December 4, 2006 |

Monday Accident & Lessons Learned – The UK Ladbroke Grove Rail Accident Once Again Proves That Failing to Perform Root Cause Analysis and Fix Incidents Can, and Usually Does, Precede Major Accidents

 Sys-Images Guardian Pix Pictures 2006 10 31 Ladbrok372X192

I often have people question the need for root cause analysis of incidents and near-misses. But failing to perform good root cause analysis and fix the causes of incidents is almost always a precursor for a serious accident.

As the case against Network Rail slowly makes it’s way through the UK courts (it’s been 7 years since the accident at Ladbroke Grove that killed 31 and injured 400), The London Times reported that there had been six incidents when signals were passed when red between 1996 and 1998 at that same sight and either the incidents were not investigated or corrective action was not implemented prior to the accident.

Since that accident, Network Rail has implemented a “Train Protection Warning System” or “TPWS” that Network Rail says would greatly reduce the chance of this type of accident.

However, the London Times says that in 2006:

  • The number of trains passing danger signals has risen sharply.
  • Between July and September of 2006, there were 94 cases of signals being passed at danger (SPADS) and that four of them were “potentially severe” (that sounds really bad).

So … This leads UK train riders to wonder:

“Are current SPADS being investigated adequately with advanced root cause analysis

and are effective corrective actions being implemented in a timely fashion?”


When I see 94 SPADS in three months, I really have a hard time believing that they are doing effective root cause analysis.

So it doesn’t sound to me that they learned from the lessons of the Ladbroke Grove disaster.

Under the TapRooT® System this failure to learn would fall under the Management System – Corrective Action – Corrective Action Needs Improvement root cause.

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