Lessons learned from Cannon Street crash

This recommendation sadly echoed the findings of an earlier inquiry following the Clapham Junction rail crash, which killed 35 passengers in December 1988. Although the circumstances of this accident were very different - a signal fault caused by human error - Mk 1 EMU rolling stock and its lack of robustness was determined to have greatly contributed to the number of fatalities. 

All of the Mk 1 stock has now gone from regular service. All Southern-designed stock was withdrawn by 1995, but it would take a further ten years for the last slam-door Mk 1 EMU to be retired from frontline service post-privatisation in 2005. 

The provision of seatbelts and a ban on passengers standing on trains were swiftly ruled out as impracticable, but the report called for better provision of hand-holds and greater consideration for the way luggage is stored in future coach designs. 

The inquiry asked for legislation criminalising railway employees with safety responsibilities being impaired by alcohol or drugs, and for laws permitting the mandatory testing of employees involved in safety incidents. In 1991 it was illegal for railway staff to be under the influence of alcohol, but incredibly there was no equivalent law for drugs, effectively ruling out criminal proceedings against Maurice Graham for his proven use of cannabis. This scenario was rectified by the Transport and Works Act 1992. 

The inquiry also called for the end of drivers being able to book on for duty unsupervised. In future, train crew would have to book in by telephone or report to a supervisor who could visibly look for signs of unfitness for duty. 

This was another recommendation that had previously been made - this time in 1972 in the aftermath of the Eltham Well Hall rail crash, in which six people died following a derailment caused by driver Robert Wilsdon travelling at excessive speed while intoxicated by alcohol. 

The provision of ‘black box’ on-train data recorders was requested to provide information about the actions of a driver and the operation of brake and traction systems. This would aid with future accident investigations, by making them far less reliant on driver testimony (which was entirely absent in the case of Cannon Street). A standard for On-Train Monitoring Recorders (OTMR) was published in October 1993. 

A recommendation was also made that BR review its training given to drivers concerning the control of trains into terminal platforms. All aspects of driver training have been given attention since 1991, including the development of Professional Driving Policies. 

The report also called for Automatic Train Protection (ATP) to be installed across the entire rail network as quickly as possible, and finally that BR install new or modified buffer stops combining sliding and hydraulic designs, which may have helped cushion more of the impact at Cannon Street via a number of retarders placed on the rails behind the buffer stop. 

Regrettably, it would require a further fatal accident at Ladbroke Grove in 1999 before Train Protection and Warning System (TPWS), which was considered to be more cost-effective than ATP, made the types of incident at Cannon Street far less likely.

Twenty-five years later, there are no physical signs of the incident remaining at Cannon Street, but its legacy lives on through the safety improvements made in its wake and the robust design of Mk 2 and Mk 3 coaches. It may never be known why Maurice Graham misjudged his braking distance, or failed to brake at all. 

• This feature was published in RAIL 792 on January 20 2016