A buffer stop collision of the 07:58 commuter train from Sevenoaks into Cannon Street - a line and service my Dad commuted on for many years and that I was pretty familiar with, and the 4EPBs that were involved - though by
8th January 1991 Dad had retired and I was near Devizes.
Reading the report at
https://www.railwaysarchive.co.uk/documents/HSE_Cannon1991.pdf I see many old features which are characteristic of some previous accidents such as a question as to whether the driver was sober (or under the effect of alcohol or cannabis) - noting too the Eltham Well Hall rail crash, caused by an intoxicated train driver, kills six people and injures 126. (11th Jun 1972)
New aspects entered such as computer simulation looking at the effect of the crash on the passengers in the train, and witnesses asking if they can claim expenses for attending the enquiry to give evidence. The refusal of the driver to give evidence was also a new one on me.
"From the evidence available to me I can find no defect in either the braking or traction system, either permanent or intermittent, which would have prevented brakes from operating effectively. Therefore, I must conclude that [the driver] failed to make the proper brake application and that by his omission he was responsible for the accident. I am unable to reach any firm conclusion as to the reasons for his error or as to whether [the driver]'s use of cannabis was the cause of his omission...
Despite its age the rolling stock had been properly maintained and it did not contribute to the cause of the accident. Nevertheless, its now superseded design did result in more severe damage to the rolling stock and an increase both in the severity and number of injuries. In particular, the overriding of the fifth and sixth coaches occurred because of the inadequacy of the single buffer coupling and the lack of structural strength in the coach bodies."