Confusion resulted from too many groups dealing with similar issues.

There were Spads at Royal Oak in London on 10 November 1995, and at signal 109 on 4 February 1998.

The primary cause of the crash was the failure of the Thames Trains driver Michael Hodder to stop at a red signal as he left London.

Mr Hodder, 31, was killed in the crash. He had qualified only 13 days before and had received inadequate training.

Poor sighting of signal 109 and bright sunlight at a low angle contributed to Mr Hodder's belief that he could proceed.

Mr Hodder had not been informed properly about the type of signal in place at Ladbroke.

Problems with signal sighting had been accentuated by incompetent management.

Signallers inadequately instructed and trained in how to react to a SPAD.

A Slough control centre signaller tried to prevent the collision.

But there was a failure to realise the importance of communication between the signaller and driver.

Great Western passengers had difficulty in knowing how to open the external doors, and where to find and how to use hammers to break windows.

Main recommendations

Lord Cullen made 89 recommendations. They included: