 It is the 5th of October 1999 at around 8am and newly qualified driver Michael Hodder prepares his class 165 train on platform 9 at Paddington for its next working to Bedwin in Wiltshire. The station is bustling with travellers consisting of commuters and holiday makers. Trains serve Paddington from all over the south west of England and south of Wales and this includes packed local trains and fast intercity services. The departure time is 8.06am and the initial part of the train's journey was to travel over a very complex section of track which allows trains to enter and exit London Paddington station. Part of this complex journey involves observing and obeying a signal known to be troublesome especially during times of the day when the sun is at its lowest but at just three minutes departing as the train heads towards Ladbrook Grove. Disaster strikes and the free carriage train travels head-on to an intercity train killing 31 and injuring 417. The disaster will highlight many shortcomings in the British railway industry spanning driver training, signal training and will boost a growing need for infrastructure changes and a more modern train protection system. As such I'm going to rate this disaster here six on my scale but here eight on my legacy scale as if you've travelled on a train in the UK then the aftermath of this event has pretty much ensured your safe travel. The disaster at Ladbrook Grove was a long time coming with multiple failures within the industry but before we get into the accident we need to look at the development of the railway signalling systems. Safety on the railways has always been a difficult task as you're relying on humans to be faultless which as we know is not the case this is why we do things to mitigate this. Take the gear shifter in my car as an example to stop you from accidentally rolling forward you can't go into drive without your foot on the brake pedal trains benefit from high efficiency of movement due to the reduced friction surface between wheel and rail but this has a major drawback and that is in stopping distances and conflicting movements. Ever since trains have achieved speeds that can mean it can't stop within the line of sight the railway has tried to keep trains safely apart which is what signalling is for. A conflicting movement is where one line joins another which needless to say is where collisions can occur. Railway signalling in its most basic form is to allow one train in one section at one time and the history of this goes all the way back to the early days of the network. Originally a timetable system was relied upon to ensure each train was kept at a safe distance but needless to say that this method of working breaks down very quickly if a train goes too slowly or stops unexpectedly. Next came block signalling which was controlled by the signaler for each block as a train passed through and passed the signal box the state of the line will be telegraphed to the previous and next signaler. A natural progression of this was for the state of the line to be communicated to the signaler automatically via a track circuit. The vista work, the sections or blocks of track are electronically insulated from one another via a thing called an insulated block joint which is made from a non-conductive material. As the steel wheel and axle enters the block it completes a circuit which can revert a signal to danger and once the last set of wheels have left the block the signal can change to green showing the section is clear. This is a good system but if a train passes a signal protecting an occupied block then a collision can happen and as such it can be made safe for steel by the use of a thing called an overlap. The overlap in its most simplest explanation is a safety margin and is roughly 180 meters beyond the signal. I do cover the overlap in a little more detail in my Clapham Junction video so shameless plugs out of the way let's look at how this system can be improved upon further steel. This is where multiple aspect signalling comes into play where a red signal is communicated to the driver via the signals on the approach to it. In four aspect signalling this comes with two types of cautionary aspect preliminary caution or double yellow and caution single yellow. The next signal after caution is danger or red. The signals and the driver's knowledge of the route allow them to drive accordingly within the permissible speed for the line so if you're going past a single yellow then you've got to be slowing down for that red ahead. We can make this system even more safer with the addition of extra warning of the signals. What if we can give the driver of the train advance information on the signal aspect before the signal? Well that's where a thing called AWS comes into play. AWS or automatic warning system gives an audible and visual indication of the signal ahead to the driver. The way this works is via two magnets between the running rails on the approach to a signal at around 180 meters. One of the magnets is permanent and the other magnet is an electromagnet. When a signal is at caution preliminary caution or danger the second magnet is de-energised. This is picked up by a sensor underneath the train and sends a signal to a device called the driver's visual reminder or DVR which displays this sign and then this sound is heard. The driver has around 1.9 seconds to cancel the horn using the AWS acknowledge button. If the driver fails to do this then the emergency brakes come on and bring the train to a stand for 60 seconds. If the signal is green when the electromagnet is energised the sensor picks up on this as the train passes over the magnet and the DVR will display this sign and a bell sound will be heard. The driver in this case doesn't have to do anything. This system was introduced in the 1950s and helped improve safety on the railway but it has one major flaw. Did you notice it? Well AWS's major problem is that both a danger and a caution signal create the same warning for the driver. If it is acknowledged then the train can still sail past a red signal. This is also a major problem in poor visibility as if the driver doesn't react appropriately then a signal past danger can happen which is why in today's railway if your AWS is cut out then you can only travel at a maximum speed of 40 miles per hour in situations of bad visibility. This is a big problem and throughout the 1980s the rail industry tried to find a solution but we'll look more into this later on but first let's look at junctions. In colour light track circuit signalling junctions are protected by signals much like ones used on normal running lines but instead of being controlled by the passage of trains they are controlled by the signal and as such are known as controlled signals. Diverging and converging points are when a train changes from one line to another and these are navigated at various speeds depending on the layout of the track and the condition of the track. Clearly when a train is passing through a junction you'd want to stop all other conflicting movements this necessitates bringing a train to a stand at a red signal. If a train is to be signalled from one line to another a driver could receive one of two indications a junction or route indicator both do pretty much the same thing junction indicators can only convey seven routes whereas a route indicator usually consisting of a fiber optic display can in theory display an unlimited number of routes. Well that was my brief introduction to rssb signalling rules let's return to october 1999 and the 806 to bedwin. The class 165 diesel multiple unit was operated by a post privatisation company called tems trains the company had been working the franchise since 1996 and boasted a fleet of 57 trains 53 year old driver brian cooper was working his hst which made up of the 603 first great western he had been driving for just over two hours and was making good progress the hst dating from the late 1970s was made up of two power cars and eight mark 3 slamdoor carriages driver cooper was on the final part of his journey to paddington as part of this he needed to navigate the upper mainline they're in total six bi-directional lines on the approach to london paddington with trains moving in both directions as traffic flow increases in the morning it is a regular occurrence for trains to be held at signals to allow intercity services to terminate and this morning is no different driver cooper is receiving clear aspects although single and double yellows but the closer he gets to paddington he starts to see greens driver hodder upon receiving a clear signal at paddington departs at around 806 on time he departs on a green and a route indicator for line four his next signal is also green by now he has taken power up to around 44 miles per hour he receives a horn and a caution indication from the aws and he acknowledges it this prompts him to slow down to below 40 miles per hour expecting the next signal to be single yellow again the aws shows a warning on the approach to signal sierra november 87 him he is given a junction indicator to the left he is now heading for line three he should be slowing right down and looking for his next signal which should be red but he just coasts along at near 37 miles per hour by now the sun is low and is bleaching the next signal sierra november 109 the light bounces off the lens making it look yellow the aws goes off exhibiting a warning and like before he cancels it but he is now fallen into the trap of the limitations of the system the signal is actually red thinking that the line is clear he takes power to just below 50 miles per hour the train continues across the points onto the down main driver cooper of the hst on the approach to signal sierra november 120 at green notices something a driver does not want to see his signal turns back to red in front of him the train is traveling at 81 miles an hour and cooper slams on the brakes meanwhile driver hodder sees the hst in the distance and slams on his brakes the two trains collide on a combined speed in the region of 130 miles per hour the hst and the turbo were offset due to the angle of both trains resulting in a glancing blow of the turbo train due to the hst being an older design crumple zones were not built in which resulted in the thames train taking the brunt of the collision both drivers of the trains were killed instantly with the hst driver brian cooper being thrown from the wreckage the power car the hst rose up and fell towards the right multiple carriages of the hst were derailed and during the impact fuel tanks on the thames train were ruptured sending the wreckage into a fireball an emergency call was made at 8 10 am and fire crews from north kensington fire station arrived a minute later they were confronted with a fireball and a cloud of smoke as more fire crews police and london underground emergency response units arrived rescue operations began the derail carriages were secured enabling passengers to be recovered from the intact parts of the trains but many were trapped in the mangled wreckage first responders bravely fought the fire and helped find survivors in the wreckage much like what we saw at the morgate and at clappham rescue workers went well above and beyond what was expected of them in total 31 people died in the crash 24 were on the thames train and seven were on the hst nearly all of the deaths were related to the initial and subsequent impacts but one of the victims died later in hospital due to the effects of the fire in total 417 were injured in the accident with many experiencing severe burns after recovery of the bodies clearing works could begin which involved a crane starting on the 9th of october the last carriages of the wreckage were removed on the 13th of october with such a tragic disaster investigators looked into the cause that could lead to such an event the obvious cause being the signal passed at danger but the actual cause ran much deeper and would point the finger directly at the railway industry of course the accident might seem straightforward but can be divided into two parts what the driver could have done to prevent the spad and what could have been done to mitigate the after fix of the spad signal seara november 109 was notorious for drivers that work trains in and out of paddington before october 1999 there have been eight known incidents where train had passed its movement authority at the location since its re-signalling in 1993 because of this seara november 109 was classed as a multi-spad signal meaning it had been passed multiple times when at danger the number of incidents at the signal put it in the top 22 most passed signals in the country leading it to be described as a black spot multi-spad signals are not a unique thing on the railway and can be caused by a combination of infrastructure and human factors that make them high-risk places train operating companies have certain processes to make drivers aware of incidents through the use of notice boards and incident folders where staff become for duty but ultimately it is down to the driver to know the risks of the route over which they drive one such way to prevent incidents is in the use of defensive driving which is where a driver reduces their speed when driving under restrictive aspects this strategy was known by tems trains and information had been passed out to drivers although little extra training had been given needless to say if you're new to the job then there is a higher risk of not knowing instant hotspots and thus a higher risk of contributing to the spad statistics but this is usually mitigated through training driver hotter of the tems train had only been qualified for two weeks before the collision which brings the question as to whether his training was adequate during the investigation it was found that driver hotter's training was far from acceptable you see privatization of the british railway operations was still relatively new and as part of the dismantling of the national network into multiple small private train operating companies the standard of training varied as companies sought out to streamline their syllabus back in the be our days a more unified experience for driver training was used where a similar standard was set irrespective of depot and driving location this was due to a driver essentially having to learn both passenger and freight services the situation at tems trains was pretty dire leading up to the disaster and this was mainly linked to training and management the company had twice the industry standard number for signal past at danger six of the eight spads at seara november 109 were attributed to tems trains although having a terrible record the company hadn't made any serious improvements to its root learning training root maps were never provided and during root training instructors didn't see it as part of their job to teach characteristics of the lines driven this led to a serious gap in driver hotter's knowledge of the paddington to lab brook grove area but the buck doesn't stop at the driver's mistake as humans make errors it is also down to the railways industry as a whole to mitigate the danger of resulting from an accident the hsc investigation led by law cullen highlighted multiple infrastructure issues you see seara november 109 had a very dangerous layout of its signal heads in an unusual and non-standard reverse l shape when compared side by side you can see how its setup could lead to confusion the style of the signal head also can create a high risk of misreading as they are susceptible to a thing called bleaching where sunlight reflects off the lens washing out the color displayed in the modern day railway rulebook a bleach signal should be reported to the signal using the rt3185 form which would have also given the signal a chance to inform driver hotter what the actual aspect on display was after re-signalling in the area multiple complaints came in from drivers about the sighting and risk of read across for gantry 8 which house seara november 109 as part of the modernization and electrification of uk railways the paddington area have received overhead line equipment in 1995 this required the installation of stanchions the infrastructure installation further added to the cluttered visibility of gantry 8 the addition of banner repeaters was put forward which would have given an advanced visual indication of the signal ahead but these were not installed due to cost implications and the fact that the line speed would be restricted it was also found that during the re-signalling of the area a type of anti-collision system could have been implemented and that is called flank protection when a signal is held at danger at a junction the points can be set so that if a spat occurs the train can be directed towards the route least likely to cause a collision although in theory a simple addition it would have required the routing computer to work out the least dangerous route to be set which could have operational issues as it adds another level of complexity the other reason that the system was not implemented was the belief that a type of automatic train protection was just around the corner and this leads us to the final thing that could have prevented disaster automatic train protection during the final years of british rail and in the aftermath of the clap and rail disaster a form of train protection was in the making you see underground lines the whatford dc and a number of other routes had a type of protection called trip cock train stop as i mentioned in the moregate crash video is a form of stopping the train after a spad by means of mechanically activating trains brakes the system is reliable and has shown great results in preventing collisions from conflicting movements and spads but it did have a number of drawbacks one such thing is that it is not very reliable at high speeds due to the trip cock potentially being damaged if struck too hard it also added a certain level of complexity and that is of the lowering of the train stop because of it being a mechanical item either electricity or as employed on the underground air is needed to lower the train stop this resulted in british rail looking for another form of protection and the system they sought to trial was called ATP this employed beacons in the track that would stop a train if passed a signal at danger without authority the system was installed in the 1990s on the Paddington to Bristol route which ran right through signal Sierra November 109 and was active on the day of the crash but installing the train mounted system was time-consuming and expensive many trains had ATP fitted including the HST involved in the crash although it was defective on that particular train Thames trains had employed engineering firm WS Atkins to perform a cost of benefit analysis for fitting their trains and track with the ATP system it was found that the cost of benefit was not significant enough to employ ATP and as such Thames trains rolling stock was not retrofitted part of this analysis also took into account the cheapest system called train protection and warning system which was also being trialled elsewhere and was looking to be the preferred system thus leaving ATP obsolete WS Atkins came under criticism by overestimating the cost of installation of equipment by costing the installation of line side equipment which in most cases would have been paid for by rail track the company in charge of UK railway infrastructure at the time all of which factored into Thames trains decision to not install ATP all of the factors from driver error to lack of safety system led to the disaster which changed the railway industry forever TPWS has been installed on most main lines in the UK now and greater emphasis on training and personal protection strategies have increased safety on the railway but sadly accidents still happen we saw this recently with the Chow Fountain Latimer near miss where tripcock brake demand was reset resulting in two trains nearly having a head on collision another improvement that can be seen rolling out across the network today is the use of led type signal heads these are less susceptible to bleaching from the sun and although not perfect they are a step in the right direction and even more advanced step in train protection than TPWS is ETCS a type of in cab train control and signaling which ironically is being rolled out on some parts of the great western lane line this system has other benefits in achieving automatic train operation like what can be seen on the Thames Inc core where train is fully controlled by signaling the disaster has changed the UK railway industry for the better but even still those tragic deaths on that day in october 1999 will still leave a mark on the industry this video is a plain difficult production all videos on the channel are creative comments attribution share alike licensed many videos are produced by me john in a currently very wet and gloomy corner of southeast london uk help channel grow by liking commenting and subscribing check out my twitter for all sorts of photos and odds and sods as well as hints on future videos i've got patreon and youtube membership as well so check that out if you fancy supporting the channel financially and all that's left to say is thank you for watching