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15th OCOTBER 1994





extracted and adapted from the report by


1 At about 08.27 on Saturday 15 October 1994 in foggy weather, two similar passenger trains, each formed of two Class 205 

diesel-electric multiple units (DEMUs), collided head-on near Cowden Station on the single line between Hever and Ashurst 

on the Uckfield branch line. The infrastructure belonged to the South Zone of Railtrack plc and the trains were operated by the 

Network South Central Train Operating Unit of British Railways. Five people were killed in the accident and 12 others were 

taken to hospital suffering from shock or minor injuries. They were not detained in hospital. The five who died were the driver 

and guard of the Up train, the driver of the Down train and two passengers in the Up train. The guard of the Down train was 

one of those taken to hospital suffering from shock.

2 The track layout of the branch line, which runs from Oxted to Uckfield in East Sussex via Hurst Green Junction, had been 

altered in 1989/90from double line throughout to include three stretches of single line. Modern colour-light signalling fitted 

with the automatic warning system (AWS) on all signals and driven by a solid state interlocking (SSI) system in Oxted Signal 

Box was taken into use in 1990. One of the features of SS1 is that it contains a data recorder. This recorder was operational 

and provided an invaluable record of events. It was concluded that the layout of the signals conformed to the standards in 

force at the time and that even had retrospective action been taken to implement later, applicable, standards these would have 

had no bearing on the course of the accident. The layout was adequately and safely signalled.

3 Class 205 units, which were built in the late 1950s, are Mark I coaching stock. They are powered by a diesel-motor 

generator set located in a compartment behind the driver's cab in one of the three vehicles in each unit.

4 Britlsh Railways' National Radio Network (NRN) covered the general area of the Uckfield branch but in the topographical 

conditions the actual coverage along the railway was patchy. This deficiency also applied to the commercial mobile telephone 

networks. The plan to install the cab secure radio (CSR) system on the Uckfield branch had not been implemented, but one of 

the units involved in the accident had been fitted with CSR radios. These do not operate on the NRN system. As a temporary 

expedient, trains on the Uckfield branch were provided with commercial mobile telephones but this expedient had fallen into 


5 Post-accidenttesting, including the analysis of the SS1 data tape, proved conclusively that the Up train from Uckfield to 

Oxted had passed the signal protecting the entry to the single line from Ashurst to Hever at Danger. On the balance of 

probabilities it was concluded that the AWS system mounted on the Up train was working correctly. However there was no 

doubt that the signal had a degraded performance which was exacerbated by the fog. There was some dispute about the degree 

of degradation, the scientific evidence contrasting markedly with that of experienced signal engineers. Nevertheless it was 

possible to estimate that, on that morning, the signal aspect should have been discernible at a distance between 50 m and 20 m 

away. There appeared to be no defects in the controls or the brakes of either of the trains.

6 The guard of the Up train was riding irregularly in the driver's cab. There appears to be no reason for the total disregard of 

the signal aspect other than distraction of the driver. There is some doubt as to who was actually at the controls of the Up 

train; this matter will be addressed in Part 2 of my report following the Coroner's Inquest. Nevertheless I conclude that the 

driver of the Up train, Driver Barton, was wholly responsible for the accident; no fault attaches to the driver of the Down 


7 The signalman at Oxted was alerted to the inevitability of the accident by an alarm which sounded when the Up train ran 

through the points onto the single line. Some 2 minutes elapsed between that event and the collision but, in the absence of any 

form of communication with the trains, he was unable to do anything other than alert the Control Room at Croydon. It was 

concluded that, in the time available to the signalman, the accident could have been averted had cab secure radio been 

available but it would not have been if either National Radio Network radios had been fitted to the trains or commercial 

mobile telephones had been carried by the drivers. The report notes that the decision to install CSR on the Uckfield branch 

was taken in December 1994.

8 This accident was entirely preventable by an automatic train protection (ATP) system. The reasons for the lack of progress 

in fitting such systems are discussed in the report which notes that the Health and Safety Commission had accepted the view 

that it is not reasonably practicable to fit network-wide the A TP systems currently under trial but that the Commission expects 

provision of A TP as a minimum on all new high- speed lines and that it should be considered for major resignalling schemes. 

This is reflected in my detailed recommendations on ATP and on the interim measures to reduce and mitigate the 

consequences of signals passed at Danger (SPAD).

9 The lack of crash worthiness of Mark I rolling stock is discussed, as are the effects of the decision to extend the life of such 

rolling stock without safety enhancements beyond the period given in the Hidden Recommendations54 and 55. The 

consequences of the decision are that, coupled with the lack of provision of ATP, the conditions under which the continuation 

in service of Mark I rolling stock is acceptable, have now lapsed. A fresh programme of research and the agreement of a plan 

to implement its results by HM Railway Inspectorate is recommended. Neither train was fitted with an on train monitor and 

recorder (OTMR). Had they been, some of the doubts over the working of the AWS on the Up train would have been resolved. 

Fitting of OTMRs was recommended in the Hidden Report and accepted. However only a percentage of the train fleet

has actually received them. It is therefore recommended that a plan for completing the fitting of OTMRs is submitted to the 


Part 2

10 The Inquest into the five deaths was held from 14 to 16 August 1995 at Tunbridge Wells in the presence of a jury. In the 

main, the evidence was given by those who had given evidence to the Inquiry. Additional evidence was given by a pathologist 

and by a member of the Kent Fire Brigade. Despite the additional evidence it was still not possible to determine who was at 

the controls of the Up train and it is considered unsafe to come to a definite conclusion in this respect. The conclusion that 

Driver Barton, as the driver of the Up train, was wholly responsible for the accident is reiterated. The jury returned verdicts of 

Accidental Death on the train crew of the Up train and Open verdicts on the other three people who were killed.

Conclusions and recommendations

11 The conclusions and recommendations are given in Appendices 2 and 3 respectively at the end of the report. 


The course of the collision

12 Shortly after leaving Cowden Station, the 08.04 Oxted to Uckfield passenger train (2E24), the Down train crewed by 

Driver Rees and Guard Boyd, comprising two three-car Class 205 DEMUs and running under cleared signals, had travelled 

about 300 m when it collided head-on with a similar train, the 08.00 Uckfield to Oxted (2E27), the Up train crewed by Driver 

Barton and Guard Brett-Andrews. The two leading vehicles of 2E24 and the leading vehicle of 2E27 were derailed, blocking 

the single line. The weather at the time of the collision, about 08.27, was very foggy, visibility in places being down to 50 m. 

Two passengers in the Up train, the train crew of the Up train, and the driver of the Down train were fatally injured and 12 

others, who included the guard of the Down train, suffered minor injuries and shock as a result of the collision.

The site

13 Cowden Station lies about one-third of the way along the line from Hurst Green Junction to Uckfield. Before 1969, this 

line was part of an alternative route from London to Brighton via Lewes, but in February of that year the section beyond 

Uckfield was closed. The importance of the line was accordingly lessened and, by the mid-1980s, it had deteriorated to such 

an extent that a number of speed restrictions had been imposed due to the condition of the track. It was apparent that, unless 

some improvements were made, the line would only deteriorate further and several options were examined. As a result, the 

decision was made in 1988 to single the line without electrification, but to equip it with modern signalling. This was 

completed in the early part of 1990 and the line is now single from Hever to Uckfield with long passing loops at Ashurst and 


14 The route is fairly heavily graded and passes through wooded country. The single line between Hever and Ashurst, on 

which the collision occurred, lies more or less north-west to south-east and rises continuously from Ashurst in the Up 

direction on a series of left- and right-hand curves, culminating in a maximum gradient of 1 in 100 for almost a mile before 

Cowden Station. The salient features of the line between Ashurst and Cowden are shown in Figure 1. Figure 2 at the back of 

the report shows the signalling of the single line and of the Ashurst loop and details of the collision site. Both Cowden and 

Ashurst Stations lie in the county of Kent, although much of the line between them passes through the county of East Sussex. 

The signalling

15 The line is fully track-circuited, is signalled by colour-light signals which have AWS inductors associated with them and is 

operated under the Track Circuit Block Regulations from Oxted Signal Box. The signal box is equipped with the SS1 system. 

The signalman's display is a standard entrance-exit (NX) panel driven by duplicated panel-processor microprocessors. The 

interlocking of points and signals is accomplished by three interlocking microprocessors arranged in a checked, triple-

redundant mode. A further microprocessor acts as a diagnostic module which monitors the inputs and outputs to and from the 

interlocking processors and sounds one of two types of alarm if a fault is detected. The 'critical alarm' sounds, together with a 

visual indication, if a fault which immediately affects the operation of the signalling system occurs. The 'non-criticalalarm' is 

given when a failure such as the first failure of duplicated signalling equipment occurs. Data link modules (DLMs) connect the 

signal box processors to the data highway to the outside signalling equipment. DLMs are also used at the field locations to 

connect the trackside functional modules (TFMs) to the data highway. TFMs are double redundant microprocessors and 

separate types are used to drive the signals and points. Track-circuitoperation is monitored through either type of TFM. All 

SS1 data sent to or from the signal box is logged chronologicallyon tape which can either be interrogated or removed 

completely for subsequent investigation. Time on the tape is recorded in 1 minute bands. The SS1 cubicle is located in the 

relay room on the ground floor of the signal box at Oxted but there is a fault printer adjacent to the signalman's panel on the 

first floor. The train describer and the annunciator for the telephone concentrator at either end of the signalling panel both use 

VDU displays.

16 From Hurst Green Junction, where the branch diverges from the main line to East Grinstead, all the signals except 0D61 at 

Crowborough are two aspect colour-lights. Entry to the single line between Hever and Ashurst in the Down direction is 

through Points No 530 at Hever Junction while in the Up direction through Points No 532 at Blackham Junction. The Down 

signals protecting the single line are 0D55 and OD55R while Signals 0D58 and OD58R protect it in the Up direction.

The trains and the damage sustained

17 The composition of and damage sustained by each of the two trains is shown in the table overleaf. Each set is 60.99 m long 

over couplers and weighs 122 tonnes. The DMBSO weighs 57 tonnes.

The damage to the permanent way

18 Points No 532 and their operating connections were damaged as a result of being run through and four concrete sleepers 

required replacement. Some track realignment was also necessary.


As to the background information

19 Mr C T Jago, Director Railtrack South Zone, described the line including the signalling and showed a video film taken 

from the cab of a train similar to those involved in the accident. He also described the outline course of the accident, the 

functions of the various control rooms and a brief history of the singling and resignalling of the line. He agreed that the loops 

at Ashurst and Crowboroughwere long ones.

20 Mr G C Eccles, Director Network South Central Train Operating Unit (TOU), described the train operating arrangements 

on the line. He mentioned that of the trains involved in the accident only one of the four units (205018) actually had a radio 

fitted in the cab. It had been the policy, where possible, to fit radios to trains in advance of the provision of base station 

facilities so that whenever and wherever those facilities were available the radios could be used. The Uckfield line had not yet 

been equipped with radio base stations for cab secure radio. However commercial cellular telephones had been made available 

to train crews after the line had been singled and he described the operating instructions for them. He said that there were 

black spots in the telephone cover in that area.

21 Superintendent A J Clift, British Transport Police, was the Area Commander for the geographical area in which Cowden 

lies. He describedthe involvement of the emergency services following the accident. He also describedsome of the 

investigative work which had been undertaken by the police and explained where the fatally injured had been found.

As to the running of the trains and the course of the collision

22 Signalman S W Webb, Railtrack South, was on duty in Oxted Signal Box on the day of the accident and had relieved a 

colleague there at 06.50 after having had a full period of rest. He explained that, although he was classified as a 'rest day 

relief', he was fully conversant with the train service, also with the operation of Oxted Signal Box, and had worked the 

morning shift there a number of times. On the morning of 15 October all was in order with the signalling equipment and, 

before the collision, there were no difficulties with the operation of the signal box.

23 Mr Webb set the route for 2E24, the 08.04 Oxted to Uckfield (the Down train), as far as Signal 0D59 in Ashurst Loop and 

also the route for 2E27, the 08.00 Uckfield to Oxted (the Up train), to Signal OD58. This was his normal practice and was 

done so that each train would be able to run into the loop and call at Ashurst Station without being delayed. Knowing that the 

Up train would arrive at Ashurst before the Down train, Mr Webb watched his signalling panel indications and, when it had 

passed Ashurst Junction, he set the route for the Down train through to Uckfield. At this stage, there was nothing else 

requiring his attention until the Down train had passed Blackham Junction so, noting from his signalling panel indicationsthat 

all appeared in order, he decided to prepare his breakfast.

24 Shortly after beginning his preparations,the critical alarm in the signal box sounded to warn him that something was 

wrong. On turning round to check the signalling panel, he saw that the indicator light above the switch for Points No 532 at 

Blackham Junction was flashing, showing that the points were ‘out of correspondence'. Mr Webb checked the other 

indications on the panel and, seeing that track-circuits LF and LD were both showing occupied, realised that the Up train had 

run through the points and that a collision was virtually certain. He was, understandably, somewhat distressed but he 

immediately rang the Railtrack Control at Croydon to apprise them of the situation and to ask them to call the emergency 

services, recording the time as 08.28. Mr Webb added that, althoughthere was a time indicationobtainable from the SS1 

equipment, this was not in agreement with the signal box clock. As he was aware that the latter clock was checked daily, all 

his timing recordswere made from this. He then placed reminder appliances (collars) on the signal and point controls to 

preserve their settings and, additionally, set the signals for the East Grinstead line to work automatically.

25 In answer to questions, Mr Webb said that there was nothing else that he could have done; there were no signals ahead of 

either train, and he was not in radio contact with their drivers. Cellnet telephones had, for some time, been provided for 

communication between the signal box and drivers, using the British Telecommunications (BT) system but they had proved 

unreliable and had fallen into disuse. He was conversant with the use of CSR and was of the opinion that, had such equipment 

been provided, he could have warned the drivers in time for them to have stopped before colliding because, when the alarm 

sounded, the two trains would have been about a mile and a half apart.

26 Trainman R Boyd, Network South Central TOU, was the guard of the Down train. He booked on at Selhurst Depot that 

morning after more than 12 hours rest and worked the empty stock thence to form the 05.58 East Croydon to Uckfield and its 

return working, the 07.00 Uckfield to Oxted. On these two journeys the weather was misty and swirling in patches and, 

although his driver, Mr D Rees, spoke to him when he changed driving cabs, he neither commented particularly upon the mist 

nor did he mention any difficulty in seeing signals. In Mr Boyd's view, because both he and Mr Rees regularly worked on the 

Uckfield line, neither of them considered the weather as anything unusual.

27 The Down train was a little late in starting from Oxted owing to the shunting movement into the bay platform there being 

carried out across the London end crossover at the station instead of, as was usual, the country end. The journey as far as 

Cowden Station was, in Mr Boyd's opinion, normal and Mr Rees was driving as steadily and smoothly as he normally did. 

Shortly after leaving Cowden, however, there was an emergency brake application, which Mr Boyd thought was due to the 

driver having released the driver's safety device (DSD), and almost immediately there was what he described as a 'crunch' and 

the train came suddenly to a stand.

28 On looking from the window of the guard's compartment, Mr Boyd saw that the leading vehicles of his train were derailed, 

so he put on his high-visibility vest and climbed down to the track to investigate. At that time, he did not realise that there had 

been a collision and thought that his train had struck something on the line. He arrived at what he thought was the 'front' of the 

train and, seeing that the driving cab there was unoccupied, thought that his driver had gone forward to carry out protection in 

accordance with the Rule Book. So, after obtaining detonators and a red flag from the cab, which he put down ahead of the 

train, he returned to the rear, checking with and reassuring his passengers as he did so. Mr Boyd continued past the train to 

Cowden Station to report the incident where he met a colleague, a Mr Hodges. Although there was a telephone at the station, 

neither of the two men knew the number of Oxted Signal Box and had to obtain the number by telephoning the Oxted 

Operating Supervisor. It was only after speaking to the Oxted signalman that Mr Boyd realised that his train had been 

involved in a collision.

29 Rail Operator V D Hodges, Network South Central TOU, travelled on the Down train as a passengerfrom Oxted and 

alighted at Cowden to attend to station duties there. He did not speak to either the driver or the guard and, when the train left, 

he went into the booking hall to tidy up when he heard what he described as 'a bang'. Thinking that some contractors' materials 

left on the station might have exploded, he went to investigate but found nothing amiss and resumed his work. At about 08.35, 

he decided to telephone the supervisor at Oxted, whose number he knew, to inquire the whereabouts of the Up train which, he 

realised, was late. He was told that it was at Ashurst and, on putting the telephone down, saw Mr Boyd approaching, walking 

along the platform. When he asked Mr Boyd what had happened, he was told that the Down train had struck something and 

that he needed to contact the signalman at Oxted. The relevant telephone number was not displayed at the station so Mr 

Hodges rang the supervisor again to find out the number of the signal box.

30 Mr D M Stone, a passenger on the Up train, boarded it at Buxted Station together with his wife. He had been unable to 

purchase their tickets on the station and, never having travelled on the line before, was concerned as to whether he could do so 

on the train. He was, therefore, scanning the train as it approached Buxted to see if there was someone on the train from whom 

tickets could be obtained. As the train drew closer, he could see that there was a man in uniform standing in the driving cab to 

the driver's right and near to the middle of the cab.

31 Although Mr Stone had not journeyed on the line before, he felt that, between Crowborough and Ashurst, the Up train was 

travelling fast; he described the movement of it as 'a rocking motion' which he likened to that of a road vehicle going 

downhill. Detective Chief Inspector V M Miller, British Transport Police, said that, subsequent to the accident, passengers 

from both of the trains involved had been interviewed and a number of those from the Up train had remarked upon its speed or 

on the ride as having been 'jerky'. Mr Miller pointed out, however, that not only were these witnesses not qualified to comment 

upon the riding qualities of trains, but that their recollections may well have been distorted as a result of the accident. 

Nevertheless, all those interviewed agreed that the weather was foggy in patches and that some of the patches were quite 


32 Another passenger on the Up train, Dr B A Lawton, has also provided me with her notes written shortly after the day of the 

accident. She had travelled from Crowborough and had seen Mr and Mrs Pointer (who were later to be fatally injured) enter 

the leading first class compartment. She herself travelled in the leading vehicle of the second unit. She noted that it was foggy 

in patches and that the train seemed to be going faster than usual. After stopping at Eridge the train dropped to its more usual 

pace for the run to Ashurst. The fog was still patchy and dense in places. Both at Eridge and Ashurst the station stops were 

just long enough for passengers to board or alight. She noted that there was no Down train at Ashurst as might have been 

expected. The start from Ashurst was smooth, she did not hear a bang as the points to the single line were traversed and the 

train continued at its normal pace. Approaching Cowden the train slowed naturally and did not appear to brake (she knows the 

feel of sudden braking). There was no fog and she could see quite far back down the line towards Ashurst and thought that, 

but for the bend and the trees, she would have been able to see Cowden Station.

33 Rail Operator (Rest Day Relief) W Burton, Network South Central TOU, was engaged in ticket office and platform duties 

at Edenbridge Station on the morning of the accident. He had travelled to Edenbridge on the 06.48 train from East Croydon, 

the crew of which were Driver Barton and Guard Brett-Andrews, both of whom he knew. On the train's arrival at East 

Croydon, Mr Burton noticed that the guard was in the leading cab with the driver. He then got out of the cab and, after having 

deposited his guard's bag in the brake van in the middle of the train and switching on the train lights from there, returned to 

the leading cab. When, at Edenbridge, Mr Burton gave a handsignal that the platform work was complete, it was 

acknowledged by the guard from the driving cab.

As  o the events following the collision

34 Deputy Controller K McManus, Railtrack South, was on duty in Croydon Control when Signalman Webb telephoned to 

advise of the impending collision. He realised that the signalman was distraught and was at pains to repeat the message back 

to ensure that he had the details correctly. After having logged the time that their conversation was finished, 08.34, he reported 

the situation to his Control Manager. At that time, Mr McManus did not know the site of the collision so the two men 

consulted ordnance survey maps and a reference book available to them in the Control Office so that accurate directions could 

be given to the emergency services. They had just decided upon a suitable access point when they received a telephone call 

via the Kent

Police advising them of the collision.

35 Mr R P Westwood, also of Railtrack South, was the senior control manager at Croydon and was the Control Manager to 

whom Mr McManus reported. In addition to controllers from his own company, Railtrack he also had representatives from 

Network South Central TOU working under him and, in his capacity as Control Manager, was responsible for dealing with 

any abnormal situation. He explained the arrangements that had been set up for notification of the emergency services by 

means of direct telephone calls through the BT system and also the various railway officers who would need to be told of a 

major incident. The latter were contacted by a telephone pager message through the BR National Telephone Network (NTN) 

that would be sent out to all

Railtrack staff in the entire South Zone but, additionally, the Director, Railtrack, and the on-call officer would be called 

directly. There was some difficulty, however, in contacting the Department of Transport and it was not until some three-

quarters of an hour after Mr McManus had reported to him that contact was made. These procedures were specified in a 

manual for emergency procedures produced by Railtrack headquarters and dated June 1994.

36 Although he had received training for emergency situations, including simulated incidents, and had visited an ambulance 

control room, Mr Westwood had not been given any instruction in dealing with people who have suffered from shock. He was, 

nonetheless, primarily concerned for the welfare of Mr Webb and made arrangementsfor a man from Oxted Station to go to 

the signal box and remain with him until relief could be organised, because he was fully aware that a movements inspector 

would, of necessity, take some time to travel to Oxted.

37 He had just decided, with Mr McManus's assistance, upon the informationto be passed to the emergency services when, at 

08.40, he received a call from a colleague in the Kent Railtrack Control to say that they had been advised of a collision on the 

line by the Kent Police and that the location was required. He thereupon spoke directly to the police and told them that 

Cowden Station was the most suitable point for their control room to be set up.

38 Area Movements Inspector D G Morgan, Railtrack South, was 'on-call' at home when, at about 08.30, he was telephoned 

by Croydon Control and told of the collision. He was aware how Mr Webb would have reacted to the incident so, after 

speaking to him for a few minutes on the telephone, told him that he was coming to Oxted, arriving there at about 09.00. On 

entering the signal box, he took notes of the signalling panel indications and signed the Train Register Book, his observations 

confirming the sequence of events that Mr Webb had reported and also that he had taken the proper steps to protect the route. 

He had known Mr Webb for about 6 years and was fully satisfied with his performance as a signalman, having last examined 

him in Rules some 3 months before the accident, a test which he passed with ease. 

39 Mr Morgan then made arrangements for Mr Webb to be relieved, a problem that he had turned over in his mind on his way 

to Oxted. It was his responsibilityas the on-call movements inspector to do so because, as it was a weekend, there was no 

roster clerk on duty who would normally perform this function. Also, there were no relief signalmen available at the time and 

he had to move staff around to obtain a relief for Mr Webb. In the event, it was some hour and a half after the collision before 

Mr Webb was able to go off duty. During this time, Mr Morgan assisted with telephone messages, the signals on the East 

Grinstead line also controlled from Oxted Signal Box having been set to operate automatically.

40 M. J.A.B. Street, a Railtrack Field Manager, was in his office at Epsom when, at approximately 08.35, he received a 

message on his pager to ring Croydon Control. The message did not give any details, a procedure which he favoured, because 

he preferred to speak to someone to obtain as much information as he could about an incident before leaving for its site. 

Having telephoned to Railtrack Control to obtain the information that he wanted, he immediately rang Signalman Webb who 

seemed badly shaken but advised him what had occurred. He said to Mr Webb that he would get to Oxted Signal Box as soon 

as he could and that Mr Morgan was, in fact, on his way there. In the event, Mr Street did not go to the signal box; in the 

course of his journey there, he was again paged and, on telephoning, was told that a passenger from one of the trains had 

called the emergency services from a farm near to the railway and that Mr Street should, therefore, go to Cowden Station. 

41 Upon his arrival, Mr Street made contact with members of the emergency services, all of which were, by that time, at 

Cowden. He was told that officers from the services were at the scene of the accident so he decided to go there. Although, as 

the senior railwayman on site Mr Street had assumed the position of Railway Incident Officer, he did not make any 

arrangements to leave a message at the station as to his movements; he wished first to apprise himself of the situation. At the 

site, he eventually spoke to the commander of the Kent police who said that he was their incident officer. Mr Street advised 

the commander that he was acting in the same capacity for the railway, identified himself and informed him of the 

arrangements that were being made, and also that engineers and other specialists were being called to carry out investigations 

at the site. He made only a cursory examination of the scene and did not draw any conclusions from his observations, after 

which he returned to Cowden Station.

42 Mr C R C Cljfton, Safety and Standards Manager, Railtrack South, was also an on-call officer that week. He was at home 

when, at 08.56, he was telephoned by Mr Westwood and told of the circumstances of the collision and that the emergency 

services had been called to the scene. After ensuring that arrangements had been made to provide assistance for Mr Webb and 

that the necessary engineers had been called, he left to take over as the Railway Incident Officer on site. This requirement was 

a part of his duties and, although he had no formal training as such, he had attended table- top exercises. Upon his arrival, he 

went directly to the scene of the accident where he made contact with, among others, Mr Street and Mr Hanson. At that time, 

although an incident room had been set up at Cowden Station, it was not properly manned, so he posted Mr Hanson there as 

his representative while he identified himself to the Fire Brigade and BT Police incident officers. As a result of the telephone 

conversation that he had had with Mr J. Westwood from the Signal and Telecommunications Department (S&T), he arranged 

for police officers to guard the sites of signal OD58 and points No.532 at Blackham Junction. At that time, so far as he was 

aware, no representative of the S&T or any of the other technical departments, with the exception of Mr Collins, had arrived 

on site to carry out any investigations but he pointed out that, had anyone gone to Ashurst Station and walked along the line 

from there without reporting to the incident room, he would not have known of their presence.

 As to the post-accident investigations

43 Mr J Collins, the Signal Maintenance Assistant, British Rail lnfrastructure Services (BRIS) Brighton, received a group 

page message at about 09.00 from the lnfrastructure Control advising him of 'Collision at Cowden'. He explained that this 

control, although situated at Croydon, was separate from the Railtrack Control and usually sent such brief messages so that 

any of the recipients who needed to respond could then telephone for details. This Mr Collins did and, on receiving further 

information, telephoned his Signal Maintenance Engineer, Mr V G McLellan, who, after discussing the accident with him, 

asked him to attend on site. He arrived at about 12.00 and, after reporting to and discussing with Mr Clifton the requirement 

for police officers, set off to walk along the line to Points No 532, carrying out a visual inspection as he did so. He was 

accompanied by a colleague from the S&T and two permanent way engineers.

44 When he reached Signal OD58, Mr Collins checked that it was showing a normal Red aspect, basing his opinion upon his 

railway experience of 30 years. In view of the urgent necessity to examine the signal head, although a police officer had not 

arrived, he decided to unlock and open the head and make a visual examination internally, together with a photographic 

record. In his view, his action was acceptable because his three companions would be able to confirm his findings and that he 

had not disturbed any of the interior equipment. All was in order except there was contamination on the insides of both of the 

signal lenses, the red lens seeming to be more affected than the green. Also, the wooden clamp retaining the signal cables did 

not look effective; he did not, however, check this by pulling the cables to see if they were loose. Mr Collins then closed and 

re-locked the signal head case and the group moved on to Points No 532. On their way there, he made visual examinations of 

the lineside apparatus cases but did not find any fault. He also made notes of the details of the apparatus record cards but could 

not recall whether or not he had signed them as examined but believed that he did. At Points No 532 there was evidence that 

they had been run through; the point fittings were bent, a view confirmed by the permanent way engineers with him.

45 On the day following the accident, Mr Collins was a member of the investigating team working under the direction of Mr 

R M Bell. In the presence of a police officer he, with the assistance of colleagues, disconnected and removed the head from 

Signal 0D58 and sent it for examination at the BR Technical Investigation Centre at Crewe.

46 Mr V G McLellan,the Signal Maintenance Engineer, BRIS Brighton, also received the pager message from Infrastructure 

Control. He telephoned the engineer on call, Mr R Adams, but on hearing that he was not familiar with Cowden, asked Mr 

Collins to go to the site and went to Oxted Signal Box himself to set up the site engineers' office there to enable the technical 

staff, including Mr Collins, to keep in touch. Before leaving, he arranged for a fault team from Croydon, which included Mr P 

D Percival, a specialist in SS1 equipment, to go to Oxted Signal Box. There they were to remove the tapes from the data 

recorder and to note the signalling panel indications. Mr McLellan did not instruct Mr Percival to await the attendance of a 

police officer at the signal box and in the event, Mr McLellan was told, the tapes were removed, sealed and only subsequently 

handed to a police officer.

47 On the day following the collision, Mr McLellan visited the site as a member of the investigating team and took particular 

note of Signal OD58. Upon his approach to the signal, he viewed it with the aid of a periscope to raise his eye level to that of a 

train driver and thought that it was 'a good red'. Since the accident, however, he had taken a particular interest in the 

luminosity of signals and had noted that there was a considerablevariation.Inhindsight, hisopinionwas that the signal was ‘a 

reasonable red’ notwithstanding that he was told that, on test, it had an efficiency of 13.6% only; in his view, this figure was 

very questionable. He examined the signal both externally and internally, taking notes as he did so, with a police officer 

present and noted the deposits that Mr Collins had described.

He also checked the alignment of the signal and found it to be pointing slightly low and to the right of the driver of a train 

approaching it.

48 In answer to questions, Mr McLellan explained that signals were subjected to quarterly and annual servicing, the schedules 

for which were laid down in a Railtrack group standard. The quarterly check consisted of external cleaning, includingthe 

lenses, and a visual examinationto ensure that all was secure. Internal examination and cleaning is carried out annually and, in 

addition to internal cleaning, include a functional check. In his opinion, which was also held by other S&T Engineers, the 

internal examination should be implemented more frequently, the last such for Signal 0D58 being in April that year. Mr 

McLellan added that there was a system provided for drivers to report any problems with signal sighting, their reports being 

passed to the S&T organisation for action; so far as he was aware, no such reports about Signal 0D58 had been received.

49 Evidence was made available to me regarding the maintenance of Signal OD58 by TechnicianOfficer (S&T) Mr A Pearce 

of British Railways Infrastructure Services (BRIS) South Central. He explained that he had carried out quarterly services in 

February and July and an annual service in April 1994. Although the actual schedule for a quarterly service did not include 

internal cleaning of the signal he nevertheless did so. Because it is fairly isolated, he had also looked inside the signal on 12 

October 1994 while carrying out other maintenance duties. He said that on this out-of-routine visit he had brushed away a few 

dead flies. On that day he could see the signal from Ashurst Station and considered it to be a good signal. He did not consider 

Signal 0D58 to be particularly prone to contamination by flies. He admitted using an unauthorised spray for the corrosion 

protection of the internal terminals. He was careful not to let this contaminate the back of the lens or the lamp. It should be 

noted that subsequent chemical analysis of the contamination on the back of the lens showed that this was not due to the use 

of the spray.

50 Mr P D Percival, EngineeringAssistant, Signalling Technical Support, BRIS, was present in Oxted Signal Box when the 

data tapes were removed from the SS1 recorder and confirmed that no police officer was present at the time. He sealed the 

tape and in due course, took it to Mr D M Warwick for safe keeping prior to analysis in which he assisted.

51 Mr H Nixon, an assistant in the BR Technical Investigation Centre, Crewe, carried out a functional test and an internal 

examination of the head from Signal 0058. He did not find any fault except looseness of the terminals associated with the 

attachment of the incoming tail cables which, he gathered, had been disturbed when the signal head was disconnected. He was 

unable to comment upon the wooden cable clamp because this had been removed, in order to disconnect the tail cables, and 

tied to the outside of the head. During the testing, the remark was made that the signal 'appeared a bit dim' and, as a 

consequence, it was sent to BR Scientifics to check the light intensity.

52 Mr D A Jack, the leader of the Optics Section of BR Scientifics at Crewe, carried out the optical tests of the signal head. 

Before doing so, he examined it internally and externally and, while there was no corrosion present and the general condition 

was good, there were the dead bodies of a number of insects inside and the internal surfaces of the lenses were contaminated 

with a waxy substance which, on analysis, proved to be fly excrement. When, subsequently,an attempt was made to remove 

the contamination, a substance similar to paint stripper was found to be necessary, a chemical which would not be available to 

signal technicians in the field. The lamp bulbs also showed evidence of fly excrement, as well as a brown discoloration on the 

insides of their glass envelopes. This, Mr Jack explained, was caused by the deposition of tungsten from the filaments and was 

typical of lamps that had been in service for a considerable period. He added that he had not previously seen that level of 

deposit on lamps from the field as they were usually changed due to filament failure as the result of vibration from trains 

transmitted through the track formation.

53 A series of comparative tests on the whole system and on the lamps individually, both before and after cleaning, was 

carried out against a signal obtained from the laboratory store. This was neither a reference standard nor a new signal but only 

a representative one. The lamp fitted to this signal for the tests also was not new but was a 'secondary standard' which had 

been recalibrated every 20 hours of use. It had actually been used for about 10% of its expected life and, for the purpose of the 

testing, was considered to have the light output of a new lamp. In Mr Jack's view, the use of this particular signal and this 

particular lamp was justified as Signal 0D58 was to be compared with a normal signal and not with a particular standard. In 

the event, he found that the luminosity of the red aspect of Signal 0D58 to be only 13.6% of that of his 'reference'. He was also 

of the opinion that, in the misty conditions obtaining at the time of the collision, the driver of the Up train would have had 

only about 1 second in which to see the signal. He based this opinion upon a table, which he produced, showing the calculated 

reduction in daylight visual range of the actual signal head from Signal OD58 due to the attenuation caused by increasing 

densities of fog.

54 Mr D G Marriott, Testing and Commissioning Engineer, Railtrack Major Projects Division, was called to the site on the 

day of the accident. There he met Mr R M Bell, his immediate superior, who appointed him as the investigating officer for the 

incident. Together with Mr Bell and accompanied by a police officer and Mr Short of HM Railway Inspectorate, he went to 

examine Points No 532, Signal OD58, and Signal OD58R before carrying out a functional test of the system. He confirmed 

the evidence of other witnesses regarding the points and signals but thought that Signal 0D58 was 'a little dim', but he pointed 

out that he viewed the signal from ground level and not from that of a driver's eye.

55 Mr Marriott, after having decided upon and noting his plan for the functional test, carried this out before conducting any 

detailed examination of the equipment involved. He preferred to do this so that nothing would be disturbed that might affect 

the result of his tests. Each action that he took was recorded by the SS1 equipment in Oxted Signal Box and printed out at the 

technicians' terminal there. He also noted the signal controls and called each one out to Mr Bell, who checked them against the 

control tables. Nothing was found amiss with the interlocking and all the controls associated with Signal 0 0 5 8 and Points No 

532 were in order. The only item that seemed to him to be a little unusual was that there appeared to be two extraneous wires 

in the SS1 cubicle which, he was told, had been installed at the time that the Uckfield line was commissioned. On making 

subsequent inquiries, he found that the wires could be used to examine the system from within Oxted Signal Box without 

having to disconnect equipment elsewhere; he understood that the wires had been added to the diagrams.

56 Although at that stage he did not know where the Down train was when the Up train passed Signal OD58, Mr Marriott 

decided to simulate an Up train passing the signal after the route for a Down train had been set. When he did this, he was 

interested to note that the occupation of track-circuit DN, the overlap for Signal OD58, did not replace to Danger Signal 

OD55, the entry signal for the single line. T o do this, the occupation of track-circuit LF was necessary and he also noted that 

the train describer's indication of a Down train then stepped forward to Signal 0 0 5 9 ; this arrangement was, he found, 

entirely in accordance with the control tables. The use of track-circuit LF as the trigger for stepping forward the train 

description did not surprise him, but he agreed that it would have been equally logical to use track-circuit BL for this purpose. 

The correct functioning of the trackside AWS equipment was tested. That associated with Signal 0D58 was entirely in order 

but that at Signal OD58R had a slightly loose terminal, the effect of which could have been a right-side failure; in other words 

the indicator in the cab of a train would have sounded a horn and not a bell when the signal was green. The horn would also 

have sounded for a yellow signal, the aspect of signal OD58R at the time the Up train passed it.

57 Mr Marriott was also present when the alleged incident of a prolonged blackout of Signal 0D58 occurred in January 1990. 

He was testing following a run-through of Points No 532 when a train driver reported the loss of the signal aspect despite the 

panel showing it still to be green. Interrogation by the technician’s terminal showed that a lamp filament failure had occurred 

lasting 4 or 5 seconds, this being the time lapse between the reports of it being off and then on again which was probably 

longer than the actual occurrence on the ground. The driver had subsequently reported by telephone that the green aspect had 

come on again. He later conducted a test on another signal at Oxted which showed that the maximum length of blackout 

during what he discovered to be the power disable test (PDT) was between 1 and 1.5 seconds. Mr L H Page, Signal Engineer, 

Railtrack South, had been the Maintenance Engineer at the time of this incident. He explained that the current record of this 

incident had not been made contemporaneously and that it was in error in recording the cause as being a power disable test. 

The precise happening was never really established, but the whole circumstance had been rendered irrelevant to the accident 

on 15th October1994 because both the trackside functional module and the signal head had been removed in 1990 for testing 

and had been replaced by fresh equipment.

58 The analysis of the SS1 data tape removed from Oxted Signal Box by Mr Percival was explained by Mr D

Warwick, Signalling Strategy Engineer, Railtrack South. He confirmed that interpretation of the recordings from the tape only 

gave the time stamp to within the minute in which the message occurred and that there is a possibility that from time to time 

messages are recorded slightly out of order. This tended to occur with fault alarm messages and route calling messages which 

are generated in a different part of the SSI. In this particular instance it was possible to see the actual event, which caused the 

fault alarm being shown, some two or three messages earlier. He also drew attention to the series of messages which showed 

that a PDT had occurred at 07.22 and that no such messages had occurred 1 hour later. He explained that a PDT would occur 1 

hour after a previous one and only if there was a change of output state. Failing a change of output state, a PDT would occur 5 

hours after the previous one.

59 Mr Warwick described how he, and others, had plotted, from the information on the tape, the movements of trains and the 

states of signals and track- circuit indications over a time-band of 07.00 to 09.00. This time-band captured the movement of 

the first two Up and Down trains on the branch on the day of the accident, the accident itself and afterwards to see if anything 

significant occurred. He detailed the actual movement of the two trains and in particular how and when the routes were set, the 

attempt by the motor itself of Points No 532 to restore normal detection and of Signalman Webb's attempt to do so using the 

individual point switch. He was confident that the order of the messages from the same module was the right order. 

Many of the crucial ones came from the same module. Hence allowing for the time correction between the tape record and the 

signal box clock, the critical alarm would have sounded at between 08.24 and 08.25 signal box time. He confirmed that the 

output to the AWS electro- magnet was shown separately from that to the signal lamp and that, in this instance, no failure had 

occurred at Signal OD58. He also said that, if the electro-magnet was being fed (ie because the signal was green) at the time 

of a PDT the feed would be cut, but there was just a possibility that a train driver would hear a horn and not a bell with a green 

signal. It could never happen the other way round. Even when a PDT occurred and the red lamp went out, the permanent 

magnet of the AWS inductor would not be affected and a horn would be sounded in the cab.

60 The trackside functional modules controlling the operation of Signals 0 0 5 8 and OD58R were sent to the Technical 

lnvestigation Centre, Crewe, where they were examined by Mr ACross, an Assistant Technical lnvestigation Engineer. He 

described the detail of these tests and how the values found during the tests which differed from the precise requirements of 

the manufacturers’ specifications were not significant in terms of their operation in the field. He had also conducted the tests to 

confirm that PDTs occurred at the specified intervals of 1 and 5 hours and the length of time which the red aspect was 

disconnected was between 160 and 180 milliseconds. He was of the opinion that because of the decay time of the light from

a tungsten lamp during an aspect change, this 'black' period would be imperceptible to a driver. He went on to say that the 

software modifications to the TFM in relation to the PDT had arisen because in some locationsthe PDT had occurred in 

connection with aspect changes in other than the main aspect, an asynchronous change.

Hence the PDT had occurred at a time when the main aspect was lit and not when it was changing. Therefore the 'black' period 

may have been perceptible. The arrangements at Signal 0D58 were not such that this asynchronous change could occur. There 

was therefore no reason why the software for the modules driving Signals 0 D 5 8 or 58R had to have the modification.

61 The chairman of a special signal sighting committee convened to examine Signal 0 D 5 8 was Mr R F Cawley, Operations 

Reliability Engineer, Headquarters BRIS. He said that the committee had viewed the signal on the Sunday morning following 

the accident in as near similar conditions, with the exception of the fog, as had occurred the previous day. From the Down side 

at Ashurst Station the signal was clearly visible but he described it as very much an average signal, having a somewhat matt 

appearance unlike the sparkling brightness when the eye is in the beam of the signal. It could clearly be seen at well over the 

minimum distance on a clear day. He checked the alignment of the signal which was slightly misaligned from the normal 

position observations and those of other experienced signal engineers. He tended to agree with comments that it was the 

human eye which was in practice used to observe signals. He was quite clear in his own mind that the aspect of Signal 0D58 

on the morning of the accident was a perfectly good one.

64 Mr Bell went on to describe some of the technicalities of the power disable test. He was satisfied that one had not occurred 

at or about 08.22 that morning. The phenomenon, known colloquially as a 'blinking aspect', also affects the green aspects but 

this was less of a worry to him. He was satisfied that the later software modifications had overcome most of his worries. He 

did not believe that a PDT could have affected the aspect of Signal 0D58 at the time the Up train passed it. He did not believe 

either that a PDT was the proper explanation of the January 1990 incident at the same signal. He agreed with the observation 

that the signal spacing was greater than necessary for the current trains using the line, a condition known as 'over-braking'. He 

also agreed that it was undesirable to have a station stop between the distant and stop signals but disagreed with the suggestion 

that an extra stop signal should be installed at the end of the Up platform at Ashurst. Its value would be very limited, he 

considered. He was, he said, perfectly satisfied that the signalling principles, under which the line had been resignalled, led to 

a safe system on the single line; subsequent changes to the signalling in response to any changes in the principles would 

merely reflect the benefits of those enhancements.

65 Mr H A Podciborski, Contracts Engineer, Railtrack South, was one of two on-call engineers for Railtrack South on the 

day of the accident, nominally covering the South-Eastern sector. He explained that his normal duties covered the supervision 

of permanent way maintenance contractors and that he was an experienced permanent way engineer. He responded to a 

general message from Railtrack Control but when he was at Ashurst Station he was asked to walk from there to Cowden to 

locate someone who was thought to be unaccounted for and who might have wandered down the track. This he did but 

observed the state of the permanent way as he did so. At that stage, about 10.35, the weather was quite clear. As he passed it 

he noted that Signal 0 D 5 8 was a showing a normal red aspect. He found damage to the switch blades and point operating 

mechanism of Points No 532 which, in his view, was recent and consistent with the points having been run through in a 

direction for which they were not set. When he reached Cowden he reported to Mr Clifton, who was the Railtrack Incident 

Officer, and told him what he had found. He said that, apart from the damage to the points, only about four sleepers had 

needed changing and the track fettling as a result of the accident.

66 Mr L F Carroll, a PrincipalTechnical Officer at Selhurst Traction Maintenance Depot of Network South Central, explained 

the arrangements for the examination of Class 205 units when they returned to the depot, which, for the units on the Oxted 

line, was generally every day. The fault repair book would be examined to see if there were any entries for faults requiring 

attention. He considered that if there had been a pre-existing fault, it would have been attended to on the Friday night before 

the accident. If the AWS had been isolated, that too would have been noted and attention given to it. As far as he was 

concerned Set 018, the leading set of the Up train at the time of the collision, would have been in proper working order, as 

would its AWS equipment. He commented that the latter was the 'simplified' equipment which had a 'yodalarm' fitted in the 

cab. This, in his view, gave a quieter sound than the alternative air-horn for indicating passage past a signal at Caution or 

Danger. Other than that, the systems were the same. He described the location of the AWS isolating device and said that the 

air cock handle was linked mechanically to the electrical isolating switch. He confirmed that tripping the miniature circuit-

breaker (MCB) in the cab would have the same effect in that if the brakes were off they would be applied and that if they were 

applied they would not be released. He said that on 21 occasions out of 25 in the last 4 years a set had come into the depot 

with its AWS isolated and yet no fault had been found. He could not comment upon why.

67 Mr Carroll went on to explain that there were several ways of applying the air brakes in an emergency if the driver's brake 

handle failed or jammed, of which releasing the driver's safety device was one. Switching off the engine would not result in an 

immediate brake application, but the compressor would stop, eventually leading to a loss of brake-air pressure. If the DSD 

was released when under power, the train pipe was vented and the brakes applied. Loss of pressure in the train pipe resulted in 

the control governor pressure switch operating which would cut off traction power and revert the engine to idle. He stated that 

the DSD was specified to act, when released, in not more than 3 seconds and that, when called for, 90% of the braking effort 

(representing a brake-cylinder pressure of 45 Ib sq in) would be achieved in between 4 and 4.5 seconds.

68 Mr Carroll said that some cabs were fitted with electric windscreen demisters but all had windscreen wipers but not 

washers on the driver's side of the cab. He was unaware if Unit 018 had demisters. Despite the authorisation being given over 

a year ago to fit cab secure radio to the units, only one of the units operating on the Uckfield branch had been so fitted. Mr 

Carroll knew that this unit was one of the units involved in the accident. He also commented upon the fact that there had been 

corrosion problems both of the body panels and of the ribs. Minor corrosion could be dealt with at Selhurst but more major 

work had to be done elsewhere.

69 The engineer who was responsiblefor auditingthe effectiveness of the maintenance standards achieved by Selhurst Depot 

was Mr M A Moerel, Audit Engineer, Network South Central. He said that he was satisfied with those standards and that units 

sent into service would be in a fit condition. On the day of the accident he was acting as on-call rolling stock engineer. He has 

had experience as a breakdown and recovery supervisor and was also a qualified crane supervisor. He had been a rolling stock 

inspector attending most of the major accidents which have occurred in the former Network South East sector since the 

accident at Clapham. He arrived at Cowden at about 09.55 and began his inspection, accompanied by a police officer, by 

looking at the brakes of the Up train. He recorded brake pressures and piston strokes as he went and the readings of the 

pressure gauges in each of the cabs. He also took photographs. The temperature of the wheels varied from warm to cool. He 

could not recall if the brakes were newly blocked but considered that they were in good condition. His opinion was that the 

train had had a normal service brake application but not an emergency one. None of the brakes had been isolated. He did the 

same for the Down train and again considered that the brake system was in good order. Clearly there had by then been some 

loss of air pressure due to leakages but he said that, from the point of view of his examination, the Down train also had had a 

service brake application. He had also made an examination of the electrical connections. One &way jumper on each train had 

become disconnected. He thought that this would have occurred during the collision because a pre-accident disconnection 

would have resulted in an immediate brake application. The couplings were also in good condition and were all still coupled, 

even those between the leading and second vehicles. He had not found any skid marks on rails.

70 Mr Moerel said that, after some necessary isolations had been made, the rear five vehicles of the Up train had been moved 

back towards Ashurst under their own power. This indicated to him that there was nothing untoward with the braking or 

control systems of that train. He described how as much of the AWS equipment as it was possible to examine on the vehicles 

had been examined before it was removed to Crewe for testing. Similarly, sufficient of the parts of the brake control and DSD 

systems of the leading vehicle of the Up train had been recovered and bench tested. No faults were found. Tests were also 

done to check the time taken to achieve a brake pressure of 45 Iblsq in by moving the brake handle to the emergency position 

and by releasing the DSD. The former appeared to be slightly quicker (at 1.24 seconds and 1.29 seconds for two tests) than the 

latter (at 1.65 seconds and 1.54 seconds for two tests). Similar tests had been conducted on the brake controller of the Down 

train and they showed that it performed within specification.

71 Mr H Nixon of the Technical Investigation Centre at Crewe had also been responsible for the testing of the AWS equipment 

from the leading cab of the Up train. The various components had been tested individually as far as the damage to them would 

allow and some had been tested on a test rig. The testing and examination showed that, with one exception, all the items were 

either functioning correctly or that the damage that was sustained was consistent with damage caused in the accident and did 

not pre-exist. The one item which raised concern was the isolating switch mounted under the solebar by the driver's cab. This 

showed signs of pre-existing contamination and the closed contacts had a high but variable resistance. That resistance could 

be lowered by continuously making and remaking the contacts. Mr Nixon said that the high resistance, which had been 

measured with a portable multi-meter, would have been tantamount to an open circuit. This in turn would have either resulted 

in a brake application if the brakes were not applied, or in the driver not being able to release an already applied brake. 

However, Mr Nixon was of the opinion that once the necessary contact had been made, it was unlikely to have been broken 

during the normal course of events. In other words, once the AWS had been powered up and brakes released it would not have 

been necessary to isolate the AWS. He expected that the AWS had been working correctly at the time of or just before the 


72 The person from British Rail Research who examined the damaged vehicles was the team leader of the 

crash worthiness section, Mr J H Lewis. He had arrived at Cowden at about 15.30 and had begun by looking, from a safe 

position, at the damage to the leading vehicle of the Down train. This appeared to have the top of the front caved in by about 2 

m, but the damage became progressively less the lower it was towards the frame. In contrast, the leading vehicle of the Up 

train had had the first 5.5 m totally demolished. He said: 'In my experience I do not think that I have ever seen a vehicle quite 

so badly damaged in terms of the amount of bending and twisting of the metal that forms the underframe of the vehicle. The 

superstructure of the vehicle had been completely wiped off as it had been overridden by the Uckfield-boundtrain. There was 

virtually nothing left above floor level at all and the roof structure had been torn off completely and was straddling the two 

vehicles. The front bogie had come off and the rear bogie was still attached but derailed. Essentially all that was left was the 

underframe and the superstructure was just a pile of wreckage'. The second vehicle of the Up train had sustained crushing 

damage to the front half up to 1 m but the remainder of that vehicle and the other vehicles in both trains were essentially intact 

with no discernible damage at all. He had not examined the interiors of the vehicles and was unable to comment on the 

damage, if any, to the fittings, seats etc on the remainder of the vehicles.

73 In comparing the damage to that which occurred in the accidents at Clapham Junction and at Cannon Street, Mr Lewis 

drew attention to the fact that, whereas at Cowden and Clapham the vehicles were BR standard Mark I structures and at 

Cannon Street they were not Mark Is but of similar construction, the coupling arrangements were very different. Those at 

Cowden and Clapham were buckeye throughout, but at Cannon Street they were chain link couplings and centre buffers which 

have little resistance to overriding. He also said that, while at both Clapham and Cowden overriding had taken place, the 

extent of the deformation of the underframe at Cowden was significantly greater at the impact point and had absorbed 

considerably more energy in the collision. He accounted for this by saying all underframes varied slightly in their strength due 

to age, manufacturing tolerances and corrosion, although the latter was probably not a factor at Cowden. Once one frame had 

started to buckle in a collision, it kept on doing so rather than sharing the deformation between the two frames. He was unable 

to say whether or not the outcome of a collision was determined by the angle at which the buckeye couplers struck each other. 

He said that the results of the recent crash tests conducted by BR Research at Derby were still being studied to see what 

actually happens from the time of coupler contact through to gross deformation. As part of his considerations following his 

examination of the wreckage, he assessed the likely closing speed at the time of impact to have been between 55 milelh and 

65 milelh (88 kmlh and 104 kmlh).

74 During the course of their inquiries, Detective Chief lnspector V M Miller, British Transport Police, said that the police had 

interviewed a number of train crew who had used on the previous day the units involved in the collision at Cowden. None had 

reported any difficulties in handling these units.

As to the train crew and their training and to the running of the test train

75 Evidence concerning the two train drivers was given by SupervisorA J Gavin,Train Crew Supervisor at Norwood, Network 

South Central TOU and by lnspector A J Bushell, Traction lnspector Network South Central TOU. Mr Gavin said that he had 

been present when both Driver Rees and Driver Barton had booked on duty. He had spoken to them both, Rees for rather 

longer than Barton, and had considered them fit and ready to take duty. He regarded Driver Rees as a very experienced and 

competent driver. He had known Driver Barton for only about 3 years but had no misgivings over his competence. After 

Driver Barton had booked on, slightly late, he had not seen him again and had had no report back that anything was wrong 

with his train. He said that a notice about weather conditions would be posted on the late notice board only if it had been 

received from Control. None had been placed that morning.

76 Mr Gavin told me about the system for issuing the cellnet telephones. The telephones used to be kept at Norwood, but later 

they were issued to the drivers at Oxted. They would normally be handed to them from the station supervisor's office at Oxted, 

but if not they would have to be asked for. He had preferred it, as a driver, when the telephones were kept at Norwood because 

the batteries were kept charged. However, the batteries did not keep their charge very well, and neither the telephones 

themselves nor the area in which they were used gave reliable communications. He regarded their value as being very limited.

77 As a traction inspector, Mr Bushell had not himself taken the controls of a train over the Uckfield line since it was singled 

although he had ridden with drivers over it. However, he knew it well as a driver when it was a double line. He was quite 

satisfied as to the general competence as drivers of both Drivers Rees and Barton. He had spoken to Rees the previous day but 

not Barton, but as far as he knew there was nothing troubling either of them. He had been one of three inspectors who had 

ridden with Driver Barton in the year following his qualifying as a driver. He was satisfied as to his route knowledge and that, 

despite Driver Barton's relative inexperience of the branch line, he thought that, even in the foggy conditions which obtained 

that morning, Driver Barton would not have been lost; there were sufficient landmarks between Ashurst Station and Blackham 

Junction for him to have been aware that he had passed Signal OD58.

78 Mr Bushell confirmed that the rules required that, if the AWS were to be isolated, then in foggy weather the train should be 

driven no faster than 40 milelh (64 kmlh). He also said that fog was not one of the authorised reasons for having a guard in the 

driving cab. He said that these were restricted to those occasions when the DSD had failed or when examination of the line 

had to take place. He also said that he regarded the proper course of action in fog after passing over the AWS magnet for 

Signal 0D58 would be to drive at no more than walking pace until the actual aspect of the signal could be seen. Equally the 

proper course of action to have taken if the signal had been inadvertently overrun would be to stop and protect the train.

79 The train crew supervisor at Selhurst Depot responsible for guards was Supervisor GA Tryon. Mr Tryon had booked both 

men on duty on the morning of 15 October 1994. He had only been at Selhurst for some 7 months but felt that he knew them 

well enough. There was nothing unusual about their demeanour that morning and as far as he was concerned they were both fit 

and competent for the duty that morning. He knew that Guard Brett-Andrews had occasionally changed turns so as to travel 

on the Uckfield line and that, having once been based at Norwood, had tended to maintain his social connections there rather 

than at Selhurst.

Trains Inspector L J Ward of Network South Central TOU based at London, Victoria, was one of those responsible for the 

competence and fitness of Guards Boyd and Brett-Andrews. Mr Ward said that he did not know the latter that well either 

although since the time that he had become a trains inspector he was getting to know him better. He agreed that Guard Brett-

Andrews was a friendly, somewhat extrovert, and talkative character. He had passed his guard's exams on the first attempt and 

whenever he had ridden with him Mr Ward considered him to be safe and competent. He was aware that Guard Brett-Andrews 

had aspirations to be a driver but not why he had failed to become one.

80 It was Mr Ward who had first given Guard Brett- Andrews a verbal warning in mid-1992 for riding in the front cab of a 

train with the driver. He was later found again to have been riding in the front cab and was given a more severe warning, not 

amounting to a formal disciplinary action, by a senior manager. This was thought to have been sufficient but on 8 January 

1994 he was again caught riding in the front cab and was formally disciplined and given a final warning on 4 February 1994. 

He said that it was not correct that trains inspectors had suspicions that, on occasions, Guard Brett-Andrewsactually drove trains.

81 Mr Ward agreed that a propelling move was one occasion when a guard could legitimately be in the leading driver's cab. 

However the manoeuvres of the units on leaving Selhurst and reversing at Norwood on the morning of the accident did not 

involve a propelling move although the reversal at Oxted probably did. Under these circumstances the guard might have a 

need to touch the brake handle but not the master controller. The latter, in any case, would be non-effective as there would be 

no driver's key inserted.

82 Mr M C Bassett, the Traction and Train Crew Principles Manager, Network South Central, gave evidence on a number of 

matters including that of some trial trips to establish the likely running pattern of the Up train involved in the accident. He 

confirmed Mr Bushell's evidence about the occasions upon which the Rule Book authorises the guard to ride in the leading 

cab with the driver. He also agreed about the rule regarding an isolated AWS in foggy weather. In such conditions his method 

of driving after leaving Ashurst Station would have been much as Mr Bushell's. He was adamant that, despite there not being 

at present any formal audit of the effectiveness of driver training, the present method, that of formal traction training followed 

by route learning, was the most effective method. He was satisfied that the annual rides on Network South Central, which 

were twice as frequent as the laid-down number, were sufficient to confirm train drivers' route knowledge. He also confirmed 

that, while both trains had cab heaters, only the Down train had a demister in the leading cab. After listening to the evidence 

given before he was now of the opinion that having a layout whereby a station stop was interposed between distant and stop 

signals but more importantly between the AWS magnet and a stop signal was most undesirable and could well result in the 

driver forgetting the message of the previous signal or AWS.

83 Mr Bassett summarised the results of the test train trips. From a standing start at Ashurst in the Up direction the speed on 

passing Signal 0D58 was 38 milelh, passing over Points No 532 at Blackham Junction it was 42 milelh and at the point where 

it was necessary to shut off power in order to stop at Cowden Station it was 50 milelh. The speed on passing over the collision 

site was 42 milelh. A further run, not stopping at Ashurst, gave a speed at the collision site of 50 milelh. Similarly, in the 

Down direction, starting normally from Cowden the train reached 25 milelh on passing the accident site in a time of 42 

seconds. During these test runs a video film had been taken and from it a number of timings had been calculated. The elapsed 

time between leaving Ashurst Station and receiving the horn indication from the AWS magnet associatedwith Signal 0D58 

was 1 minute 6 seconds and a further 12 seconds elapsed before the signal itself was passed. It took 1 minute 50 seconds after 

leaving Ashurst to pass over Points No 532 and then a further 2 minutes 2 seconds to reach the site of the collision. While 

most of these timings could reasonably be valid for the actual Up train involved in the accident, they should not be taken as 

exactly what had happened on the day. As to the resignalling of the line

84 Mr J D Child, a retired senior engineering assistant in the Southern Regional Signal Engineer's department, asked to give 

evidence to the Inquiry. He said that between January and August 1989 he had been the person in charge of testing the 

resignalling of the Uckfield line and had expressed his concerns that no signal guarding the entry to the loops had been 

provided as was later required by Standard Signalling Principle (SSP) 57. He regarded this SSP as codifying a long- held, 

unwritten, rule. He was also concerned at the time at the configuration of the SS1 because, apparently if one of the duplicated 

data-link systems were disconnected, the panel indications would flash and any green signals would flash red. He did not 

believe that this phenomenon had ever been put right. After he had ceased to be the tester in charge, he had noticed one 

occurrence of a PDT at a signal in Oxted which he reported and was told by the signalling contractor that it was a known 

matter. The dark period he estimated as being about one third of a second, which agreed with the

160 to 180 milliseconds quoted in previous evidence. He also explained that he was concerned at the consequences resulting 

from a train passing either Signal 0D55 at Hever or Signal 0D58 at Ashurst at Danger and considered that a form of ‘train 

running away’ alarm should be fitted in the signal box.

85 Mr F P Wiltshire, Standards Manager (Signalling and T elecommunications) Railtrack, explained the role of standard 

signalling principles and said that there were no specific ones governing single lines. With modern track-circuited signalling, 

the older forms of single-line signalling using a tangible authority were no longer necessary, the rules governing the clearance 

of signals on bidirectionally signalled lines being the same as those with a unidirectionalflow. SSPs were designed to 

rationalise the signalling practices of the pre- nationalised main line companies in meeting the Railway Construction and 

Operation Requirements of the Department of Transport.

86 He went on to detail the SSPs which were applicable at the time the resignalling of the Uckfield line was designed. While 

SSP57 had been formally published after that time it was then under discussion. One of the reasons for its introduction was the 

particular circumstances of the Uckfield line. Nevertheless a positive decision had been taken at the time not to require its 

provisions to be retrospectively implemented on the Uckfield line. SSP43 governs the requirements for fitting AWS inductors 

to signals. It does not require them to be fitted to 2-aspect stop signals, merely to distant signals, a hangover from semaphore 

signalling practice. However the decision was taken to provide them at all signals on the Uckfield line. SSP34 was also 

applicable. This SSP governs the spacing of the signals in terms of the standardised braking performance of trains. He agreed 

that, in designing the signal spacing for 85 milelh running, the signals were unnecessarily far apart for a line speed of 70 

milelh. In practicethey have been installed with just under 9% over-braking for 85 milelh, well within acceptable limits. He 

did not accept that it was now a practical proposition to reposition the signals for 70 milelh running in view of the possibility 

that during the life of the signalling the line speed could be raised.

87 Mr Wiltshire then told me of the effects of SSP78 which governs additional precautionsto be taken at particularly risky 

platform starting signals. Signal 0D58 does not fall within the ambit of that SSP but it was considered that additional 

precautions were advisable at Signal 0D55 at Hever. Accordingly an additional AWS magnet was placed so that a train 

overrunning the signal at Danger would receive an additional audible warning. He went on to consider the practicability of the 

other possible measures listed in SSP78. He accepted that trap points, while not being a universal panacea, would be more 

easily installed on the Uckfield line than elsewhere. However his view was that any such installation should depend upon a 

proper risk study. A general layout risk assessment method was currently being developed which would encompass the 

circumstances of the Uckfield branch, which SSP78 did not, and which would provide a methodology for determining what 

extra measures, if any, should be taken on lines like the Uckfield line. The development of the method was due to be completed in June 1995. Mr Wiltshire also considered the effect of automatic train protection on signalling principles. He felt 

that in addition to requiring one or more principles purely on ATP itself it would probably be necessary to revise many of the 

existing SSPs with which it may interact.

88 Regarding A TP itself, Mr Wiltshire explained that part of the problem facing the railways as a whole was that probably 

any system which might eventually be selected would have to be compatible with the existing line-side signalling. Any 

attempt to overlay the existing system with a different signalling system with built-in ATP would be likely to prove more 

complex and less cost-effective than installing a revised system from scratch. He was of the opinion that the accident at 

Cowden would have been completely prevented if ATP had been installed. Nevertheless his view of the signalling of the line 

was that it was safe and sufficient for the number of trains using it and that in this respect he disagreed with Mr Child.

89 Mr D H Burton, Director, Product Quality South and East Passenger Train Group of British Railways, explained that he 

was also the Deputy to the General Manager of the passenger group but, at the time the remodelling of the Uckfield branch 

had been under consideration in 1986, he had been the relevant passenger business manager. He said that because of the 

condition of the line at the time, some action had to be taken; it was not possible, on safety grounds to 'do nothing'. If nothing 

had been done, the line would have had to have been closed. Hence a number of alternative schemes were considered on a 

purely commercial and railway operational basis. No risk assessment of safety factors had been undertaken. He pointed out 

that the decision pre-dated the accident at Clapham and that the methodology for undertaking such risk assessments now had 

not been available then. After the initial authorisationthere had been a number of revisions both in the scope of the scheme and 

as a result of fluctuating costs. Each agreed change had resulted in a betterment of the net present value (NPV); a commercial-

led, not safety-led response. Neither the question of radio communication nor a risk assessment in the light of the 

recommendations of the inquiry into the Clapham accident entered into the equation. By the time Sir Anthony Hidden had 

reported, the scheme was substantially complete.

As to the provision of radio

90 Mr C Kessell, Director of Engineering, British Rail Telecommunications,explainedthetechnicalitiesof both the cab secure 

radio and National Radio Network systems. He said that CSR was specifically designed to provide secure communication 

between the signal box and a driver, whereas the NRN was a general purpose radio telephone network. All messages on the 

CSR system were recorded and the train driver received calls on a loud-speaker in the cab if they were voice messages or on a 

display if they were data transmissions. The NRN system used a telephone handset. The planned coverage over the country 

was 98% for the NRN; it had not yet quite been achieved. Reception was doubtful in difficult areas such as tunnels. Because 

of its nature the coverage for CSR on the lines so fitted had to be 100%. In order to prevent nuisance calls to traction units 

fitted with NRN they would only receive calls transmitted from a special 'Sitronix' telephone. These telephones would be fitted 

in principal signal boxes or train control offices. Mr Kessell said that NRN was available in the Cowden area, but its reception 

quality was doubtful and no trains had been fitted to receive it.

91 Mr Kessell described the results of some tests which had been carried out to determine the likely response times to an 

emergency message sent out on either of the two systems compared with the likely time of just over 2 minutes taken for the 

Up train to travel the distance from Points No 532 to the point of collision. He considered that using CSR the accident could 

have been averted, because by sending individual messages to each train, the first would have been contacted by the 

signalman and would have stopped in 80 seconds and the second in 105 seconds. If a general alarm had been sent out, and 

allowing the same reaction times, he calculated that both trains would have stopped in an elapsed time of 107 seconds. He said 

the extra time taken for the general alarm was caused by having to send the message out in three separate lumps so as to avoid 

CO-channel interference at the base station. Using the same criteria for response times, the same exercise was carried out 

using NRN. In the first case, the signalman had to contact the train control office by ordinary telephone, explain the situation 

and the controller then had to send a general broadcast which everyone would hear. The estimated time taken to stop the trains 

would be not less than 155 seconds, that is assuming the train drivers actually heard and acted on the message. If there had 

been a Sitronix telephone in the signal box and the telephone numbers of the relevant driving cabs were known to the 

signalman, the time taken to stop the first train would have been 100 seconds and the second 170 seconds. It would be highly 

unlikely that in general signalmen using NRN would know the relevant telephone numbers to call because there was no 

formalised system of linking the numbers to the train descriptions whereas this was done automatically with CSR. His 

conclusion was that using NRN it would have been most unlikely that the collision couldhavebeenaverted.

92 The coverage of CSR already extended on the lines of Network South Central as far south as Sanderstead. Mr Kessell said 

that it would take not less than 6 months from the date of being given a contract to install the necessary transmitters using an 

extension of the existing system. If it were a completely new system it would take at least a year. Because the line to Uckfield 

involved partly an extension and partly a new system, the likely time would be somewhere between the two to achieve CSR 

coverage off the line. He said that he was not aware that Railtrack had received a letter from Network South Central dated

December 1994 requesting the provision of CSR on the Uckfield line.

93 The business background to the development and implementationof a system of radio communication on all traction units 

was described in detail by Mr J G Nelson, Group Managing Director of the South and East Passenger Train Group of British 

Railways. It was decided in response to Sir Anthony Hidden's Recommendation43that in the Network South East sector, which 

included the Hurst Green to Uckfield line, the preferred system was CSR. In July 1989 the investment proposal was approved. 

At that time, approval was also given for the purchase of the necessary equipment for installation in the trains, but it had been 

necessary to improve the cost estimates for the infrastructure work. The target completion date was 1995.The fitting of the cab 

radios began in September l990 and some infrastructure equipment had been authorised for purchase in March 1991.However, in 

November 1991,a review of radio projects was required by British Railways Board, three schemes for CSR in connection with 

Driver Only Operation having by then been authorised for implementation. These did not include authorisation for CSR on the 

two lines south of Hurst Green which under the original scheme would have been implemented in October 1992.That it did not 

happen in October 1992 was because the whole thing had been overtaken by what Mr Nelson described as a 'funding change of 

seismic proportions'. This resulted in a moratorium on investment in 1991/92so that BRB would meet its external finance limit.

94 Mr Nelson explained that under the new structure of the railways the mechanism for paying for new investment has 

changed. In the case of radio the TOU would pay for it by an increased track-access charge, leaving Railtrackthe task of 

finding the capital investment. In the particular case of the Uckfield line it had already been indicated that the TOU, in this 

case Network South Central, had agreed to pay the necessary increased track-access charge for the provision of CSR. Mr 

Nelson said that he had been given a plan for the fitment of cab radios to Class 205 units which showed that this was due for 

completion by February 1995.

95 Mr Nelson categorised his priorities for funding as firstly the completion of contracts, such as for Networker trains, which 

had already been entered into. Secondly came essential infrastructure renewals. The third category contained other priority 

renewals such as power-supply schemes which not only had serious performance implications if they failed, but also had 

potential safety risks. The fourth was the strategic safety schemes which included cab radio. He pointed out that categories 

one to three contained those schemes which were essential to maintain existing safety standards, whereas the fourth was to 

enhance them. The fifth and lowest category was the provision of new rolling stock.

As to rolling stock

96 Between them, Mr B L Clementson, Engineering Director, Porterbrook Leasing Company and Mr G C Eccles, Director 

Network South Central, TOU, explained how rolling stock, in particular the Class 205 units, were provided, equipped and 

maintained. Porterbrook Leasing is one of three wholly-ownedcompanies of British Railways which between them hold all the 

passenger rolling stock previously owned by British Railways. As owners of all the Class 205 units, Mr Clementson said, 

Porterbrook Leasing had no plans to refurbish them. They were currently in discussion with Network South Central over the 

signing of a lease for the vehicles for years which began on 1 April 1994. Mr Eccles said that if the lease were signed, which 

at the time he was speaking it had not been, then unless he bought out the contract he would be unable to stop using the Class 

205 units and find other replacements.

97 If the lease were signed, Mr Clementson said that the units would be put into a fit state to last the 8years, but no

enhancements, other than the already-agreed fitting of cab radios, would be provided. The actual ownership of the radio 

equipment had yet to be decided. He also said that one of the objectives of the rolling stock leasing companies was to provide 

the opportunity for introducing new rolling stock and therefore he would hope to offer it to the TOU at the end of 8years or, 

subject to discussion, sooner. He thought that cascades of existing rolling stock from TOU to TOU were going to be difficult 

to manage. The question of whether Network South Central would have new or second-hand replacements for the Class 205 

units would depend not only on their availability but also the price the TOU was preparedto pay. Porterbrook did not yet have 

a complete picture of all the rolling stock which was likely to become surplus to requirements in the next year or two, 

particularly in diesel-powered units, but Mr Clementson thought that there would probably be quite a number of electric units 

which could be offered were the line to be electrified.

98 Mr Eccles agreed that he would like to hire something better than the Class 205, if it could conveniently be arranged. The 

question of financing them was not a simple one to answer, but he expected there to be a commercial formula which would tell 

him the optimum price for which to hire trains for the Uckfield line. He agreed that he would find it difficult to shop for trains 

on which any safety enhancements were either, or could be, fitted if such enhancements were recommended as a result of the 

Inquiry. In the same way Mr Clements on said that he would need access to funds to order new trains and these were unlikely 

to become available until the rolling stock leasing companies were sold into the private sector in October 1995. That would 

also be true, if it were possible in engineering terms and this would have to be investigated, should it prove to be economically 

sound to install any recommended safety enhancements on the Class 205 units or other older rolling stock.

As to the provision of on train monitors and recorders

99 Mr J G Nelson explained the position over fitting on train monitors and recorders to rolling stock. Sir Anthony Hidden had 

endorsed, in his Recommendation 40, the fitting of OTMR and said that it should receive higher priority. Mr Nelson 

considered that the programme of fitting them had been accelerated and it was still the railway's policy that this should 

continue but, as always, there was the question of funding. He confirmed that all new build fleets are fitted and approximately 

15O/0 of the total current fleet had been retrospectively fitted. The position in the future would depend on the rolling stock 

leasing companies.

As to the future provision of safety enhancements

100 Mr D E Rayner, Director Safety and Standards, Railtrack, said that, following the restructuring of the railways on 1 April 

1994, Railtrack had been asked to sponsor the project for the provision of automatic train protection. This project, which had 

been a railway-wide one, would continue on a joint basis with British Railways. He explained that in any system of ATP the 

key features would be to prevent a signal being passed at Danger, to prevent a buffer-stop from being hit and to prevent over-

speeding in the circumstances which normally occur. He identified three different categories of ATP; firstly that epitomised by 

the current trials which was designed to provide the three key features in the present infrastructure and rolling stock fleet. He 

called this BR-ATP. His second category encompassed new technology where A TP was built into a new signalling system. He 

instanced the possibility of installing transmission-basedsignalling on the West Coast Main Line (WCML) which would 

include ATP as part of an automatic train control (ATC) package. The third category was at the other end of the scale. ATP 

systems of this type would not be network-wide but would be purpose-built for particular circumstances. They would not 

necessarily include all three of the key features he had earlier identified; that would arise because a feature might not be 

appropriate or because it might be judged too complicated to embrace all three.

101 Mr Rayner explained that no decision had been taken on the strategy of implementationof any of the categories of A TP 

he had described. Were funds to be available, the strategy would depend largely on the risk assessments made as a result of the 

study referred to by Mr Wiltshire and on the actual technology to be used. He considered that Railtrack would be negligent if 

it did not look at technological innovations, such as that being considered for the WCML, but that strategically it would have 

to consider the piecemeal solution. He declined to estimate how long an innovative scheme would take to implement.

102 As part of the piecemeal approach, Mr Rayner described the joint Railtrack and British Railways Board Signals Passed at 

Danger Reduction and Mitigation (SP ADRAM) Project. Reduction meant prevention of SPAD incidents and mitigation 

implied that if a SP AD did occur, then its consequences would be minimised. The starting point had to be a proper analysis of 

the SPAD statistics. From these SPADRAM had been developed in a number of strands beginning with a value engineering 

exercise to see if the BR-ATP system could be reduced in cost without losing too many of its benefits. He could not say how 

long such a consideration would take or whether the objectives of the reduced-cost ATP system would be the same as the full-

cost one. Enhanced AWS was also being considered, but Mr Rayner did not accept the view that since this had effectively 

been rejected in the report on the Clapham accident it was not worth pursuing. He described other mitigating devices both for 

use in the driving cabs and for installation on the infrastructure. In summary he expressed a personal view that Railtrack 

would be prepared to take a positive stance to see that protection against SPADs is enhanced, but that it should not be 

regardless of cost. He thought the piecemeal approach was the right one, but was unable to put a time-scale on its fulfilment. 

He explained in some detail the basis of the report on ATP made in March 1994 to the Secretary of State for Transport by the 

British Railways Board before the railways were restructured. He said on a basis of reasonable practicability, and this included 

financial considerations, the report concluded that BR-ATP should not be installed. His view was that all safety improvements 

on the railway should represent value for money and that in all such matters it should be an industry-wide, not just a Railtrack, 


103 The views of the British Railways Board (BRB) on the provision of ATP were put by Mr T P Worrall, Director of Safety. 

There was no essential difference in this matter between BRB and Railtrack. Clearly there had been developments since the 

joint board meeting in October, but, he said, British Railways had not abandoned the concept of A TP . Railtrack was aware of 

BRB's view, but BRB would endorse caution in engaging in an unreserved commitment to any standard without considering 

the affordability elements. In their response to Railtrack following the joint meeting BRB made these points. They appreciated 

the potential of ATC (as exemplified by the WCML proposals) which would need to be effective, affordable and acceptable to 

the train operating companies. Until such time as ATC was more advanced they would wish to see a continued appraisal of A 

TP in all new significant investment projects for trains and signalling, together with ATC as an alternative where appropriate. 

Any assessment of ATP should be on the basis of an integrated reinvestment and renewal project, not just as an overlay on 

existing systems. They considered that the development of ATC was a long- term project and therefore the potential of 

existing ATP capability, including possible cost improvements, should still be explored. BRB supported the SPADRAM 

initiatives. He emphasised that, at this stage, Railtrack had still to consider, formally, BRB's input following the joint meeting.

104 Mr Worrall was of the opinion that, because a line- specific ATP or other piecemeal measure would be subject to a 

rigorous risk assessment if a proposal was affordable, then it would be acceptable to the train operating companies. That was 

true also of enhanced AWS which he felt was worth reconsidering in the light of new technology which had arisen since the 

Clapham report. He emphasised the word affordable because there was a danger of being priced out of the market in that it 

would be possible to have very safe trains but the fares would be so expensive nobody could afford to travel on them.

105 On particular issues Mr Worrall said that he would like to see the implementation of the provision of radio as quickly as 

possible but it depended upon Railtrack's resources. He was not aware of any plans to extend the coverage of CSR other than 

to the lines already agreed. It did not surprise him that doubt had been placed upon the provision of OTMRs on Class 205 

units. While he was in favour of the policy of fitting OTMRs throughout the fleet which had an appreciable residual life, he 

was well aware of the complexities and difficulties which would arise on trying to fit such old units as Class 205. He 

considered that it was up to the TOUs and the rolling stock leasing companies jointly to decide upon the replacement of 

rolling stock and that it was not a matter for him. He did not believe that the involvement of private interests would lead to an 

acceptance by the industry of lower safety standards. He agreed that driver distraction was a recognisable category of 

circumstance in which either a disregard or misjudgement SP AD might take place and that the presence of others in the 

driving cab was a recognisable cause of totally eliminating that particular cause of SPADs because there were some people 

who by virtue of their duty had to travel in cabs. It was a question of being as tight as possible in controlling the authority to 

ride in a cab.  


The issues

106 There are a number of issues which have to be considered when assessing both the direct cause and the immediate 

consequences of the accident. They are addressed individually in the following paragraphs. The issues are:

a, Was the accident caused by a signal being passed at Danger?

b, Was there any malfunction of any equipment either of the signalling or on the trains?

c, What was the actual visibility of Signal OD58?

d, Were there adequate means of communication available?

e, Did the design of the rolling stock have a bearing on the cause or outcome?

f, Did the procedures for the call-out of the emergency services and railway officials work properly?

g, Was any relevant evidence lost because of inadequate training or investigative procedures?

h, Did the track layout and its signalling conform to current standards?

i, Who was driving the Up train?

Was Signal 0D58 passed at Danger?

107 The printout of the tape from the SS1 recorder was analysed and the actions of the signalman, the running of the two 

trains and the reported condition of the signalling equipment, eg AWS magnet at Signal 0D58 de-energised, red aspect lit etc 

determined. Not only did the SS1 tape show that Points No 532 were lying normal, but also physical examination of them 

after the accident showed that they had been run through in the reverse direction. Hence Signalman Webb's evidence that, at 

the time Driver Barton's train passed Signal OD58, the route was set for the Down and not the Up train is corroborated. At that 

time, the reported aspect of that signal was that it was red. The trackside functional module was tested and found to be 

working correctly. Evidence was given of an earlier event at the sane signal where it was alleged that the signal had failed to 

show any aspect at all for between 20 and 25 seconds. A later, non-contemporaneous commentary attributed this to a power 

disable test; PDTs are the self-diagnostic checks to see if the module is working correctly. That commentary cannot be relied 

upon. Besides which both the signal head and the module had been changed after the earlier occurrence, as part of the testing, 

and what happened then has little or no relevance to the state of the equipment at Signal 0 0 5 8 on 15 October 1994. The PDT 

causes a 'blink' of about 180 milliseconds;that is no aspect at all is shown for that length of time. Such tests occur at a change 

of output state not less than 1 hour after the previous PDT or after 5 hours if no PDT has occurred within that time. These tests 

are not explicitly recorded on the SS1 data tape but can normally, but not always, be inferred. In this instance a PDT was 

shown as having occurred at 07.22. The next one was therefore due at the next change of output state after 08.22. No such 

change of state occurred between then and the time of the accident. The TFM was specifically tested to confirm that the PDT 

intervals (1 hour and 5 hours) were correct. After the accident, the red aspect of Signal 0D58 was seen to be alight. Hence it 

can be inferred that, at the time the Up train passed it, Signal 0D58 was showing red.

Was there any equipment malfunction?

108 Extensive testing was carried out on the various components of the signalling system. Couple this with the analysis of the 

SS1 data and I conclude that there was no malfunction of the signalling equipment such that a wrong side failure occurred 

and the driver of the Up train was presented with a green rather than a red signal aspect. I therefore conclude that the train 

passed Signal 0D58 at Danger. However there is evidence to show that the brightness of the aspect may not have been as it 

should and I discuss this later.

109 The individual parts of the AWS equipment from the leading end of Unit 205018, the driving trailer end of the Up train, 

were examined and tested in the laboratory.This testing showed that, with one exception, all were in working order or that the 

damage was almost certainly sustained in the accident. The exception was the AWS isolating switch. Isolation of the AWS has 

to be effected on both the electrical and air parts of the system. The isolating cock (for the air system) is linked mechanicallyto 

the isolating switch (for the electrical system) and both are mounted beneath the solebar on the driver's side of the cab. 

Isolation is effected by turning the handle of the isolating cock. The contacts of the switch were found to be contaminated and 

their resistance varied considerably during testing; a high resistance being tantamount to open circuit, a condition making it 

impossible to release the brakes.

Was the AWS isolated?

110 If the isolating switch was in such a condition that the AWS equipment had to be isolated at that end of the train, that fact 

would have been noticed before the train eft Selhurst Depot that morning. The driver and the guard would have prepared the 

train and the train would have had to have been driven from each end. The AWS equipment would have been required to be 

operational and in use but, because there are no AWS track magnets associated with the movement in the depot, there was no 

means of checking whether the whole of the equipment was functional. The inference must be at the time the train left the 

depot the relevant AWS was not isolated due to a previous malfunction. If it had been, the driver was required, by the terms of 

the Appendix to the Rule Book, to report it. No such report was made. If the AWS had failed at Uckfield or at any point on the 

last journey towards Oxted, there were ample telephones available to the driver to report that he had had to isolate the AWS. 

Again no reports were made and no passenger complained of an overlong stop at an intermediate point or of a lessening of the 

train's speed. Either Driver Barton was reckless in the extreme, not only in controlling the manner in which the train was being 

driven, but also of his observance of the rules, or no failure of the AWS occurred. I believe that it would have been outside his 

character for Driver Barton to have been that reckless. I conclude therefore at the time of the accident the AWS was operational. It is relevant to 

point out that had OTMR been fitted there would have been no doubt whatsoever as to whether or not the AWS was 


Reporting of AWS isolation

111 Appendix 8 to the Brit~shRailways Rule Book, which is still the rule book in force, deals with the AWS and in paragraph 

6 explicitly about its isolation. At 6.1 it states 'A traction unit must not enter service if the AWS is isolated in any driving cab . 

. .' and at 6.3 'If it is necessary to isolate the AWS, the Driver must inform the Signalman at the first convenient opportunity. 

The train must be taken out of service at the first suitable location without causing delay or cancellation . . .' Also, at 6.4, the 

appendix states 'If the AWS has been isolated, speed must not exceed 40 mph during fog or falling snow'. At Selhurst there are 

no test inductors at the depot so that drivers can test whether or not the AWS is working. Thus drivers are not really able to 

comply with the rule at 6.1 which implies that an AWS test should be carried out at each end of a unit before a train enters 

service. Irecommend therefore that Railtrack should ensure that adequate facilities are in place so that the A WS is properly 

tested before a train enters service. I gained the impression that there was a very wide interpretation of when was the first 

convenient opportunity for reporting an in-service failure of the train- borne AWS which required it to be isolated. 

Irecommend therefore that this instruction be stiffened to require that such reports should be made immediately either by radio 

or from the first available telephone. 

What was the actual visibility of Signal OD58?

112 Immediately after the accident, a number of experienced engineers viewed the state of Signal OD58. However, by that 

time the fog had burnt away and their visual impression could not have been anywhere near the same as that of Driver Barton 

or Guard Brett- Andrews. The consensus of opinion was that it was a reasonably good signal, although Mr Cawley did say 

that it lacked the characteristic glow. The alignment of the signal, although not perfect, was neverthelesswell within normal 

expectations. Internal examination of the signal head revealed that the back of the lens and the lamp were both dirty despite 

regular internal cleaning, in excess of that required by the maintenance manual, which was carried out by the S&T technician 


Mr A Pearce. However the latter had admitted using an unauthorised aerosol spray inside the signal head for 

the purpose of waterproofing the terminals.Testing at the Crewe laboratory showed that the contamination on the rear of the 

lens was mostly due to fly excrement and that the lamp was probably near to the end of its life and had significant deposits of 

tungsten on the inside of the envelope (lamp glass). A more-than-ordinarily-powerful cleanser was required to clean the back 

of the lens. The actual light output of the signal head was measured, but, in the absence of a performance standard, this actual 

value was useless. To provide some kind of comparison, a similar signal, taken at random from the laboratory shelves, was 

also tested and showed that, apparently, the light output of the red aspect of the signal head from Ashurst was only 13.6% of 

that of the other signal head.

113 Was this comparison valid or even worthwhile? For sound reasons, during the testing the Ashurst signal was fed with 

signalling mains voltage and the voltage used to drive the lamps derived from the signal's internal transformers. Although 

signal lamps are rated for use at 12 v, they are deliberately underrun at voltages between 10.5 v and 10.9 v. The outputs from 

the transformers lay within this range both for the Ashurst signal and its comparate but were not the same. A similar exercise 

was carried out for the lamps themselves; but this time a laboratory 'standard' lamp was used to compare with the output from 

that from the Ashurst signal. All the lamps were driven at their rated voltage of 12 v. This latter exercise merely told the 

investigators what proportion of the loss of performance was due to the lamp alone. While this is an interesting by-product it 

does not contribute to answering the question of whether the driver could see the signal in the fog.

114 The laboratory considered this question by calculating the ability of the human eye to contrast the colour of a signal 

aspect against the background illuminance of daylight for a range of attenuation due to fog. The daylight visual range was 

calculated for visibilities between 20 km (clear) and 10 m (dense fog). Assuming the density of fog at Ashurst that morning to 

have been such that the visibility was approximately

50 m, the daylight visual range of the degraded- performance red signal was 22 m. The evidence was, however, that the fog 

was patchy but, even if the density gave a visibility as high as 125 m, the daylight visual range would only have risen to 55 m. 

I consider therefore that the driver of the Up train would not have been able to see the red aspect until the cab was between 50 

m and 20 m from Signal OD58. It is not possible, for the reasons given earlier, to estimate at what range a 'normal' signal 

could have been seen because there is no such thing as a defined normal signal.

115 A paper on the design and performance of colour light signals by MS B Perkin, Signalling Equipment Engineer, British 

Rail SIGTECH, Signalling Equipment Group which was presentedto the Inquiry,explained that the design of the signal head 

of Signal 0 0 5 8 was the latest in use on British Railways. Its on-axis beam intensity was probably some four times better than 

that of other designs of colour-light signals. It was MS Perkin's view that, given the diversity of lamps, types, ages and 

conditions, the measured light performance of Signal 0D58 was no worse than would be reasonably expected from a 

significant proportion of the UK railway signal population at any given time. Hence it was perfectly conceivable that, despite 

the actual loss of performance described by Mr Jack, Signal 0D58 could still be regarded by the unscientific, but nevertheless 

experienced, eyes of senior signal engineers on the morning of the accident as a 'good signal'. I therefore believe that the more 

realistic assessment of the performance of Signal 0 D 5 8 at the time it was passed by the Up train is that obtained by using the 

calculated daylight visual ranges of the signal based upon its performance measured in the laboratory.

116 There was corroborative evidence from the analysis of the SS1 tape, the test train trips, and the descriptions by the 

passengers, to show that the likely speed of the train on passing Signal 0 0 5 8 was 38 mileth. This equates to an average speed 

between 16.5 and 16.7 mls over the daylight visual ranges given earlier and sighting times of the order of between 3 and 1 

seconds. Driving at the speed (38 milelh) which it is considered that he did and which, in the light of the prevailing conditions, 

was probably too fast, the driver of the Up train probably had insufficienttime to registerthe aspect of the signal, especially if 

there was the slightest distraction at the crucial moment such as turning to speak to the other person in the cab.

117 From the foregoing it is possible to construct a number of possible scenarios to try and explain why after having made a 

successful, and presumably accurate, stop at Ashurst the driver of the train should drive it so far into the single line without 

authority to do so. There is no doubt in my mind that Signal 0D58 was at Danger and that the AWS electro-magnetwas de- 

energised. Therefore the signal was passed at Danger (a SPAD) and, because of the distance and manner of the overrun this 

SPAD falls into the category of a disregard; but why? Was the driver lost in the fog? This is unlikely, even for an 

inexperienced driver, as the stop at Ashurst without an overshoot or last minute braking shows. Driver Barton could be classed 

as inexperienced; this was only his 60th trip on the Uckfield branch. If Guard Brett-Andrewswas driving he could be classed 

as a very inexperienced driver in the sense of control of a train but he knew the line well and was unlikely to be lost. It was the 

considered opinion of the senior drivers that a properly trained driver, as Driver Barton was, would not have been lost. Was 

the signal aspect missed and the train's AWS isolated? The calculations show that the available sighting time of the signal was 

very short and, if there was no prior warning from the AWS, the possibility of it being missed would be fairly high. I have 

concluded earlier that, on balance, the evidence for the AWS to have been working was slightly more persuasive, but the 

hypothesis that it was not and as a consequence the signal was missed is tenable. But the rules call for a reduction in speed if 

the AWS is isolated and the evidence against the train being driven at reduced speed or of any other of the rules governing 

driver's actions if the AWS was isolated being observed is compelling and hence I must reject the hypothesis. Similarly if the 

signal aspect was out, for example because of the power disable test, and the AWS was legitimately isolated this must also be 

rejected as a theory. It is conceivable but extremely unlikely that the AWS had a wrong side failure after passing Signal 

OD58R and before reaching Signal OD58, again with the aspect being missed.

118 1 have already stated that I do not consider that a power disable test, which would have caused no signal aspect to be 

shown, occurred, but I do consider that the fog was such that the sighting time of a lit signal was very short. To have 

disregardedthe audible warning given by the AWS and not to have reduced speed to give ample warning time is therefore 

inexcusable. A moment's distraction is enough to have caused the driver to have missed seeing the signal aspect but he would 

have had to have ignored two previous audible warnings and distraction from observation of those is less likely. However, the 

stop at Ashurst Station may have wiped out the earlier warning in the driver's memory despite the reminder of the visual 

indicator (the 'sunflower'). Cancellation of the AWS does tend to become an automatic reflex action and in this case there 

would have been no change of the visual indicator as a second reminder. I am inclined to believe therefore that he driver must 

have sub-consciously cancelled the AWS warning and was distracted by the other person in the cab at the crucial moment. To 

have run by the signal in these circumstances is blameworthy but understandable.To have driven on without consciously 

registering the aspect of the signal to a point where he must have realised that the signal had been passed is not only 

inexcusable and blameworthy but also totally irresponsible. In this instance it does not matter who was actually at the controls, 

Driver Barton was in charge of the driving of the train and I conclude therefore that Driver Barton is wholly responsible 

for the accident.

Were there adequate means of communication?

119 Signalman Webb recognised the inevitability of the accident but was powerless to do anything about it because he had no 

direct means of communicating with either train. If cab secure radio had been available there was sufficient time after he had 

become aware of the situation for him to have sent an effective 'stop' message to each train. Had the National Radio Network 

system been available it is very doubtful, because of the way it is engineered, that SignalmanWebb would have had enough 

time to contact both drivers. I consider the matter of radio communications in general later but I must conclude at this 

juncture that had cab secure radio been available this accident could have been prevented.

120 There appears to be more than enough telephones available for use by drivers for them to report if they have had to isolate 

the AWS and I find no fault on this score. However the provision of mobile telephones, which were regarded as a substitute 

for an adequate radio system, was unsatisfactory.Carrying one was not mandatory. There was no proper system for issuing 

them or of recording which trains had which telephone. Their reliability was poor and their battery endurance low. There were 

notorious black spots on the Uckfield branch where mobile telephones became unusable. Because the object of having them 

was said to be to enable drivers to call the signal box there were no adequate arrangements for reciprocal calls. In short, 

despite promises made to various rail users groups, the system fell into disrepute and thence disuse. The similar scheme for 

use on the Waterloo-Exeter line beyond Salisbury has also fallen into disuse for much the same reasons. For speed of 

establishing contact between signal box and train, the mobile telephone system might have been marginally better than the 

National Radio Network, but it suffered from the same drawbacks of the patchy nature of coverage on the Uckfield line. While 

it might have been possible to contact Driver Barton on the Up train, Driver Rees on the Down train, passing through Mark 

Beech Tunnel and into the 'black spot' area around Cowden, would probably not have been able to receive a telephone call. I 

conclude therefore that it is unlikely that the accident would have been prevented entirely by NRN but it might have 

taken place elsewhere between Cowden and Ashurst and with less violence.

What effect did the design of the rolling stock have?

121 The rolling stock involved in the collision was all in Class 205. These DEMU are based on the standard Mark I carriage 

design which has a comparatively light body mounted on an underframe. It has drophead buckeye couplers at the outer ends 

and solid-shank buckeye couplers for the intermediate connections. In this sense it is similar to those trains involved in the 

Clapham accident but has a different coupling arrangement to the trains at Cannon Street. However, all three accidents 

involved one train or part of a train overriding another, the frame of one coach slicing through the bodywork of the other. 

Much of the work of investigation of both previous accidents applied to Cowden, the results of which were entirely 

predictable in terms of loss of survival space. I consider the future of such rolling stock later in this report.

Was the procedure for the notification of an emergency adequate?

122 The first notification of the accident to the emergency services came from a passenger who made a telephone call from a 

neighbouring farmhouse. Guard Boyd of the Down train, who was uninjured but in a state of shock, took some time to 

determine what had happened and return to Cowden Station to use the railway telephone there. Fortunately Mr Hodges, the 

travelling ticket examiner was there, but they took some time to establish the telephone number of Oxted Signal Box. 

However, the Railtrack Control Room, which is also used by the Train Operating Unit, was aware of the imminence of an 

accident from Signalman Webb's earlier call to them about the Up train passing Signal 0D58 at

Danger. Because site access is difficult, the Control Room deliberately held off alerting the emergency services until they had 

had confirmation of the actual location of the collision. Thereafter the notification to all, except the Department of Transport, 

worked adequately. Examination of the relevant pages of the emergency procedures manual showed that that document had 

not entirely kept up with the organisational changes both internallyto the railways or externally to governmental organisations. 

It is imperative that emergency telephone number lists are kept up to date in control rooms and that the relevant telephone 

numbers of control rooms and signal boxes are displayed at every railway lineside or station telephone which has dialling 

facilities. I therefore recommend that Railtrack review what information is displayed at such telephones with a view to 

incorporating all key telephone numbers likely to be required in an emergency and that action be taken to ensure that control 

room manuals contain up-to-date information. 

Was any relevant evidence lost?

123 Although there was some delay in setting up and staffing the incident reporting room at Cowden Station and a not entirely 

satisfactory hand-over procedure between railway officials which led to some examination of the signalling in the absence of a 

police officer, I do not consider that any perishable evidence was lost and I so conclude. The police view was that the 

system worked well. However, I cannot allow to pass unchallenged Mr Collins' observation that it was in order for him to 

examine the inside of Signal 0D58 without police presence because other witnesses were present.

It was not. Equally it was not in order to remove the SS1 data tape in the absence of a police officer. Subsequent events, 

however, showed that there is a need to decide at the scene of the accident what further evidence needs to be collected so that 

laboratory testing at a later date can be properly directed. It turned out for example that the internal condition of the AWS 

isolating switch at the leading end of the Up train gave cause for concern as to whether it would have been necessary to have 

isolated it. The front end damage was such that the instinctive reaction was that it was not possible to determine what the 

position of the switch was. With hindsight, a more deliberate probing of the remains might have assisted the

investigation. Again with hindsight it is possible to say that some of the testing procedures at the various testing laboratories at 

Crewe could be improved. It should have been automatic to take voltage, current and resistance measurements across the 

AWS isolating switch when it was being supplied by the correct operating voltage instead of merely using a multi-meter 

across the terminals. Similarly, a test procedure for the comparison of the output from Signal 0D58 should have involved a 

properly calibrated reference standard instead of a signal head plucked at random from the laboratory shelves. Such a test was 

only necessary because there were no written optical performance standards for signals.

I recommend therefore that a review be made of laboratory procedures to ensure that all testing is subject to rigorous 

protocols and that proper standards are established against which such tests are undertaken.

124 In this accident a full SS1 data recording was available for analysis and this provided vital corroborative evidence as to 

the actions of Signalman Webb, the state of the lineside equipment and the running of the trains. The recording however 

suffered from two major disadvantages. The first is that the time- bands are 1 minute broad. It was therefore not possible to 

determine with an accuracy greater than that when any particular event occurred. Between two events the range therefore is 

from a few milliseconds to almost 2 minutes and this prevents any significant conclusions being drawn for example about the 

speed of the trains. The second disadvantage arises from the fact that the SS1 processor takes nearly 1 second to poll in a fixed 

order all the trackside functional modules to which it is connected. Hence the order in which events occur is absolutely 

accurate for any given TFM, but events reported by different TFMs may have occurred on the ground in a different sequence 

from that shown on the recorder. In this particular instance, this phenomenon was not relevant to the reporting of the aspect of 

Signal OD58, the occupation and clearance of its berth and overlap track-circuits, or the detection of Points No 532 because 

these were reported by one module. It does however affect any analysis of how far apart trains were at any instant and 

calculations of elapsed time do need to be made with due regard to the limits of accuracy provided by the data recorder. One 

other feature is worthy of comment. The clock time of the recorder is not necessarily the same as that in the signal box or of 

Greenwich. In this case there was some 2 minutes difference. In this accident investigation this was not significant because the 

recording could be recalibrated against real time. However I have observed before, in connection with inspections of new and 

altered works, that more and more processor-basedsystems, each with its own clock and display unit, are being installed in 

signal boxes and control rooms. None of these clocks are linked, each shows its own time albeit differing by only a few 

seconds, and with no ready means of accurately synchronising them. I would urge the industry to come to grips with this 

problem as one day it may otherwise seriously hamper accident investigation. Irecommend that all clocks or other devices in a 

signal box which show or record the time are properly synchronised,

Did the layout and signalling conform to current standards?

125 When the line was singled it was resignalled in accordance with the then current Standard Signalling Principle 6 which 

defined the method for signalling at junctions. The ends of a reversibly signalled line (which in this case means the single line 

part between the remaining double track sections) were to be regarded and signalled as a junction if a driver might be misled 

into proceeding at an excessive speed for the route at that location. Therefore, although there is no difference in speed between 

the two possible routes entering the loop at Crowborough in the Down direction, this was signalled as a junction with a 

protecting signal on the single line. This was not the case at Ashurst where there is only one possible route with no reduction 

in speed and, although it was considered, no protecting signal from the single line was provided. Similarly SSP30 was 

applicable. This deals with trapping protection and sets out that the need for the provision of trap points at crossing loops on 

single lines is determined by the conditions under which trains are permitted to enter the loops. Where an adequate overlap 

exists in advance of the loop exit signal, no trap points are required. The illustrations attached to this principle do, however, 

show loop entry signals. Nevertheless,the circumstancesa Ashurst would not have required the provision of trap points and the 

Inspectorate accepted that a loop entry signal was not necessary. However, in excess of the requirements of SSPs, AWS was 

installed at all signals.

126 Since the time that the Uckfield branch was resignalled, a further SSP, No 57, has been issued which requires the 

provision of a signal not more than 800 m in rear of a set of facing points. There are some exceptions, but they are not 

applicable in this case. While this SSP would therefore have imposed a possibly implied but not stated requirement to have a 

loop entry signal, it is doubtful if the provision of such a signal would have had any bearing on the circumstances of this 

accident. The probable effect would have been to add an extra stop signal at Ashurst Junction preceded by a distant signal. 

That stop signal, under conventional arrangements, would have been a 3-aspect signal and would have replaced Signal 

OD58R. It would have showed caution, but the distance to Signal OD58, at 3600 m, would have been more than twice the 

distance between Signals OD58R and 0D58 which is already overbraked. The net effect on the driver would have been even 

more unsatisfactory than the present arrangement. If, however, Signal OD58R remained in its existing place and an extra 

distant signal had been provided in rear of the new 2-aspect stop signal, there would have been no difference whatsoever from 

the situation which occurred on 15 October 1994.

127 The likelihood of a driver passing a platform starting signal at Danger has long been recognised.

A method of measuring that risk has been provided by SSP78, which came into effect as a Group Standard in December 1992. 

If Signal 0D58 were to be treated as a platform starting signal which, strictly speaking it is not, it would fall into the category 

where additional measures to combat the hazard of a SPAD would not be compulsory. The narrowness of the scope of this 

signalling principle has been recognised and a more comprehensive study, which seeks to identify and quantify all the risks in 

any particular layout, is currently in progress. None of this work, however, was relevant at the time the decision was taken to 

resignal the Uckfield branch in the form in which it was in October 1994.

I conclude therefore that the branch was signalled in accordance with the standards in force at the time and that none of 

the relevant standards which have been produced since, even if they had been implemented retrospectively, would have had 

any bearing on the cause or the outcome of the accident. Hence I conclude that the line was adequately and safely 

signalled. However in the light of the circumstances of the accident it is right that the standards should be reviewed when the 

results of the layout risk study are available. I therefore recommend that in future before any major change is made to a layout 

or signalling a risk assessment is undertaken. Clearly it is not possible, within a sensible period of time, to undertake a 

retrospective risk assessment of all significant layout or signalling changes which have occurred in the last decade. 

Nevertheless it would be appropriate to undertake such assessments of layouts where double junctions have been replaced by 

single lead junctions and where, such as on the Uckfield branch, long stretches, but not all, of a double-line railway have been 

reduced to a single line. Such retrospective risk assessments must also await the outcome of the layout risk study. I therefore 

recommend that this study is completed urgently, say within the next 6 months, and that when it is to hand Railtrack should 

propose for consideration by HM Railway lnspectorate a plan for retrospective assessments.

Who was driving the Up train?

128 It has been suggested that Guard Brett-Andrews and not Driver Barton was actually driving the Up train. I consider the 

evidence on this issue together with the evidence to be given at the resumed inquest in Part 2 of my report. However it is 

relevant to report at this stage that evidence was available to me that both men were properly rested before they booked on 

duty and were not taking medication.


Post-accident testing

129 Reference has been made in earlier paragraphs to the various tests which were conducted on pieces of equipment, either 

immediately after the accident itself or subsequently in different laboratories or workshops. What was done was done in a 

traditional manner, each engineering discipline removing, where possible, its equipment for subsequent examination after a 

preliminary examination on site. It is easy to be critical after the event and I accept that there are always conflicting pressures 

at an accident site not the least of which are the rescue of casualties and the restoration of the railway to normal running. 

However, accident investigation is a complex business. Few on-call railway officials have much, if any, experience of 

anything other than minor derailments, signals passed at Danger, or very low-key collisions. It is easy to accept the first cause 

of the accident which fits all the facts gleaned at the site. Hence the natural inclination is, on an individual

basis, to determine which, if any, piece of equipment is faulty. If no apparent fault is found then the presumption is made that 

some individual had made a mistake. The need to re-examinethe equipment to see why that person has made a mistake is 

seldom considered and, even if it is, the chance to have another look at the evidence on site has been rendered valueless by the 

removal of the equipment for off-site examination.

I realise that this is the counsel of perfection but I think that at any accident there is both the need for control of the rescue and 

recovery operations and for a somewhat more detached view of accident investigation. At major incidents it is probably 

unwise to saddle the same person with both responsibilities. I have no ready-made solution and I therefore believe that the 

Inspectorate and Railtrack, who in most cases is expected to co-ordinate the railway's own investigation into accidents which 

occur on its infrastructure, should jointly review this problem. Itherefore recommend that this be done and

that the emergency procedures manual which deals with accident investigation should be revised to cover more than just the 

preservation of evidence and to emphasise the need for a comprehensive plan for all the subsequent investigation to be made 

at the site.

Track layout

130 Having considered the direct causes and implications of the accident I now turn to setting it in a wider context to see if 

lessons can be learnt which might prevent a recurrence. There is a natural horror of a head-on collision above that of any 

other. A head-on collision can only take place on a line on which trains

are permitted to run in both directions. It is widely felt that much less danger exists on double track lines with unidirectional 

running. The hazard is however the same, that of passing a signal at Danger, but the consequences on a bidirectional line will 

be that not only will it be much more difficult to stop both trains and thus the probability of a collision is that much greater but 

also the closing speed is likely to be greater and therefore the result would be a more severe collision. In that sense and in that 

sense only the natural instinct is correct. Therefore is it wrong in principle to countenance converting to single line long 

stretches of formerly double-line railway? If the answer is yes then it throws into doubt the wisdom of providing bidirectional 

signalling on multi-track railways and negates the benefits which accrue from making use of the full capacity of the railway 

and from being able to minimise the effects of failure or of carrying out essential maintenance. Modern signalling technology 

is such that single-line operation is no less safe than that of double- line operation providing train drivers observe the lineside 

signals. I do not consider that in principle the practice of singling double-line railways should be condemned.

However, it would be prudent in each case to subject the proposal to risk assessment as I have earlier recommended. The 

safety of such single-line operations, includingthose on bidirectionallysignalled lines, depends not only on the correct 

functioning of the signalling system but also on the observance of the signals. The responsibility for the latter lies squarely on 

the shoulders of the train drivers, but before I consider whether or not there are sufficient safeguards to prevent or reduce the 

consequences of driver's errors, I first consider the question of distraction. 

Driver distraction

131 How much of a distraction to a driver is the presence of another person or persons in the cab? There is some evidence in 

the study on SPADs to suggest that this form of distraction is significant. While it has been pointed out, not least at my Inquiry 

by Counsel for the train drivers, that single-manning of trains is comparatively recent and that historically the presence of a 

second man was not held to be a contributory cause of SPADs, I believe this ignores two things. Historically, data on SPADs 

was neither collected nor collated and that, in the days of steam locomotives, two people were required for the actual purpose 

of driving a train. Locomotive firemen were aspirant drivers. A knowledge of the road could make a good deal of difference to 

their effectiveness. The construction of and sighting from steam locomotives made the observation of semaphore signals 

difficult at times and hence a second pair of trained eyes was a valuable addition. The purpose of firemen ceased when steam 

gave way to diesel or electric motive power. Also, anecdotally but recorded in the railway accident reports of the National 

Transportation Safety Board of the United States of America, there is considerable evidence that, despite the rule which 

required others in the cab to call the aspect of a signal when it was seen, this was frequently not observed and furthermore the 

presence of a large head-end crew was distracting. Therefore, in general, I endorse the rule which does not allow persons other 

than drivers in the cab unless authorised and for a specific and legitimate purpose on each occasion. There clearly must be, 

however, exceptions to the general rule, most obviously when for some reason monitoring of the driver's vigilance is impaired 

by equipment failure or when the train crew are required to search the line. The presence of a second person in the cab with 

the specific tasks, in the first instance of ensuring the driver's vigilance is maintained, and in the second of allowing the driver 

to concentrate only on the task of driving, should be, as it is, mandatory. I do not believe the circumstances on 15 October 

1994 to have been such as to require a second person in the cab and I am forced to the conclusion that Guard Brett-

Andrews must be regarded as having been an unnecessary distraction, heightened by his acknowledged extrovert 

character. The Rule Book is already explicit enough in laying out the circumstances when more than one person is permitted 

in the cab and I have no recommendations to make on that score. However I believe that train operating companies should be 

more severe on contravention of this rule and that insufficient action was taken in the case of Guard Brett-Andrews. This 

specific case must not be permitted to divert attention from the wider issues of what the causes and effects of driver distraction 

truly are. For example, is the increased use other than at signals of AWS permanent magnets which give additional identical 

caution warnings but which have different meanings a help or a hindrance? I consider therefore that it is right and proper to 

extend the investigation into the causes of SPADs to include this subject. I therefore recommend that the question of driver 

distraction in all its forms in the environment of a modern driving cab be added to the SPADRAM research project.

Automatic train protection

132 'Time as a resource is not infinite and what there is of it should be spent wisely. . . However in any event both [ATP and 

Cab Radios] are devices vital to the safety of BR whose introduction must not be the subject of any unnecessary delays. It is 

because of the Court's concern at the potential for delay that I begin this Chapter with this emphasis'. Those words are taken 

from the introduction to Chapter 15 - The Future of Safety - of Sir Anthony Hidden's report on his investigation into the 

railway accident at Clapham Junction. In the chapter he quoted extensively from successive annual reports on the safety of 

Britain's railways. Each had looked forward to the development of ATP, saying in effect that, particularly in Continental 

Europe, railways were developing various systems. The higher levels of the advanced train control system (ATCS) being 

discussed in the USA at about the same time also incorporateda form of ATP. Similarly the more recent European effort in 

trying to develop common standards towards a European train control system (ETCS) has ATP as its cornerstone. Britain is 

taking a full part in ETCS and indeed Mr Rayner in evidence suggested that Railtrack was looking very closely at ETCS for 

the planned resignalling of the West Coast Main Line. However he declined to give a time-scale for this isolated project. He 

himself said that such a system would probably never be fitted countrywide.

133 It is convenient to classify the safeguards to prevent or to minimise the consequences of a driver's error in passing a signal 

at Danger. In the first group, Railtrack place the development of transmission-based signalling for the WCML which will, as 

part of the package for automatic train control, include ATP. Railtrack place the current pilot schemes on the Great Western 

Main Line and the Chiltern lines in a second group referred to as BR-A TP . All other measures fall within the Railtrack 

research project known as Signals Passed at Danger Reduction and Mitigation (SPADRAM). An alternative way at looking 

the measures is to divide them into those which are supervisory, such as ATP, and those which are purely advisory, such as 

AWS or drivers' reminder appliances.

134 There is no doubt that the accident at Cowden would have been entirely preventable had a system of automatic train 

protection been fitted to both track and train. It is equally clear that if all SPADs are to be prevented, then some form of ATP 

or an equivalent supervisory system will have eventually to be provided throughout the railways in Great Britain. However it 

has been accepted that BR-A TP is too expensive, in terms of cost per life saved, and therefore fitting it to the nation-wide 

network cannot be justified. The SP ADRAM project covers a wide range of measures from reduced- cost ATP to drivers’ 

reminder appliances. The higher level measures will all require development and I am mindful of the history of the 

introduction of AWS and of  BR-ATP. It is all too easy for valuable time to be lost. Development is necessary because, as BR-

ATP showed, commercially available systems designed for use on other railways are not directly able to cope with the very 

different operating conditions on British Railways and with the cost and complexity of fitting the on-board equipment to the 

majority of the current fleet of British Railway's rolling stock.

135 It is not easy to distinguish between a reduced- cost ATP system and an enhanced AWS system. For the latter to be 

regarded as a supervisory system, not only must it be able to distinguish a Danger aspect from a Caution aspect, but it must 

also give an irrevocable brake application for the former and one which can be overridden for the latter. It would, in effect, be 

a combination of the current AWS, an advisory system, with a train stop, a supervisory system. In this simple form it would 

have no speed supervision and would therefore only be effective in preventing the consequences of a SP AD if full speed 

overlaps were provided. Such overlaps would be totally impracticable to provide except on a new railway or, on an existing 

railway, where the signalling and track layout can be sufficiently altered to provide them. A possible avenue lies in providing 

some type of speed supervisory device which would have reduced the speed of an overrunning train at the signal such that it 

can be stopped within the available overlap. Were such a device to be track-borne it would need to be able to cater for the 

mixed traffic conditions to be found on most of Britain’s main line railway, a task which has, in the past, been beyond 


136 Train stops on their own are not suitable for mainline railway application with mixed traffic running. It was put to me that 

this was not the case in the limited context of the Uckfield branch. It is true that space exists for overrun trap points to be 

installed at the loop ends which, together with a train stop, would enable a train to be safely brought to a stop in the event of a 

SPAD without endangering an oncoming train. It is also true that because it is, or can be, mechanical in nature, the Class 205 

units operating on the line can have a trip- cock installed without the need for anything other than a minor addition to the 

brake air-pipes. I am reluctant to recommend such action because I believe it would cure only one symptom, not the whole 

problem. It would be limited, at most, to six signals on the line and would cover only a small part of the 

bidirectionally signalled lines which trains using the branch line also traverse.

Also to recommend such action on its own would be counter to the more universal recommendation which I have already 

made regarding the layout risk assessment. Nevertheless it remains a viable idea but one which needs to be considered within 

the ambit of that assessment.

137 There are a number of other technical options being considered as part of the SPADRAM research. Some relate to 

ancillary work which would improve the value of the existing or proposed main measures for reducingthe number of or 

consequences of SPADs. The worth of these options needs to be carefully considered in relation to whether they should be 

location-specificor network-wide. While most of them are advisory rather than supervisory, I nevertheless endorse the 

objectives of the research programme and I recommend that it be completed with the utmost priority. I have earlier alluded to 

the problem of driver distraction and of the multiplicity of meanings for a single warning and therefore I reiterate my 

recommendation that the SPADRAM project should embrace further research into the human factors aspects of driver 

distraction and driver training.

138 Not all forms of ATP will prevent all signals being passed at Danger but all must prevent an errant train from dangerous 

consequences of a SPAD; that is the train must be stopped within the safety overlap. It is therefore my considered belief that 

some form of ATP must eventually be provided throughout the railways in Great Britain. As a first step, all new high-speed 

lines should be provided, as a minimum, with ATP and similar provisions should be considered for all major resignalling 

schemes; this being the expectation of the Health and Safety Commission in their response to the Secretary of State for 

Transport on the British Railways Board report of March 1994 on automatic train protection. I accept that any one system of 

ATP need not be of universal application throughout the network so long as a traction unit which is unfitted with the ATP 

system installed on a line is not, except under stringent conditions which would give the same level of security, permitted 

access to that line. Therefore 1recommend that:

(a) as a minimum all new high-speed railways should be fitted with form of TP;

(b) every major resignalling scheme submitted for approval which does not have a specific proposal for the fitting of ATP 

should demonstrate that full consideration has been given to its fitting later, together with the risk assessment called for in 

(d) below ;

(c) every resignalling scheme should be so designed that the incremental cost of providing the selected form of ATP (which 

need not be universal throughout the railway network) is minimised; 

(d) every signalling or resignalling scheme which does not incorporate ATP should be accompanied by a risk assessment of 

the measures selected for the mitigation of SPADs until such time as ATP is fitted;

(e) once a line is fitted with automatic train control, automatic train protection or some interim measure, no train in normal 

service which is unfitted to operate that system is permitted, except under stringent conditions which would give the same level 

of security, access to that line. 

Radio and other communications

139 It was wrong and reprehensible to pretend that the provision of commercial mobile telephones was anything more than an 

ineffective substitute for proper radio communications. The underlying reason for their provision was the unreliability of the 

trains and hence there was a need for train crew to be able to call for assistance when the nearest fixed telephone was some 

distance away. It became apparent that the uncertainty of such a means of communication on the Uckfield line had not been 

taken into account. No proper control over the issuing of the telephones was instituted and no real attempt was made to ensure 

they were in full working order for the period when they were issued to drivers. Because it was believed that the only calls 

would be those initiated by the drivers, no proper system was devised so that the signalmen in Oxted Signal Box knew which 

telephone (and hence its number) had been issued to which train. The implication of the wording in the Sectional Appendix 

was such that it did not matter if there was a telephone on the train or not. The whole arrangement was a total shambles and no 

wonder it fell into disrepute. Anecdotal evidence suggests that this was also true of the only other line to be equipped with 

these commercial mobile telephones, the Salisbury to Exeter line. 

140 As far as the safe operation of a railway operated under the control of lineside signals is concerned, the principal 

requirement for a means of communication between a train driver and the signalman arises when that system of signalling 

fails. Under those circumstances direct, discrete or secure conversation between the driver and the signalman is required. 

When signals were comparatively close to the operating signal box, that requirement was satisfied by the direct, personal 

contact when the driver or fireman walked to the signal box. As signals became more remote, direct- line telephones at stop 

signals were provided. Advances in technology have now enabled the same standard of secure communicationsto be radio-

based. Cab secure radio, as it is now known, provides that essential element and is a prerequisite for the operation of trains 

crewed by one person only because it avoids the needs for the driver to leave the train to speak on a signalpost or other 

lineside telephone should they still exist. Not only are the standards of security, in the radio sense, high but also the coverage 

along the railway needs to be 100%. Both these elements are expensive to provide. 

141 At the same time not only did the railways recognise that they had a need for a more effective communication system for 

commercial reasons, but also there was a general explosion in the provision of cellular mobile telephone networks. The 

railway’s National Radio Network was therefore instituted. By its nature it is an area-based system and therefore suffers, as do 

the commercial networks, from black spots. The target coverage in engineering terms for NRN is 98%. In other words it is 

recognised that on 2% of the railway, radio telephone communications are not possible using NRN. NRN does not provide 

direct communication between driver and signal box and, when a link via a control room is established, the conversation is not 

necessarily discrete. In order to protect drivers from being distracted by 'wrong number' or other improper calls the telephones 

in traction units can only be called by special telephones; there is no bar on the driver making any outgoing call but in normal 

operation the telephone will connect the driving cab with the local control room for the area.

142 At the time of the inquiry into the accident at Clapham, the installation of both CSR and NRN was in its infancy. 

Recognisingthat decisions to be made on what type of radio system should be installed where had yet, in many instances, still 

to be taken, Sir Anthony Hidden's Recommendation 43 merely called for a system of radio communication between driver and 

signalman. He did however note in the body of the report that, at that time, BR favoured what is now known as CSR. 

Nowhere in his recommendations did he lay down a time-scale for this, but it was given in evidence and noted in the report 

that the target completion date was 1992. However, between then and now a funding hiatus occurred as was explained by Mr 

Nelson in his evidence. While the Uckfield line had been on the list for the provision of CSR, no action had been taken to 

implement it at the time the hiatus occurred. NRN in fact covered the area served by the Uckfield line at the time of the 

accident, but with one exception the trains had not been equipped for any form of radio. However, NRN would have operated 

no better than the commercial mobile telephone networks did and its value in preventingthe accident would have been nil as 

has been demonstrated in incidents elsewhere since October 1994.

143 1 will forebear to comment upon the fact that 3 days before I opened my Inquiry a decision was taken to implement the 

provision of CSR on the Uckfield line.

I will merely content myself with endorsing that decision. I do however have the following more general recommendations

 concerning radio telephone systems on the railways. 1 recommend that: 

(a) Railtrack produce a timed and costed plan for the completion of CSR on the agreed routes and of NRN to its planned 

engineering target coverage;

(b) the railway should improve the capacity of NRN to handle emergency messages to and from train 

Rolling stock

144 Cowden was the latest in a long line of railway accidents which have demonstrated the lack of crash worthiness of Mark 

I, Mark I derived, or similarly constructed rolling stock. At the inquiry into the Clapham accident British Railways proffered a 

programme of research into ways of improving the resistance of Mark I rolling stock to the kind of accident damage which 

leads to injuries to train crew and passengers. Sir Anthony Hidden accepted this and recommended that, after the programme 

of research had been completed, its results should be discussed with the Railway Inspectorate.Those improvements which 

were accepted were to be installed on rolling stock having a planned life of over 8 years. The results of that programme were 

discussed as recommended and the decision was taken that, in view of the likely cost of such modifications, it was not 

reasonably practicable even to install them on stock with a life of over 8 years. Because at that time it was anticipated that 

virtually all, if not all, Mark I or similar rolling stock would have been withdrawn from service within the eight year time-

scale, no further action was required.

145 Two things have since happened: firstly, Mark I rolling stock is likely to continue in service beyond the eight year point, 

which effectively ends in 1997. Mr Clementson's evidence on this was the first formal statement which the lnspectorate had 

had. Secondly, further research, partly in connection with a pan- European research programme, has taken place on improving 

the response of Mark I vehicles to a collision. It has been shown that, at speeds up to 60 kmth (17 mts) in a head-on collision, 

passenger compartments in Mark I rolling stock can be protected from primary damage. However the likely cost of doing so is 

estimated at not less than £300 000 per vehicle. 

146 The conditions under which the 'do-nothing' case was accepted in the light of the Hidden Recommendations 54 and 55 

have now lapsed. There appears to be no intention to implement a programme for the installation of measures to improve the 

crash worthiness of rolling stock having a life of over 8 years and a network-wide fitting of ATP is not contemplated. There is 

therefore no concerted programme to reduce the likelihood of fatalities or injuries in accidents involving older designs of 

rolling stock which are the consequence of SPADs, over speeding or collisions with bufferstops. I do not believe that this 

situation is acceptable now any more than it was in 1989 when Sir Anthony Hidden made his report. In particular the 

accidents at Clapham, Bellgrove, Cannon Street and now Cowden have shown that the chance of survival in an end-on 

collision in Mark I rolling stock is very low and is in marked contrast with the performance of the Super Sprinters in the 

nearly end-on collision (at much the same closing speed as at Cowden) which occurred near Kirkby Stephen on 31 January 


147 1 have referred earlier to the programme of research into crashworthiness. This programme is not yet complete. Its main 

aim is to enhance the design of future rolling stock in the light of lessons learnt not only as a result of accidents such as at 

Cowden but also from other industries and academic studies. I endorse this programme of research but consider that it ought 

now also to encompass another look at the practicability of implementingsome or all of the originally proposed measures to 

improve the survivability of passengers in existing designs of rolling stock which pre-date the latest standards. It is also 

necessary that rolling stock design keeps pace with the fitting of A TC, A TP or other SPADRAM measuresto the 

infrastructureand can accommodate the necessary on-board equipment.

I therefore recommend in the absence of the complete replacement of Mark I rolling stock which would be the preferred 

solution that 

(a) an urgent programme of research into the practicability of improving the crashworthiness of older designs'ofrolling stock 

again be undertaken;

(b) the results of this research are discussed with HM Railway lnspectorate so that an agreed programme of implementation 

can be drawn up;

(c) the opportunity is taken in the design of new rolling stock or major refurbishment of old rolling stock to provide 

accommodation for the installation at the time or later of ATC, ATP or other agreed SP ADRAM measures. 

On train monitors and recorders

148 The fitting of OTMRs was proffered to and accepted by Sir Anthony Hidden. It was welcomed by the train drivers. It was 

agreed by all that they should be fitted, beginning with the actual fitment in all new builds and retrospectively in the remainder 

in a programme that took into account the ease of doing so and the likely life of the stock. That programme has now fallen far 

behind schedule, only partly due to the engineering difficulties encountered in the retrospective fitment. As with ATP there is 

more than a hint that the best has been the enemy of the good. While fitting OTMRs does not lead directly to an improvement 

in safety, these instruments add much to the understanding of normal operations and are especially of value in accident 

investigation. A number of uncertainties in the investigation of the accident at Cowden would have been totally resolved had 

the trains been fitted with OTMRs. The value of having them was accepted by the railway industry as a whole, as was the cost 

of providing them. The value of them is still to the industry as a whole, not least to those responsible for accident 

investigation. I therefore reiterate Sir

Anthony's recommendation and 1recommend that a timed and costed programme, to be funded by the railway industry as a 

whole, for the fitting of all traction units having a planned life of more than 3 years with OTMRs be prepared and submitted to 

HM Railway Inspectorate for consideration. 


149 1 have been appointed as Assessor to HM Coroner for West Kent who will be conducting the inquest into the fatalities 

which occurred at Cowden.

I require the further evidence which will be given at the inquest in order to make my judgement as to who was actually at the 

controls of the Up train. I will be considering that evidence in Part 2 of my report which will also include the report required 

by Section 8 of the Regulation of Railways Act 1871.


150 My conclusions and my recommendations contained in this first part of my report are gathered together in Appendices 2 

and 3 respectively. 



151 Part 1 of the report was presented before the Prism lnquest into the five fatalities which occurred in the accident had been

 held and in paragraph 149

I explained that, until it had been held, I felt unable to come to any conclusions as to who was at the controls of the Up train at 

the time of the collision. This second part of my report addresses that issue and also serves as the formal report required by my 

appointment as an Assessor to HM Coroner for West Kent. The description given at the beginning of Part 1 (paragraphs 12 to 

18) applies equally to this part of the report. 


As to the running of the train and the condition of its equipment

152 Not all those who gave evidence to my Inquiry gave evidence at the Inquest. Those who did largely reiterated their 

original evidence but Mr M A Moerel was able to elaborate on the condition of the train-borne AWS equipment when he had 

first inspected the vehicles. He explained that the lever joining the air-cock to the AWS isolating switch was broken and that 

the air- cock itself was in a half open position. He considered that if the AWS cock had been in the 'isolated' position it would 

have been broken in the collision rather than been moved to the position in which he found it. He therefore concluded that on 

the balance of probabilities the AWS had not been isolated. Trainman R Boyd now thought that perhaps the Down train had 

actually stopped before the impact and Rail Operator V D Hodges said that at the time when Guard Boyd first walked up 

Cowden platform the visibility in the fog was about 50 to 60 m.

153 Dr B A Lawton, who appeared in person at the Inquest, confirmed the written details she had sent to me shortly after the 

accident. On the other hand Rail Operator W Burton somewhat altered his story of exactly where Guard Brett-Andrewshad 

been when he acknowledged the hand-signal at Edenbridge Station. He originally told me in evidence that the guard was 

hanging out of the driver's door thinking, erroneously, that there was one. There is neither an external door into the cab nor, in 

the actual configuration of the train, a door into a vestibule behind the cab. In evidence to the lnquest Mr Burton said that the 

guard had got out of a door; this was later changed to hanging out of a door. The only door to which this could have referred 

was the external door into the engine compartment. The only safe conclusion on this evidence remains that Guard Brett-

Andrews was at the leading end of the train. This is a slight variance on paragraph 33. 

154 In the absence of Mr. H Hixon the evidence about the testing of the train borne AWS equipment of the head of signal 

OD58 was given by Mr D R Bailey, Prism Engineering, Technical Investigation Centre, Crewe, who had approved Mr 

Nixon’s written reports. He pointed out that the contamination on the contacts of the AWS isolation switch (paragraph 71) was 

the result of ingress of material from outside the switch, for example brake dust, and not from inside. He emphasised that the 

effect, if any, of this contaminationwould have rendered the brakes impossible to release without isolating the AWS rather 

than in a wrong-side failure. He has since told me that further tests than those mentioned in paragraphs 71 and 123 had been 

conducted on the contacts of the AWS isolating switch. It was found that 90 v DC, the operating voltage of the AWS, was 

incapable of breaking down the insulating film of the contamination. He remained convinced that either the switch was 

passing current at the time or the contacts were totally isolated and thus failed safely.

155 The last railwayman, other than Guard Brett- Andrews, to have spoken to Driver Barton was Supervisor H W Dennis, 

Network South Central TOU, who was on duty in Uckfield Station Ticket Office. Driver Barton had asked him if he could 

make a cup of tea in the office. They had chatted while he did so and Barton had seemed to be in a perfectly normal mood. Mr 

Dennis did not see Driver Barton actually rejoin the train. However, he said that it would have been unlikely that the driver 

would have had time to isolate the AWS before the train moved off. He, Mr Dennis, had been a guard and knew where and 

what had to be done to isolate the AWS on Class 205 units. He also said that he had not seen Guard Brett-Andrewsthat 


As to their injuries and the places where those who died were found

156 Evidence as to the injuries suffered by each of those who died was given by Dr P G Jerreat, Home Office Pathologist. He 

said that there were significant differences between the injuries of Driver Barton and Guard Brett-Andrews. He was however 

unable to tell which, if either, of them had been at the controls at the moment of impact. Driver Barton had received more 

severe injuries to his legs and Guard Brett-Andrews' chest injuries were of a different nature. It was not possible to distinguish 

between those injuries received at the moment of impact and those which occurred as a result of them both being flung around 

afterwards. He said that neither of them showed any evidence of natural disease which would have accounted for their deaths 

and neither of them were suffering from the effects of drugs or alcohol. 

157 Station Officer S P Batchelor, Kent Fire Brigade, explained where each of the bodies had been found. Mr and Mrs Pointer 

had been flung out of the Up train but Driver Barton and Guard Brett-Andrews were trapped between the wreckage of the two 

trains. It was certainly not possible from the positions in which they were found to determine their positions at the time of 

impact. He described how it had not been possible to release the body of Driver Rees from where it had been trapped beneath 

the engine until such time as DMBSO

No 60147 had been lifted into the field at the foot of the embankment and had been righted.

158 Detective Chief Inspector V M Miller, British Transport Police added that some tests had been done to see how long it 

would have taken Driver Rees to leave his driving position and reach the place where he was found. The likely length of time 

was 5 seconds.


Review of the evidence

159 It was estimated that Driver Rees would have taken approximately 5 seconds to reach the engine compartment of his 

train. This is also the probable time taken for the brakes to have become 90% effective after he had released the Driver’s 

Safety Device. Therefore I believe that the impact took place at about the same time as the brakes were almost fully applied 

but, while the train would have been slowing, it would certainly not have stopped. I believe therefore that Guard Boyd was 

mistaken and that the Down train was still moving at the moment of collision.

160 There was some difference in the views of Mr Hodges and Dr Lawton as to the density of the fog. I do not believe that 

this was due to the patchy nature of the fog but rather to the time difference when their observations were made, those of Mr 

Hodges being made earlier than those of Dr Lawton. It would seem from other evidence that the fog was lifting fairly quickly. 

However neither of these two observations were indicative of the actual conditions at Signal 0D58 at the time Driver Barton’s 

train passed it.

161 The evidence given by Messrs Moerel and Bailey tends to reinforce my earlier view that the AWS was working or rather 

was not isolated. However even if the contacts in the AWS isolating switch were made during the manoeuvres in getting to 

East Croydon from the depot they would have been broken while the country- end cab was in use on the journey down to 

Uckfield. The question therefore arises as to whether the contacts closed properly when Driver Barton changed ends at 

Uckfield. In answer to a specific question on whether Driver Barton would have had time to isolate the AWS after leaving the 

ticket office before the train departed, MMr Dennis said he thought that there had been insufficient time. Nevertheless 

isolating the AWS does not take long. Alternatively there is also the possibility that Driver Barton could have handed his key 

to Guard Brett-Andrews to open up the cab while he was making his tea and the latter, who had some traction knowledge, 

finding that the AWS was faulty, isolated it himself. He would then have had to have compounded this by failing to tell Driver 

Barton what he had done and for Driver Barton not to have noticed that the AWS was not working during the journey from 

Uckfield to Ashurst.

I find this so unlikely a scenario that I believe that, if the AWS was isolated then either Driver Barton was aware of it or had 

isolated it himself.

Why was there a disregard of the aspect of Signal OD58?

162 Both before and after my Inquiry there has been considerable speculation as to the underlying reason for the total 

disregard of the Danger aspect of Signal 0D58 because the Up train was driven as it would have been if the signal had been 

green. The speculation has centred around the possibilities that either the AWS was isolated, or Guard Brett-Andrews was 

driving the train, or both. If the former were true then it would also have needed the overriding conviction of one or both men 

in the cab that the signal was green. I do not believe that there is any real evidence to support the contention that the AWS was 

isolated, although there was opportunity enough for it to have been done. The lack of a report of the isolation is not conclusive 

in itself because, although there were autodial telephones at Uckfield, one was at the ticket office at the other end of the train 

and the other on the platform. A report of an isolation of the AWS is required by the rules, but there is no urgency attached to 

the making of the report. Couple this lack of urgency with the disincentive of the location of the telephones, then even less 

reliance can be placed upon lack of a report of the isolation of the AWS as being indicative of there being no isolation.

163 If it were true that one of the reasons for Guard Brett-Andrews'failure to become a driver was a lack of ability to respond 

to the significance of lineside signals then he may have been convinced that Signal 0D58 was at Green. However this error 

would have had to have been compounded by Driver Barton not seeing the signal which, together with the absence of an AWS 

warning, might have led to Driver Barton believing that they had a clear run to Hever. Nevertheless, this does not drive one to conclude that Guard Brett-Andrews was actually driving, merely that he may have contributed to Driver Barton's error.

Who was driving the Up train?

164 Neither the medical evidence nor that of the Kent Fire Brigade shed any positive light on the question as to who was 

driving. Although pressed fairly hard, Dr Jerreat was reluctant to commit himself. He had not seen the actual site of the 

accident and it was not possible to sort out the order in which the various injuries occurred either to Driver Barton or to Guard 

Brett-Andrews. He was able to say only that their injuries were different but not what was the actual cause of each. The bodies 

of both men were found pinned between the roof of their driving trailer and the frame of the leading vehicle of the Down train. 

There was no direct evidence as to where they had been before the impact.

165 It was put to me that the manner in which the Up train was being driven was more indicative of an inexperienced rather 

than an experienced driver. It is true from a comparison of the timings from the SS1 tape that Driver Barton's train travelled 

some 8 km/h (5 mileth) faster than had Driver Rees' on the same journey earlier that day. That may or may not have been due 

to the relative density of the fog. On the other hand, Dr Lawton described the first part of her journey from Crowborough as 

being rather jerky compared to the second part from Eridge. If Railtrack's submission on the quality of driving were to mean 

anything it would indicate that it was Driver Barton at the controls at the time of collision, not, as Railtrack contends, the other 

way round.

166 Most of the considerable support for the view that Guard Brett-Andrewswas driving at the time of the collision rests on 

four issues. The first is his admitted history of desire to be a driver and some unverifiable statements made to the police. The 

second is the alleged reasons for his failure to become a driver which again were not produced in evidence, either directly to 

me or to HM Coroner or contained in documents made available to me. The third is some alleged opinions which related the 

position in which the bodies were found relative to where they had been on impact and the type of injury which they suffered 

and the fourth is one possible reading of Rail Operator Burton's evidence.

167 These issues are not supported by factual evidence. There was a considerable difference of view as to the characters of the 

two men depending on whether the view was being put forward by their relatives or by their colleagues at work. The former 

considered neither man as being particularly assertive, whereas Guard Brett-Andrews was regarded as an extrovert by his 

supervisors and, it was even suggested in submission, was capable of exerting undue influence over Driver Barton. I do not 

regard this latter allegation as at all tenable in view of the evidence given to me of Driver Barton’s own character.

161 as at all tenable in view of the evidence given to me of Driver Barton's own character.

168 The question of the use of the AWS is less easy to answer. There is no good evidence either way as to whether it was 

working and not isolated or not working and isolated. I am inclined to the belief that it was working but can reach no definite 

conclusion. If it was working, then I consider the subconscious cancellation of the warning to be more likely from an 

experienced driver than one with little or no experience, the sound of the 'yodalarm' rather than the slightly more 

commonplace air-horn having no appreciable affect on this. I have already discussed the speed of the Up train and quality of 

the driving. If anything I am more inclined to think that it was Driver Barton at the controls rather than the reverse.


169 None of the arguments rehearsed above, in the absence of positive proof to the contrary, are enough to upset the basic 

presumption that Driver Barton was actually driving his train. It would however, in my view, be unsafe to come to a definite 

conclusion in this respect. I am therefore able only to reiterate the conclusion reached in Part 1 of my report that, as the 

appointed driver of the Up train despite whatever else might have occurred, Driver Barton is wholly responsible for 

the accident.


170 After hearing legal submissions before addressing the jury at the Inquest, HM Coroner for West Kent, Mr F H Warriner in 

summing up said that he considered that there was insufficient evidence to sustain a verdict of unlawful killing. Such a verdict 

would have required, as in a case of manslaughter, proof beyond all reasonable doubt that an individual had either acted, or 

failed to act as the case may be, in a manner which was culpable. Whereas the standard of proof required for a verdict of 

accidental death was only that of 'balance of probabilities'. He therefore directed the jury that a verdict of unlawful killing was 

not available to them. After due considerationthe jury returned unanimousverdicts of accidental death on Driver Barton and 

Guard Brett- Andrews; verdicts with which I am in complete agreement. However I consider that the evidence was sufficient 

to allow a more definite verdict than the one reached by a 10 to 1 majority on the deaths of Mr and Mrs Pointer and Driver 

Rees on whom the jury returned Open verdicts.

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