RSSB’s Michael Woods remembers Clapham – and the effect it would have on rail’s management of change.
It was a bright, clear December morning with no problems of visibility. That’s what Mr Anthony Hidden QC’s report says about the day of the ‘appalling accident’ which happened on Monday, 12 December 1988, and yes, I remember it all too well.
I was one of the first nine people working for a division of British Rail (BR) called European Passenger Services (EPS) in the Waterloo General Offices. We were engaged in the business development for what became Eurostar, which started running on the much happier, sunny day of 14 November 1994. There were also project management experts working for the Channel Tunnel Division, at Waterloo and Croydon, plus rolling stock specialists in Derby and Paris.
The first thing we realised was that our MD, who lived at Woking, had not arrived and we had not heard from him. These were the days before common use of mobile phones, and social media were probably not even a dream. But the rumour machine started, and news filtered down of a line blockage just the other side of Clapham Junction, delays and cancellations. We looked out onto the concourse and realised that something was very wrong. Very wrong indeed. More information came in and I think that a call came round to all of us working in the General Offices for volunteers to go out onto the station to help. And so we did. I spent the rest of the day wearing my high visibility vest on the concourse helping passengers find alternative routes to get home. I went home myself, to Kent, quite late that evening to a stream of phone calls asking if I had been involved and was I all right?
On the TV news we saw our MD with his head bandaged; after making a full recovery, he would never again travel in the first or last coach of a train. And my previous boss, Sir Robert Reid, had accepted British Rail’s full responsibility in a statement made at the lineside at Clapham ‘within ten hours of the accident’. I later found out that certain members of the Board’s legal team were really uncomfortable with his public admission, expecting it to lead to a significant amount of litigation. Before he retired in 1990, Sir Robert said that the Government should treat the network according to its importance to the nation rather than to its financial value, and he wanted no repeats of the Clapham disaster. He said safety must be 'top of the agenda': the only answer was high standards, efficient systems and constant vigilance.
This started us all on a journey which is by no means over.
Others have described the nature and causes of the accident, and the inquiry process, leading to the publication of the Hidden Report in November 1989. But what I want to focus on is how the accident had a major impact on how the rail industry manages change and, in particular, infrastructure projects.
The Hidden Report made many comments and recommendations about how signalling projects in particular should be managed. It focussed particularly on the chain of command and how responsibility should be exercised. The two principal recommendations on project management are quoted in full here:
29. BR shall ensure that new works schemes in future shall have one clearly identified person in overall charge of all aspects of the project who would nominate a Project Manager from within his chain of command. For predominantly signalling schemes that individual would, in the present BR structure, report to the Regional S&T Engineer.
30. The Project Manager nominated in 29 above shall be responsible for the execution within budget and timescale of the whole project from the original estimate preparation to the project completion. He shall report to the person in overall charge as necessary for approval.
Following the resignalling project which had led to the accident, those of us at EPS became the sponsors of a wide range of such projects as well as station and depot building works, power supply upgrades and rolling stock procurement, plus the integration of them all. We moved quickly to the identification of clear project management and sponsorship responsibilities and, after much further analysis and thought, the investment (now the business) case for each project was enhanced to identify all the safety risks (and benefits) and how they were to be mitigated or optimised. Every investment committee paper now had to include a section on this, which was independently assessed by the analysts who reviewed the paper and recommended whether it should be approved. Or not. This led to quite a lot of extra work and it soon became clear that some of the skills needed, and techniques required, did not exist.
At the time the BR Board was gradually implementing a system of business management and under a new Chairman, Bob Reid (no relation) a step change in Board level ownership of the safety issue was sought. Amongst other changes, it was decided to set up a Safety Panel in May 1990 to identify improvements where the businesses could decide how to apply considerable (but strictly rationed) capital funds to create a significant improvement in safety. Inevitably, consultants were engaged, and Du Pont identified many serious organisational failings in the industry and helped pave the way for a full safety management programme.
In the Safety Panel, decisions were taken by representatives from InterCity, Network South East, Provincial, Railfreight, Parcels and EPS (I was the EPS representative). We sponsored two major improvements – dispersing rather a large sum of money on things that really made the railway safer (and rejecting or parking others that showed fewer benefits); and commissioning experts to find a way of quantifying safety benefits as recommended in Hidden 48 and 49. The Panel was chaired by Board Member David Rayner, who later led the safety group within Railtrack that eventually became RSSB; it was serviced by David Maidment who (as far as we were concerned) invented the whole concept of quantifying safety so that decision-making can be consistent, proportionate and transparent. (He later founded the Railway Children charity.)
Examples of the schemes we approved were the Safe Cess project, where walking routes alongside most of the network were improved leading to a reduction in driver and track worker fatalities and injuries, and the fire escapes at Birmingham New Street, a scheme which met no numerical criteria. It was relatively straightforward to analyse trackside accident risks, quantify them, estimate the reduction achievable and compare this with the investment needed. But the rarity of station fires (despite the Kings Cross fire which had occurred in November 1987), plus the £10m cost, meant that building the bridge and fire escapes at Birmingham could not be justified by any analysis. But the authorities gave BR one year to start work or they would, it seemed, close the station down. Sometimes there is no alternative!
The industry started recording accidents and their precursors in a systematic way with the British Rail Incident Monitoring System (BRIMS) – which eventually became the Safety Management Intelligence System (SMIS) which RSSB manages for the industry today. And RSSB has been heavily involved in researching into and giving advice on fatigue management, a subject then in its infancy. Of course, it was the later accidents at Southall and Ladbroke Grove which triggered the organisational change which led directly to the creation of RSSB. But we should not forget that Clapham Junction was an important precursor and a call to action to which the industry responded well, though not, as events were to prove, as completely as we had hoped.
I’ll give the late Sir Anthony Hidden QC the last word: It has to be said that a concern for safety which is sincerely held and repeatedly expressed but, nevertheless, is not carried through into action, is as much protection from danger as much protection from danger as no concern at all/
The photograph at the top of the page is of the clearing up at the site of the Clapham Junction train accident, taken the day after, on 13 December 1988.
It is credited to Ben Brooksbank and features by Creative Commons Licence CC BY-SA 2.0 https://creativecommons.org/licenses/by-sa/2.0/legalcode
The photograph halfway down the page is of the aftermath of the accident near Clapham Junction on 12 December 1988 – Copyright REX by Shutterstock.