Clapham Junction accident

The psychological phenomenon called hindsight bias plays such an important role in attribution of causes to accidents that it is worth spending time on it. The report on the Clapham Junction railway accident in Britain concluded ... 

Hidden, Anthony. 1990. Investigation into the Clapham Junction Railway Accident. London Her Majesty s Stationery Office. 

First, a loss of corporate memory seems evident when considering the railway accidents. It was only luck that avoided other Clapham Junction-type catastrophes. 

Such analysis differs from what would normally be conducted during an accident investigation. For example at Clapham Junction the immediate cause was human error, yet several underlying factors or systematic failures were also present. Table 1 summarises the author s assessments, classifying the systematic failures by type and by primary or secondary. 

Full privatization did not actually come until 1993 (see Ch. 11) but the threat of it and preparation for it overshadowed the company during the fieldwork period and this should be taken into account. Meanwhile other events were throwing the spotlight onto safety. During the run-up to privatization, but completely unconnected with it, there were two major accidents, one involving a fire on the London Underground and the second a collision at Clapham Junction. These events, as we will discuss in Chapter 3, led to a major re-evaluation of safety on the railways. 

During the period of data collection there were two main accidents which warrant discussion because of the impact they subsequently had on health and safety on the railways in general and indeed the very wide publicity they received at the time, namely the accidents at King s Cross and Clapham Junction. 

At 8.10 a.m. on the morning of Monday, 12 December 1988, a crowded commuter train ran head-on into the rear of another which was stationary in a cutting just south of Clapham Junction station. After that impact the first train veered to its right and struck a third oncoming train. As a result of the accident 35 people died and nearly 500 were injured, 69 of them seriously. They were all travelling in the front two coaches of the first train. (Hidden, 1989, para. 1)... 

The causes of the Clapham Junction accident were fairly clear from the beginning. But the reasons for the King s Cross accident were not immediately understood and intensive investigations surrounded the inquiry. Apart from the Court of Inquiry and the assessors appointed to advise on technical matters, a team of consulting engineers was appointed to advise on technical matters. A scientific committee was also established. 

The King s Cross report made 157 recommendations and the Clapham Junction Inquiry resulted in 93 recommendations. These covered a wide range of issues such as those addressing the immediate cause of the accident recommendations to improve the response of the railway companies staff, training, communications, and management of safety and recommendations about the role of the Railway Inspectorate. I want to focus briefly on the Clapham recommendations as it is these which are most pertinent for this study. They are particularly interesting as they are another source of information about occupational health and safety on BR and one which was contemporaneous with this study. 

These accidents and their aftermath are credited with being the catalyst for more profound changes in attitude towards health and safety. This is explicitly acknowledged in the Chairman s foreword to Railtrack s first Safety Plan (1994/5) which pays tribute to the former BR Chairman After the tragic accidents at King s Cross and Clapham Junction it was he and his team who initiated profound changes in the way safety was managed on the railways (Railtrack, 1995 1). 

In the immediate aftermath of the Clapham Junction accident, BR moved swiftly and publicly to demonstrate that it was reviewing health and safety. It employed a firm of consultants to help them do this. One result of this was to... 

A series of accidents—King s Cross, Clapham Junction, Zeebrugge and Hillsborough has resulted in a new approach to risk management and safety. On BR, the recommendations of these inquiries have been analysed in detail and have led to the formation of proposals to reduce risk. The approach to safety has been altered by these accidents and the lessons learned through the painstaking inquiries have helped to shape the strategy described in this Plan. (ibid. 4-5)... 

Moves towards an apparently systematic and rigorous approach to health and safety had already begun during the data collection period for this research. This approach emerged in response to a variety of influences, some of which were specific to the industry and others of which were general and extended beyond the railway industry. The specific events were the aftermath of the King s Cross and Clapham Junction accidents, which caused the whole railway industry to reappraise completely its approach to health and safety (see Ch. 3). 

Procedural problems are frequently cited as the cause of major accidents, contributing to some of the world s worst incidents, such as Bhopal. Piper Alpha and Clapham Junction. In the major hazard industries, fit-for-purpose procedures are essential to minimise errors, and to protect against loss of operating knowledge (eg when experienced personnel leave). 

A series of major accidents in the mid/late 1980s had a profound impact on public concern on safety issues. Major catastrophes in space (Challenger), on land (Chernobyl and Hillsborough football stadium) and on water (Zeebrugge, Piper Alpha and Thames Marchioness pleasure boat) were followed by train accidents in France (Gare de Lyon) and the UK (Kings Cross fire, London Underground, and the Clapham Junction train collision). 

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