Professionalism/Ladbroke Grove Rail Collision

On the morning of October 5, 1999, two commuter trains collided at the Ladbroke Grove junction in London, England, near the Paddington rail station. The outbound train passed a red signal (SN109), traveling onto the wrong track and colliding with an inbound high speed train. The crash killed 31 people and injured over 520 people, and is known as one of the worst accidents in Great Britain's rail history. This chapter analyzes the professional ethics of this case that led to the incident. In particular, it discusses how organizational structure influenced decision-making and thereby, safety.

Problems
There are two companies who are faulted for this incident. Thames Trains operated the Class 165 Turbo train which caused the collision. Railtrack was the group of companies that owned and operated the railway system. There are four evident factors that led to the crash: the Thames Turbo train driver’s inadequate training, problems with the railway signal, an imperfect response from the railway control center, and the lack of an automatic braking system. Michael Hodder was the 31-year-old driver of the Thames Turbo train that passed the red signal. He was a newly licensed driver, having completed his training two weeks prior to the accident. Hodder was on his first posting and was inexperienced with the Ladbroke Grove Junction.

The red signal that Hodder ran was notoriously dangerous, having been passed on eight occasions in the previous six years. The signal was difficult to read for several reasons. It was obscured by a bridge and overhead electrical signals. The track layout was unusually complex and SN109 was one of five signals on its gantry. Due to the obstacles, the signal had to be read quickly and could be confused with other signals. The sun was rising at the time of the collision, hitting the signal at an angle that would reflect yellow aspects. The inquiry report from the accident named poor sighting of the signal as a primary factor that caused the driver to proceed without caution.

The control center, Railtrack's safeguard system, failed to take timely action to warn the driver. The function of the control center was to monitor the railway and ensure that trains followed safety protocol. Signalers responded 18 seconds after SN109 was passed at danger, but it was unclear whether the emergency signal was sent in time to stop the driver. The control center changed the signal for the incoming High Speed Train to red, but the train did not stop. .

Finally, there was no automatic braking system, which could have prevented the crash.

Automatic Train Protection
The Ladbroke Grove train collision could have been prevented with Automatic Train Protection (ATP). This system is fitted to train cars and rails, and automatically applies the brakes on a train if it runs a red signal and is not stopped within several seconds. After the Southall rail crash in 1997, two years prior to the Ladbroke Grove collision, Railtrack considered fitting ATP system-wide. The Southall crash was similar to the Ladbroke Grove crash; in both incidents a driver ran a red signal and failed to stop the train before it collided with another. The crash resulted in 7 deaths and 139 injuries.

Oftentimes policymakers seek a technological fix for safety issues such as this. Professors W. Kip Viscusi of Harvard Law School and Ted Gayer of Georgetown University cite a fundamental problem with technological fixes:
 * "The conventional regulatory approach to health and safety risks is to seek a technological solution either through capital investments in the workplace, changes in the safety devices in cars, or similar kinds of requirements that do not entail any additional care on the part of the individual".

This demonstrates that technological fixes can lift responsibility for safety off of the individual and onto external factors. The individual responsibility that the quote alludes to will be discussed later in this chapter, but it is important to note that the ATP technology was not installed after the Southall collision.

After several rail collisions in the late 1990s, including the Southall collision, the firm W.S. Atkins performed an independent cost-benefit analysis around the installation of system-wide ATP in 1998. The analysis found that the safety benefits did not justify the costs of installation; a human life was considered to be worth £2.45 million ($1.63 million) while the cost per life saved of installing the system was found to be approximately £7 million ($4.7 million). Based on this analysis ATP was not installed. After the Ladbroke Grove collision, the cost-benefit analysis was revisited and upheld. Lord Cullen, the judge responsible for investigating the Ladbroke Grove collision, justified the decision not to install ATP, saying:
 * "The use of a cost benefit analysis where human life is concerned is intuitively difficult to accept, but it is a concept which is well used by the rail industry, the HSE [Health & Safety Executive] and Government".

Assuming that cost-benefit analysis is an important piece of criteria for developing safety regulations, do companies like Railtrack and Thames Trains simply accept that trains will crash and people will be killed? Clearly there are other measures that can and should be taken to ensure safety, including holding individuals and organizations accountable for the safety of rail passengers.

Organizational Structure & Culture
Following the privatization of the British rail system in 1993, Railtrack became solely responsible for tracks, stations, and other infrastructure while 25 train operating companies operated trains that utilized the railways. Functions that had previously been integrated under British Railways were now separate, leading to confusion, finger-pointing, and a complicated network of interrelated responsibilities.

In addition to Railtrack's monopoly on rail infrastructure, "local monopolies were awarded to train operators, undermining the very purpose for which privatization was undertaken". The existence of these monopolies was further complicated by a lack of cohesion among responsible parties. For example, Railtrack owned the tracks but not the maintenance companies, and the maintenance companies often contracted their work to third-parties.

Railtrack's Culture of Inaction
At the time of the collision, Railtrack had an organizational culture of inaction. Inquiry reports contain candid responses from Railtrack employees on the professional culture of the firm. A Railtrack manager spoke of how “so many apparently good people could produce so little action”. The firm was criticized publicly for poor management. Comments from Lord Cullen's inquiry report indicate that employees were not empowered to make independent safety critical decisions, reflected in a statement by the Chief Executive of Railtrack:
 * “The culture is one in which decisions are delegated upwards. There has been little empowerment. People have tended to manage reactively, not proactively" .

However, this differed from Railtrack's historical culture. A Railtrack manager explained, "the culture of the place had gone seriously adrift over many years," indicating a normalization of deviance and tolerance for inaction within Railtrack.

Normalization of deviance was also present in Railtrack’s control centers. SN109 had been passed at danger on eight occasions and the control center had become accustomed to the trains stopping on their own. Controller Dave Allen, working at the time of the Ladbroke Grove collision, said that he “monitored the workstation, expecting the train IK20 to stop" . Allen was also inexperienced with the Cab Secure Radio (CSR), which communicates with the train driver. The actions of the controllers on duty demonstrated that Railtrack had become negligent in enforcing safety protocol.

Railtrack’s culture of inaction is best demonstrated by its failure to respond to several requests to address dangers associated with signal SN109. Alison Forster, the Operations and Safety Director of First Great Western, a British train company, wrote to Railtrack on three separate occasions urging action on SN109. In her first statement in August 1998, Forster wrote:
 * "I should be grateful if you would advise me, as a matter of urgency, what action you intend to take to mitigate against this high risk signal".

Forster’s second and third letters again mentioned the risks presented at SN109 and stated that “very little action” had been taken and that Great Western remained “seriously concerned". Some within Railtrack also expressed concern about SN109. Railtrack’s Signaling and Development Engineer, Colin Bray, urged Railtrack to take action on SN109 and told management:
 * "I consider that it is our duty to try and reduce the number of SPADS Signal Passed At Danger now and that some radical changes may be necessary".

Bray also proposed changes to the light that were not implemented. Railtrack addressed Bray's and others' concerns by announcing its plans to create a signal sighting committee for SN109. However, no committee was ever created, reaffirming Railtrack’s culture of inaction.

Thames Trains' Training Standards
Thames Trains also had an organizational culture that contributed to the collision. The training culture of Thames Trains had become lenient and indicated normalization of deviance. The previous training system under British Railways had stricter standards for training than the train driver Michael Hodder received from Thames Trains. The Thames Trains’ Operations Manager admitted that the training system was "based loosely on what had been practice in British Rail days". Lord Cullen’s inquiry report describes the informal structure of the training. Hodder’s training had been delivered by Raymond Adams, who felt that he was not responsible for teaching route knowledge and said “this is Paddington and sort of make the best of it really" . Hodder was never informed of the high risk that SN109 presented, which would have been required under the previous system. Under British Railways, trainees drove with a qualified driver for a year before beginning their own training. Drivers were only allowed to drive through high risk areas, such as the Ladbroke Grove junction, after two years of experience. In contrast, Hodder received 16 weeks of training and was certified only two weeks before the Ladbroke Grove collision.

The poor training procedures of Thames Trains had surfaced before the Ladbroke Grove collision. As early as 1996, Her Majesty’s Railway Inspectorate (HMRI) raised concerns about the training regime. In a meeting between HMRI and Thames Trains, HMRI voiced that it was "very concerned about driver training". The concern centered around trainers that were “too young or too inexperienced” to lead training. Thames Trains responded, "all drivers on Thames Trains have had or are receiving briefings on SPADs as part of the SPAD strategy". Yet Hodder never received any training concerning SPADs or SN109 in particular. Thames Trains exemplifies how an organizational culture that is lax towards safety standards can lead to serious consequences.

Outcome & Conclusions
As a result of the Ladbroke Grove rail crash, public distrust in the administration and safety regulation of the private British railway system significantly increased. Both companies involved were held responsible; in 2004, Thames Trains paid approximately £2.1 million ($3.2 million) and in 2006, Network Rail, an organization that developed out of Railtrack, paid over £4.2 million ($7.4 million). An important professional dilemma evident in this case is the division of responsibility where multiple companies are accountable for one operating unit. Thames Trains' and Railtrack's negligence with respect to safety contributed to the poor safety record of British railways in the 1990s. Often, the solution to this kind of dilemma is an external entity that monitors safety throughout an entire industry. The Cullen Inquiry led to the establishment of the Rail Safety and Standards Board (RSSB) in 2003 and separate branches for investigatory and regulatory functions in 2005. However, an external environment that encourages safety does not always suffice and it is critical that companies maintain strict internal standards.