but effective. The only catch (terrible pun) was that it was difficult to tell from the outside whether or not the door is latched. So, in addition, as a safety precaution, a pear-shaped piece of steel was mounted midway along the top edge of the door opening so that in its lowest position, where it should fall to through gravity, it will prevent the door falling open even if unlocked.When this pear drop catch was installed, it was purely gravity operated and not secured, but after a few instances of it failing to work correctly, a threaded screw was added to the large end of the drop, so that when it was in the safe and dropped position, the screw could be tightened into a clearence hole on the door to hold it in place. In order to catch the eye, this pear drop was painted red.
This seemed to all involved to be a reasonable safety system, and should prevent any accidents from taking place.
Now that the involvement of the door was apparent, investigators needed to gain an understanding of the history of it, so they looked into the maintainance history of Western Talisman.
What they found, was that the locomotive had been serviced on Old Oak Common depot the night preceeding the accident, spending some time in the heavy maintainance shed, affectionatly known as “the factory” by those that worked there.
It was established that the locomotive batteries had been placed on charge, while other maintainance had been taking place on one of the two engines. The fitter respnsible for putting the loco on charge recounted how he would have fixed the pear drop in the upper position to allow the doors to open. The screw that was used to hold it closed, was routinely also use to hold the catch in the upper position, not keeping the door shut. He also recalled that when he left his shift at 6 30 in the morning, he recalled one of the battery box doors being open on Western Talisman.
Sometime after 7am, a shift supervisor at the depot told how he had seen a set of ladders square onto the window in the side of the locomotive. He recalled seeing a fitter leaning into the window, but also saw that the door to the battery compartment was closed. In fact with the ladder where it was, the door couldn’t have been open.
The key statement was from one of the labourers in the factory. At around 10am two of them started to clean Western Talisman. In order to do this they used a wheeled scaffold which was pushed along the side of the loco. He said that when they started to clean the side of the locomotive there was one battery box door open, adjacent to the portable steps near the other end of the locomotive and that, so that they could move their scaffold along the side of the locomotive, someone came and pushed the door shut. He said that he did not shut it himself and that the man who did, whom he did not recognise and was wearing blue overalls also removed the charging leads. He made no reference as to whether the pear drop was touched at all.
Prior to Talisman being released for duty, the battery attendant on shift was asked to “box up” the loco. He found all the battery doors closed and assumed that they had been properly secured. He didn’t check though, or check the pear drops.
It was never proved who had pushed the door shut, but the possibility is that it was someone who wasn’t appreciative of the method of doing so safely, who wasn’t aware of the importance of the locks and pear drop.
Enter Driver Owen.
When he took Western Talisman from the depot, he had a number of responsibilities with regard to the preparation of a locomotive for service, as laid down in the Driver’s Manual. The instructions set out a long list of items to he examined or checked, the majority of which are in the driving cab or inside the engine compartment. There are only 3 specific items on the outside of the locomotive that a driver is required to check. Non of these three is the state of the battery compartment doors.
In the course of his preparation, in addition to these three specific points, he would walk round a loco, glancing alongside it and checking that the brakes, the brake blocks and the wheels were in proper order. He said that he could not remember ever having seen the pear-drop catches on the battery box doors in other than the correct position, During his preparation of No. 1007 on the 19th, he noticed nothing whatsoever wrong with the locomotive. He took an empty coaching stock service into Paddington and prepared Talisman for the Oxford Express.
The report is clear in it’s conclusion, The immediate cause of this derailment is not in doubt. The rearmost battery box door on the near de of the locomotive, which was unlocked and had its pear-drop safety catch secured in the raised position nd so ineffective, fell open as a result of vibration some time after the train left Paddington.
The last factor to understand is specifically how the the door contacted the motor itself. The battery door was supported in a horizontal position by the two steel stays. It shouldn’t have been as low as the motor itself.
To answer this question, the investigators retraced Talismans journey from Paddington to Ealing.
At Old Oak Common, an illuminated ‘Limit of Shunt’ sign on the cess side of the Down Main line had some distinctive damage. Itbeen hit from the Paddington side at a point approximately 2 ft 11 inches outside the cess rail and 12 inches above rail level. The position of the sign and the damage to it was measured in relation to where an open battery box door on the near side of a locomotive of Class 52 would be. The results were clear. This is what caused the damage, and it also placed the door as having opened between paddington and old oak common.
The next indications were found at Acton where a number of cast iron cable brackets on a retaining wall on the approach side of the Down Main platform and along the platform face had been broken off.
Further similar damage was observed at Ealing Broadway where, in addition, there were marks of something having been in contact with the coping of the ramp at the East end of the Down Main platform and of having impacted heavily with the underside of the coping on the ramp at the west end of the platform, lifting and dislodging some of the coping stones. Yet again, a clear correspondance was matched between the location of the damage and the position of the door.
The last object the door hit prior to the points machinery, had been the coping stones on the ramp at Ealing Broadway. This contact forced the door downwards on its hinges and tore away the two hinged stays, allowing the door to drop into a position in which its edge was approximately two feet outside the running rail and 6 inches below rail level. Exactly where the impact which cause the damage was found to the points motor and rods was established to have taken place.
The last point of consideration was how could the accident be prevented going forwards.
Well for a start, as soon as it was known that a battery door had been involved, an emergency briefing was sent out to all depots who operated the class 52 locomotives to pay close attention to the safe closure of the doors. This even took place on the night of the accident itself. The immediare risk was reduced swiftly, but there were other factors to consider, institutional ones.
It had become clear during the course of the investigation that that there was not an effective system in operation at Old Oak Common Depot to prevent a locomotive being released to traffic without a check being carried out by a responsible person to ensure that all roof hatches, body side doors, battery box doors and safety catches were secure and properly fastened.
It was not part of the driver’s duties to check the security of the battery box doors during his preparation of the locomotive which he carried out outside the Factory in the poor light of a December afternoon. Somebody else may have possibly have noticed the peardrop catch in the raised position, drawn attention to it, and so prevented the accident, but the fact that Driver Owen did not see it does not make him in any way responsible for what ensued. He failed in no duty.
The same could not really be said for the fitter who was asked to box up Western Talisman but thought it looked OK. If he’d simply walked over and checked, I wouldn’t have much to record about an nondescript section of train in Western London, where nothing really ever happened.
Granted he wasn’t asked specifially to go and ensure every single lock was locked, and every safety catch down and secure… but should have needed that?
What was clear was that this lack of accountability needed addressing, and the lead recommendation of the investigation was to make it part of an A exam, that somebody has responsibility for exactly that, ensureing that every catch was secure and locked. By the time the report was issued, 9 months after the accident, arrangements had already been made for the paperwork covering all repairs which would require access to hatches to include reminders to secure them, as well as requireing that the form be signed by the tradesman responsible and countersigned by a supervisor.
The last recommendation was around the pear drop themselves. Again, by the time the report was issued, these had all been retrospectivly removed from the Western class. Board. The modification that had put the screw in had turned out to not have been approved by senior designers. It was this modification that had contributed to the catch being held clear of the door on the 19th.
A new design was produced, in which the safety catch was now replaced by a substantial steel bar, 6 inches long.
This bar was limited by stops welded to the door and bodyside from being raised more than just enough to allow the door to he opened or closed. No method for fixing the bar in any position was applied.
The new design was painted yellow to give the maximum contrast with the blue livery of the locomotive. This left a clearly visible group of short vertical lines, along the side of the loco, if one of these wasn’t angled correctly, it should be clearly visible to a fitter or driver. By September 1974 this modification had been fitted to all Class 52s that were still remaining in service, and additional training had been provided around the dangers of unnapproved modification.
The accident at Ealing in 1973 didn’t lead to any wide ranging and sweeping changes across the industry, not in the way that some other accidents have done in any case. This was primarily due to the nature of the way it took place. This was a perfect example of how small errors and bad processes could lead to disaster.
Whoever the mystery man had been who had closed the door at Old Oak Common was probably not supposed to have done so. Anybody who would have been supposed, qualified to, close these compartments up would have knwn the importance of making sure that both locks were securly closed and that the pear drop should have been positioned correctly and secured.
I don’t believe for a second that there was any malicious intent, he must have seen the cleaners, seen the door and putting two and two together, known that the door must have needed closing for them to carry out their task. He probably thought, “I’ll be a good chap and grab that for them”. The knock on being that nobody else who saw it assumed it had been closed incorrectly.
The sad bottom line is that this person had no right to meddle with the door. Even the cleaners themselves, who had probably seem them closed many times, knew that they needed to go to see the supervisor to arrange for a competant fitter to close them if needed. This is what they would have had to do if the kind stranger hadn’t assisted.
The rules existed, they were bent. The best intentions are not insurance against disaster.
All of the biggest changes needed had already been implimented by the time the report was issued. BR had made arrangements for somebody specifically to have responsibility for checking latches going forwards, and the latches themselves were painted in a way so that they would be painfully obvious if positioned incorrectly.
These are things that have transfered across from BR, to the franchised operators that replaced it in the 90s.
Most enineering procedures that take place on a depot will follow a set process, a process that will take you back to the point where a vehicle is fit for traffic. Even then, most operaters use something like a fit for traffic check list which depot staff complete before the units can be released. A driver won’t take his train off shed in the morning if that isn’t there. If somebody is putting their name down to say they’ve done something the likelyhood is that they have more of a vested interest in making sure it is!
If there is a setting or lever or switch that needs to be set up in a certain way to be safe for traffic, you can be fairly confident it was somebody’s explicit job to ensure that it was.
This principle even follows through to some of the challenges the industry has experienced over the last 12 months. I know that the company I work for has implimented checks and balances to make sure that additional cleaning has been taking place and reaches standards. Cleaners complete a small sheet that is left in the cab, so traincrew taking over the unit kow it’s been sanitised since the last person was sat in the chair.
When we look at the response BR had to the issue of the pear drop catch. Painting handles like this yellow is something that has never gone away. Most trains still have some degree of underfloor cabinets, and these are normally secured by handles or clips.
A great deal of these are still yellow. Hitachi’s 80X class trains are a prime example, known by various names across the Network, LNER Azumas, Hull Trains Paragons, GWR’s IETs, transpennine express’s Nova ones. Whatever the name or livery, one thing is a constant. At the bottom of the underfloor cabinets is a row of bright yellow handles, all horizontally orientated, if they’re not, it needs checking. It’s a solution which is elegant in it’s simplicity.
Musical Swell (into Credits?)
Some of the accidents we will discuss on this podcast have been the result of a critical, crucal, error, or a catastrophic faliure of a specific component.
This wasn’t the case here as I’ve said earlier. In the time I’ve spent researching this episode, and writing it, the overarching feeling has been how easily avoidable this was. If the kind stranger hadn’t of intervened and pushed the door shut, if the fitter asked to close it had actually made sure it was done properly or if the driver had notice by chance that the catch was not the right way round.
Any one of these is a tiny alteration to the actual narrative, but any one of them, let alone all, could have changed the story, and saved the lives of 10 people…
Thanks for tuning into episode 12, we’re really starting to come along now aren’t we?
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Until next episode, Travel Safe!