Intended for healthcare professionals


Accidents that should never have happened

BMJ 1999; 319 doi: (Published 16 October 1999) Cite this as: BMJ 1999;319:1018

When technology to prevent accidents exists it should be used

  1. Robert A Cocks, professor and director (
  1. Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong

    Personal view p 1079

    Early one October morning an express slammed obliquely into the side of another train.1 By all precautions they should not have been sharing the same piece of track, and 20 seconds earlier or later they would not have collided. The ensuing fire consumed the bodies of many passengers and injured many more, and for days no one was sure exactly how many perished.2 The subsequent inquiry was full of discussion about human error, blame, fire prevention, and automatic train protection.3

    This was not last week outside Paddington, when two commuter trains collided and burst into flames, but October 1928, when the Derby to Bristol mail train of London, Midlandand Scottish Railways struck a Great Western goods train at Charfield, Gloucestershire. In December 1928 the official inquiry into the Charfield crash called for the “eventual”installation of automatic train control, which could have stopped the train: 71 years later we are still waiting for it to be implemented.

    The memorial in Charfield churchyard bears the name of Philip Jenkins, probably the first person to be the subject of an inquest under section 18 of the 1926 Coroners Act, one held where no body has been found. The fire at Charfield was so intense …

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