Britain's Railtrack has been condemned for its "lamentable failure" in a public inquiry report into the Paddington train crash that claimed 31 lives.
Railtrack failed to respond to two earlier instances of signals passed at danger before the October 1999 accident, the report by inquiry chairman Lord Cullen says.
Lord Cullen's report says the fact Railtrack had many groups dealing with similar issues led to confusion.
The accident at Ladbroke Grove, west London, was caused when a Thames Trains service passed through a red light and crashed into a Great Western express.
The report is also critical of Thames Trains, whose driver Michael Hodder (31), was killed in the crash. The report says the removal by Thames of all their in-carriage emergency hammers before the crash "compromised the safety of passengers".
The report says there was "a lack of appreciation within Railtrack that deficiencies in the infrastructure could play a significant part in SPADs [signals passed at danger]".
Lord Cullen said there had been concern SPADs occurred at twice the industry rate on Thames Trains services and although there had been an improvement in this respect during the period June 1996 to June 1998 "more could and should have been done to organise driver-training and management in a systematic manner."
Lord Cullen concluded the training of Mr Hodder who had only just qualified as a driver, was not adequate andhe probably believed that he had "a proceed aspect" at the signal he passed at red - signal 109. This signal had been passed at danger on a number of occasions before.
On the "lamentable failure" on Railtrack's part, Lord Cullen was referring to recommendations of serious SPAD incidents at Royal Oak in London on November 10th 1995 and at signal 109 on February 4th 1998. PA