An inquiry into the 1997 Southall rail crash in west London has blamed driver error and faulty safety equipment. Seven people died when a Great Western Trains express collided with a freight train. The BBC's transport correspondent Tim Hirsch explains the report's significance.
What was the main finding of the report? The main finding was that the crash was primarily caused by the failure of the driver, Larry Harrison, to respond to two signals which should have warned him of the freight train blocking the track up ahead.
He could not explain why - the report says he may simply have "dozed off". It also finds that Great Western Trains and Railtrack both contributed to the tragedy by failing to set and implement safety rules which would have prevented it.
What safety systems did the train have and why did they not prevent the crash?
It had both the basic Automatic Warning System, which sounds a buzzer in the cab when a warning signal is passed, and a pilot version of the more advanced Automatic Train Protection, which applies the brake if the driver fails to stop.
They did not prevent the crash because neither was working at the time - the AWS because it was broken and the ATP because the driver was not trained to use it and it was switched off.
Would the government's preferred new safety system have prevented this accident?
Not as currently designed. The Train Protection Warning System, due to be installed across the rail network by 2003, is only effective at speeds up to about 75mph, and the Southall crash happened when the express train was going about 80.
But a modification proposed only this week called TPWS+ would make this system effective up to 100mph and the government says this enhanced version would have prevented the Southall tragedy.
What did the inquiry say about the training given to drivers on Great Western Trains?
It was inadequate. Most significantly, it found that drivers were not given training on what to do when the basic warning system of a train fails.
Larry Harrison said in a statement on Thursday: "I did not realise how dangerous it was to drive a high speed train without the AWS. If I knew then what I know now, I would never have taken the train out. I wish I could turn the clock back".
What did the inquiry say about safety rules generally in the privatised rail industry?
It said that the fragmentation of the industry had resulted in some confusion and inconsistencies in safety procedures which must now be put right.
Do these findings give any hint as to the likely outcome of the inquiry into last October's crash at Ladbroke Grove near London's Paddington station?
Not really. One can guess that there will be common ground on issues like driver training and the evacuation of passengers.
But wider questions such as train protection systems across Britain have not been tackled by the Southall inquiry and will instead form part of the wider Ladbroke Grove inquiry chaired by Lord Cullen.
How far has rail safety already been improved as a result of these crashes?
There have been a lot of pledges and commitments, like improved driver training and a confidential hotline for staff to report problems.
But there is little evidence that at this stage rail travel is safer than it was. However it is worth pointing out that rail travel is still vastly safer than travelling by car.
