The Clapham Junction train accident

The first time someone used a non-industrial incident to help me understand the principles of Process Safety Management, it was the 1988 Clapham Junction train accident, which happened 36 years ago today.? As with so many high consequence incidents, the lessons remain every bit as valid today as they did back then.

On 12 December 1988, during the morning rush hour, three commuter trains carrying around 1,300 passengers collided at Clapham, one of Europe's busiest railway junctions.? Thirty-five people sadly lost their lives and hundreds were injured, many of whom suffered permanent disabilities.

A train had stopped on the tracks approaching Clapham, having received a red stop signal upon entering that track section.? But that signal was in error, and another train speeding towards it saw ‘only greens’ as it rounded a sweeping bend into Clapham, and the driver had no chance to stop the collision, despite desperately applying emergency braking.? A third train was passing on the adjacent line in the other direction and collided with the wreckage immediately after the initial impact.

So why did one driver see red, whilst the other saw green?

Two weeks prior to the incident, an under-trained and over-worked Signals Technician was installing new wiring at the local relay room, as part of a major re-signalling project.? He left a bare wire dangling inside a relay box instead of cutting it back, tying and insulating it, something which appeared to have become accepted practice in order to speed the job up.? A fortnight later, the same technician was working on the adjacent relay and - most likely - jolted the loose wire, causing it to touch a terminal and make a connection which would cause that signal to change at random.? Hours later, disaster struck.

Two major causal factors that are directly applicable to the Energy, Power & Process industries are the role of fatigue and the fact that the re-signalling work was not being treated as a safety-critical project.

The Signals Technician had worked seven days a week for 13 weeks and had undertaken constant, repetitive work which had ‘blunted his working edge’, in the words of the lead investigator.? We are now well into ‘maintenance season’ in the northern hemisphere, with many refineries and petrochemical plants conducting turnarounds that require intensive work periods from operators and technicians, creating tired minds and bodies.? If your folks are facing this, what active Fatigue Management steps are you taking to make sure that frontline workers stay sharp and alert?

Regarding the re-signalling project, the lead investigator wrote that ‘the appearance of a proper regard for safety was not the reality.? Working practices, supervision of staff, the testing of new works all failed to live up to the concept of safety.? They were not safe, they were the opposite.’? There was no single project manager and the engineer who was supposed to inspect and sign off all wiring modifications had a two week backlog, and so changes were happening without oversight.? If upgrades or modifications to elements of your Safety Instrumented Systems (SIS) - even something such as migrating their maintenance schedule from one planning system to another - how are you guaranteeing the accuracy of the work?? A healthy degree of paranoia is needed if we are to be sure that nothing slips through the cracks.??

Did the operators of the British rail network properly institutionalise the learnings of Clapham?? Evidence would suggest not, for similar incidents and near misses happened in 2016 (Cardiff), 2017 (London Waterloo) and 2022 (Derby) with eerily similar casual factors; uncontrolled wiring modifications done during rushed and poorly resourced upgrade works.? Corporate memory isn’t a natural feature of any organization - in fact ‘institutional amnesia’ is arguably the normal state of things - and no-one should be so naive as to assume that because we are conscious of incident learnings today that we will remember them tomorrow.