Corporate knowledge and organisational culture

The disastrous collision at Clapham Junction on 12 December 1988, in which 35 people died and 484 were injured, was a turning point in the history of Britain’s railways. The immediate cause of the accident was poor working practice by a signalling technician, and the subsequent public inquiry into the accident highlighted serious deficiencies in the management of safety, particularly around the design, modification, testing and commissioning of signalling systems. Putting in place the recommendations of the inquiry fundamentally changed several aspects of how the railway is run, and for signal engineers one of the most important was the approach to routine tasks, such as testing alterations to signalling installations. It was therefore concerning for RAIB to discover, during our investigation of the collision at Waterloo in August 2017, that some of these important changes were not reflected in the way that signalling modifications were being undertaken.

Some of the people involved in the signalling work connected with upgrading Waterloo station and its approach tracks did not keep proper records of temporary works, or ensure that additional temporary wiring was shown on the design documents. Leaving that temporary wiring in place when it should have been removed led to a passenger train being diverted onto a blocked line and colliding with wagons. Compliance with the existing standards, developed since Clapham, would have provided the controls needed to stop temporary wiring being installed and used in the uncontrolled manner which resulted in this accident.

These symptoms of a deep-seated problem should give us all pause for thought. How can organisations ensure that lessons from events that happened outside the personal experience of present-day railway people are taught and retained? Compliance with a standard comes more naturally to people when they understand the purpose of the requirement, and the consequences that may arise from disregarding it.

We are recommending that Network Rail takes action to reinforce the attitudes and depth of understanding needed for signal designers, installers and testers to safely apply their technical skills and knowledge. This should include the establishment of processes to educate present and future staff about how and why the standards have been developed. It’s also important to equip our engineers and technicians with the cognitive and social skills that are needed to work safely, both by themselves and as part of a team.

I believe that this accident at Waterloo starkly demonstrates why the lessons of Clapham should never be forgotten.

Very sobering.  Wasn't there another very similar incident in Cardiff during the resignalling a couple of years ago which was just as concerning for the same reasons?