The official report into the Paddington train crash published yesterday accused the operators of Britain's railways, Railtrack, of "institutional paralysis" and insisted that improvements in safety must be made within six months.
Survivors and relatives of the 31 people who died in the disaster called for senior staff at Railtrack, including its former chief executive, Mr Gerald Corbett, to be prosecuted. Railtrack insisted that safety had improved since the crash but acknowledged that more needed to be done.
The report following Lord Cullen's three-month inquiry into the October 1999 disaster contained criticism of the entire rail industry, including one of the train companies involved, but Railtrack was singled out for particular condemnation.
It was criticised over its "lamentable failure" to learn the lessons of earlier train incidents, including eight separate occasions when Signal 109 was passed at danger. The company was also accused of a "serious and persistent failure" to consider how the sighting of signals might be improved.
The crash happened when a Thames train which had just left Paddington station passed Signal 109 at red and proceeded into the path of an oncoming Great Western express from Cheltenham. The trains collided at a combined speed of about 130 m.p.h.
The driver of the Thames train, Mr Michael Hodder, had qualified only 13 days earlier, and Lord Cullen criticised Thames Trains over "significant shortcomings" in his training.
The company had demonstrated a "slack and less-than-adequate" attitude towards training. The report also said the removal by Thames Trains of all in-carriage emergency hammers before the crash had "compromised the safety of passengers".
Lord Cullen said the crash had exacted an "appalling" toll of deaths and injuries to passengers. "Naturally it calls for feelings of deep sympathy for all whose lives were affected," he said, "but it also casts a shadow across the safety records of the industry. It disturbs public confidence in a familiar and trusted mode of transport."
Among more than 80 recommendations in the report, Lord Cullen said Railtrack should conduct a safety examination of the layout of signalling and track for two miles outside Paddington.
The crash led to large fires inside the train carriages, and the report said train companies should implement procedures to prevent the dispersal of diesel fuel.
As the Transport Secretary, Mr Stephen Byers, insisted safety was "at the heart" of government policies aimed at regenerating the rail industry, the leader of ASLEF, the train drivers' union, said Railtrack's "greed and negligence" were to blame for the crash.