Remembering Cannon Street 1991
At 08:44 on 8 January 1991, a heavily loaded passenger train struck the buffer stops at London Cannon Street, causing the fifth carriage to partially override the sixth. Two people were killed and 542 were injured.
There were – as there always are – several factors that combined in this accident. One involved the rolling stock. Of the two coaches that suffered the worst damage, one was built on an underframe dating from 1934, having been refitted with a new body in 1953 and involved in a previous collision with a locomotive in 1958; the other was built on an underframe from 1928. They were simply not as crashworthy as more modern stock, and so withdrawals of this type – and indeed the Mark I-based stock implicated in the Clapham accident of 1988 and many others around this time – were accelerated.
As the driver in the Cannon Street case had failed to operate the brake successfully on the run in to the platform, British Rail was also recommended to review its driver training in this regard. And of course much attention has been given to all aspects of driver training and assessment since 1991; the development of Professional Driving Policies has emphasised indeed the need for due care when approaching potentially hazardous locations like terminal platforms.
The investigation also recommended BR include terminal platforms in its ‘Automatic Train Protection systems evaluation’. ATP was implemented on the Great Western and Chiltern routes, although an alternative solution – TPWS – became the industry standard, as we know. Its provision went on to cut the number of buffer stop collisions significantly.
Yet there was a cultural element to Cannon Street too. The driver was not tested for drug use until three days after the accident. When he was tested, traces of cannabis were found in his system. But because of the time lag the investigation report could only speculate on the drug’s part in the casual chain.
All the same, it did recommend that legislation be introduced to make it an offence for railway employees with safety responsibilities to be impaired by the consumption of alcohol or drugs (hitherto, only alcohol had been covered). This came into force under the Transport and Works Act 1992.
We need to keep testing; Cannon Street reminds us precisely why…
The full accident report may be found on the excellent Railways Archive website:
Accident at Cannon Street on 8th January 1991 :: The Railways Archive
Head of Waterfront Engineering, CEng FIET, FPWI
4 年Daniel Fox has produced a very interesting podcast about this incident and a quite a few others. They are called 'Signals To Danger' and you can listen to them for free on most places that host podcasts. I like that they are very factual and he takes all of his information from good sources. Definitely worth a listen.
Chief Safety & Assurance Officer at Transdev Australasia
4 年Thanks for sharing Greg. I was based at Dartford in those days and can remember the incident and the aftermath vividly. Another set of lessons that we, as an industry, mustn’t forget.
Principal consultant at HaRMUK Ltd
4 年Thank you Greg for the reminder. I remember at the time the drug’s part in the causal chain was ‘reasonable cause’ to anyone with eyes that can see. What is interesting I thought at the time was how cultural and political aspects placed much more emphasis on mitigation in this accident (crashworthiness and automatic train protection systems). British Rail was underinvested for a long time and preparing for privatisation (Organisation for Quality strategy 1992) which was implemented with infrastructure in 1994 and operators in 1997). But the legal influence ‘hit the nail on the head’ with the Transport and Works Act. There was indeed a long standing cultural problem in rail with alcohol, less so with drugs. The rule book references intoxication and associated duties and responsibilities and there were voluntary screening for recruitment and transfer of drivers. The driver signed on duty without seeing a supervisor. This in known as remote signing on. No fitness checks are made. Even if there was a face to face check it would be a subjective one but better than none. The accident was a wake up call to the cultural and political tolerances in which work was done and context to the underlying and root causes.
Employee Relations Partner
4 年Excellent piece Greg. Cannon Street is part of the corporate memory that all of us in the railway family must never forget. It transformed how we dealt with the issue of Drugs and Alcohol on the railway. The tragic events of that day and the learnings from it, made the railway safer.
Cutting the 'complicated' from coaching and assessment. See our 'about' section to see how we can cut your training and coaching costs by 50%!
4 年Quite chilling reading the passenger accounts. A good number of regular travellers on this route report a perception of absence of braking until very late into the platform. 'freewheeling' was described. A few points leapt out at me (apart from the cannabis use): The driver was phoning in at 0130 to request a change to his working pattern. He was due to book on at 0700. What was he doing up to that hour instead of getting his head down?; Given the effects of cannabis use (variable in different people), it must surely have played a part in the actions (or lack of them) of the driver. Of course, we do not know if the drug was ingested in the hours immediately before the crash. Nor do we know the use of the drug by the driver - habitual or one off, or what effect, if any on the drivers' general mental state; The unwillingness by the the driver to testify on the advice of his legal team in case it implicated him in a prosecution also speaks volumes, in my opinion.