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SOUTH CROYDON STATION

24th OCTOBER 1947

Involving Motormen H. Goldsmith & A. Clack

extracted and adapted from the report by

A.H.L. Mount Lieut.-Colonel


The aftermath of the 1947 South Croydon train crash is captured on film


 

I have the honour to report for the information of the Minister of Transport, in accordance with the Order of 24th October, 1947, the result of my Inquiry, at which I was assisted by Brigadier C. A. Langley, into 

On the 24th October, 1947 a collision occurred in dense fog at about 8.37 a.m. near South Croydon Junction on the Central Section of the Southern Railway. The 8.4 a.m. electric passenger train, Tattenham Corner to London Bridge, running on the Up Main line, was improperly allowed to approach and pass through Purley Oaks under clear signals, and came into violent collision with the rear of the 7.33 a.m. electric passenger train, Haywards Heath to London Bridge, which was passing South Croydon Junction Home signal at slow speed after having been checked by the Distant at Caution.

The accident occurred at the height of the peak morning traffic, and both trains were overcrowded, with passengers standing jn the compartments. It is estimated that the Haywards Heath train was carrying 800'and the Tattenham Corner train 1,000, seating accommodation being for 536 a n 8 750 respectively. I regret to report that 31 passengers lost their lives, of whom one died after admission to hospital, whilst the motorman of the Tattenham Corner train was also killed ; 183 passengers suffered injuries or complained oT shock, of whom 58 were taken to hospital, 41 being detained. The majority of the casualties were sustained in the leading coach of the second train.

As a result of short circuit,the breakers at Purley Sub-Station and South Croydon Track Paralleling Hut opened, and power was cut off immediately from the Up and Down Main and Down Local lines. It was shut off from the Up Local at 8.52 a.m. on the request of the South Croydon Stationmaster. who arrived on the scene a few minutes after the collision. There are no grounds for considering that any passengers suffered from electric shock as a result of the accident.

Relief wprk was carried out very efficiently, an immediate call having been sent to the police and fire brigade. The first ambulance arrived at about 8.40 a.m. followed by many others from Croydon, Wallington, Beckenham, Purley and the L.C.C. Casualty Service Section, and all the injured passengers Wele removed to hospital by 9.40 a.m. Police, firemen, doctors, nurses, the Company's staff trained in first aid, and the inhabitants of Sussex Road rendered most valuable assistance. Six sets of emer- gency first aid equipment were available on the two trains, and t h e e were used.

Clearance of the lines was effected expeditiously ; the Up Local was opened three hours after the accident, and the Down Lbcal was cleared by 4.0 p.m., in time for the evening business traffic. The Up and Down Main lines were finally cleared and normal working was resumed at 10.30 a.m. on 25th October.

The Haywards Heath train consisted of two 2-car sets from Haywards Heath and one 4-car set attached at Redhill, totalling 8 coaches with 6 motor units. The length was 516 feet over buffers, and the total loaded weight about 350 tons. Westinghouse brakes operated on non-ferrous brake blocks throughout the train, and efficiency (unloaded) was 65.5 per cent. The coaches were of com- posite construction, timber framing and steel panelling on steel underframes, having been built in 1932.

The Tattenham Corner train consisted of two 3-car sets from Tattenham, and one 3-car set from Caterham which was attached at Purley, totalling 9 coaches with 6 motor units. The length was 580 feet 9 inches over buffers, and the total loaded weight about 400 tons. The Westinghouse brake operated on q s t iron blocks throughout the train, the efficiency of which (unloaded) was 79 per cent. The coaches were of timber construction on steel underframes, with the motor cabs faced with steel panelling. They were originally built in 1921 and adapted for present service in 1930.

The impact was severe and the leading buffers of the Tattenham Corner train underrode the rear buffers of the Haywards Heath train. Both rails were buckled, probably by the action of the leading bogie of the overtaking train, which was derailed and tore up the track for 120 yards. The Down Main was also destroyed for 40,yards and debris was thrown across the local lines.

The rear coach of the Haywards Heath train was thrown off its bogies and turned on its side, causing the body to break away from the frame ; the van and rear motorman's cab of the train were shattered. The rear of the next coach was also damaged but it was not derailed.

As regards the Tattenham Corner train, the body of the leading coach, except the last two com- partments, was swept away. The underframe was badly buckled and twisted, and the motorman's control gear and cab equipment were torn away and thrown on the track about 50 yards from the point of collision. The second, third and fourth coaches were derailed owing to the track disturbance, but were not seriously damaged.

It was misty in the early morning but by the time of the accident visibility had deteriorated to about 50 yards, on account of fog. 

 

 Accident at South Croydon on 24th October 1947

 

DESCRIPTION

The site of the collision was 367 yards south of South Croydon Junction signal box on the Up Main from Brighton to Victoria. At this point the line runs from south to north with four tracks designated Down Main, Up Main, Down Local, Up Local in that order from east to west. The gradient is falling 1 in 263 from Coulsdon North to South Croydon. Curvature is easy on a radius of 95 chains left-handed, over a mile in length, through Purley Oaks Station, up to a point 270 yards in rear of the collision, where formation is on bank. The general layout is shown on the accompanying plan ; the stations and signal boxes referred to hereafter are as follows in order from the south :-

Coulsdon North Box, where trains'are described to Purley North and South Croydon Junction.

Purley Station, where there is an additional pair of tracks on the east side to accommodate trains from Tattenham Corner and Caterham which join the Main line here.

Purley North Box, which controls movements at the north end of Purley Station.

Purley Oaks Box (a block post with no connections) where the signalman in charge erroneously accepted the Tattenham Corner train while the Haywards Heath train was standing in the station.

Purley Oaks Station, where the Haywards Heath train stood for 6 to 7 minutes, awaiting the lowering of the starting signal.

South Croydon Junction Box, where the branch line from Oxted, with connections from East Grinstead and Tunbridge Wells, joins the Main line on the east side.

South Croydon Station.

Signalling.-The system of signalling in use is Sykes’ Lock-and-Block system and the points are worked manually by the operation of levers mechanically interlocked in the normal manner.

Purley Oaks signal box is on the east side of the line, set back 50 feet from the Down Main and 170 yards in rear of the south end of Purley Oaks Up Main platform. The frame contains 56 levers, of which 13 only are working. The box is used as an intermediate block post between Purley North and South Croydon Junction, and is open daily from 6 a.m. to midnight. A diagram of the instrument shelf and a sketch showing the position of the signals and treadles is attached. 

Trains are described on Walker's type transmitters from Coulsdon North to Purley North and South Croydon Junction, but not to Purley Oaks. Passenger trains on the Up Main from Coulsdon and beyond are offered forward by giving the " Is-Line-Clear " bell signal 3 pause 1. The Tattenham Corner and Caterham trains, which join the Main line at Purley North, cannot be described on the Walker transmitters, and are therefore offered by giving the special " Is-Lineclear " bell signal 3 pause 3 pause 1. Owing to the intensive working and the interlacing of the Tattenham Corner trains into the flow of traffic through Purley North, incorrect description of trains sometimes occurs, and the special bell signal 5 pause 3 is used to call attention to this prior to transmitting the correct signal.

At South Croydon, the Up Main signals are only 276 yards in rear of the convergingjunction ; consequently, when a train has been accepted from Oxted, Up Main line trains from Purley Oaks are allowed to approach in clear weather only, in accordance with Block Regulation No. 5, " Section Clear, butStationorJunctionBlocked.” When this arrangement is in force, Block Instrument No.19 in Purley Oaks box remains locked, but Warning Instrument No. 20 is changed from “ Locked “ to “ Free “ by operation of the special plunger in South Croydon Junction box. Purley Oaks signalman is then able to reverse Warning Signal No. 20 which he should not do until the train has been brought nearly to a stand. During peak traffic in clear weather, many trains are sent forward under the authority of this regulation ; but in foggy weather, its use is prohibited, and under these conditions Main line trains may be delayed for several minutes at Purley Oaks when Up Oxted trains are accepted by South Croydon Junction. 

 

 

REPORT AND EVIDENCE

Owing to deterioration in the weather, the fogmen had been called out before dawn on 24th October, and by 8 a.m. all were in position at Purley Oaks, South Croydon Junction and South Croydon Station Up Main and Local Distant signals. Estimates of visibility varied in different places from 200 yards at Purley North to between 20 and 100 yards at South Croydon. At Purley Oaks the estimates of different witnesses varied from 20 to 170 yards.

Motorman A. Clack, of the Haywards Heath train, stated that on approaching Purley Oaks Station, the Distant signal was at Caution and he brought his train to a stand at Starting signal No. 19 which was atDanger. He thought he remained there for 7 or 8minutes and then the signal was lowered and he proceeded forward. He had whistled on passing the Home signal near the box, but was exempt from carrying out Rule 55, having regard to the protection afforded by the Lock-and-Block system. The South Croydon Junction Distant signal was at Caution and a detonator was exploded there. The next signals, viz. the Junction Home, with South Croydon Station Distant under it (seen at a range of probably 60 to 100 yards) were both "Off ", and he therefore released the brake and opened his controller. He judged that he had increased speed from about I2 to 20 m.p.h., when the coliision occurred, his driving cab being about 3 coach lengths on the London side of these signals. Marks, however, on the track indicated that the cab could have been only one coach length past the signals and the speed of the train may have been less than Clack’s estimate. He judged that visibility was about a train length (170 yards) at Purley Oaks. (The rear of the train was some 190 yards from the signal box).

Guard W. C. Waters, who was travelling in the brake van at thc rear of this train, generally con- firmed this evidence, but considered that visibility at Purley Oaks was much worse than Clack had estimated, namely, no more than 60 yards. The train, which left Coulsdon South moderately well loaded, became crowded wi!h passengers when waiting at Purley Oaks platform. On leaving, speed was low, about I2 m.p.h., and the fog was so thick that Waters did not see the South Croydon Junction Distant signal ; nor did he hear the detonator explode. Shortly afterwaids there was a very heavy impact from the rear, and he was thrown into the right-hand corner of his brake van, from which he was most Fortunate to escape with only minor injuries-~-hiscompartment was completely shattered.

Acting Guard A. F. Sims, of the Tattenham Corner train: said that: it arrived two minutes late at Purley Station, where the Caterham portion was attached in the rear. A large number of passengers got in and the train was crowded when it started at 8.35 a.m. Visibility was restricted to about 30 yards, hut improved a li:t!e when t!ley passed through Purley Oaks, at a speed of 20 to 25 m.p.h. He noticed a fogman at the side of the track, but he could not recognise the signal he was displaying, nor was he certain at which signal he was working. Almost immediately afterwards, he felt the shock of collision. There was a great deal of noise as if a weight was being pulled along the rails, followed by a thump which threw him forward. He thought that-the brakes must have been applied before the collision took place. They had been tested after coupling up the Caterham portion at Purley, when the train pipe pressure was between 60 and 75 lbs. per square inch.

Motorman H. Goldsmith, of the Tattenham Corner train, was unfortunately killed at his post, and the control gear and cab equipment were so damaged by the collision that it was not possib!e to tell whether he had had time to apply his brakes.

Lengthman J. Langridge took up his position at South Croydon Junction Up Main and Local Distants foggingpost, at about 7.45 a m . The fog was thick a t the time of the accident and he estimated that visibility was 20 to 30 yards. When the Haywards Heath train passed the Distant was at Caution, and Langridge exhibited a yellow hand-signal and heard the train explode a detonator. Some l 1/2 to 2 minutes later, the Distant was lowered and the Tattenham Corner train passed about half a minute afterwards at a speed considerably higher than that of the Haywards Heath train, be thought at about 40 m.p.h.

Lengthman L. Tipper was on fogging duty at South Croydon Station Distants, which are carried under the South Croydon Junction Home signals. He thought that visibility was only 20 yards immediately before the accident. The Distant was " Off" for the Haywards Heath train which approached at a speed of about 15 m.p.h. Immediately the front of the train passed, he heard the noise of the collision.

Signalman B. Neary, of Purley North box, stated that at 8.23 a.m. he offered the Haywards Heath train to Porter Signalman H. D. Hillier of Purley Oaks box, who accepted it at once. Neary transmitted the " Entering-Section " signal at 8.27 a m . and expected to receive " Out-of-Section " from Hillier one or two minutes later. In the meantime, the Tattenham Corner train had arrived at Purley North and the Caterham section had been attached in rear, whilst at 8.33 a.m. a passenger train from

Ore was described from Coulsdon South. Neary had to decide which of these two should be given precedence on the Up Main after the Haywards Heath train, and, not having received " Out-of-Section " from Hillier, he spoke to him and asked " How he was looking an the Up Main." The only reply he received was " Gor Blimey," and then the telephone receiver was replaced. Neary could not make anything of this, but a few seconds later he received from Hillier the " Out-of-Section " signal and thereupon decided to give precedence to the Tattenham Corner train which he offered on the special code 3-3-1. Hillier immediately accepted it correctly, whereupon Neary changed the road and lowered his signals for this train which left the station at 8.34 a m .

Neary was a good witness, aged53,with 38 years’ service; of which 33 had been spent in his present capacity, the last 6 at Purley North. He explained that he spoke to Hillier in a friendly manner ; he knew he was a porter-signalman who had recently returned from the Army. He wanted to avoid making him feel " uncomfortable by saying anything about delaying the 'Out-of-Section' signal, as this would have been inclined to put the man off his balance.” He knew Hillier well, and had “ never worked with a better porter-signalman." As regards Hillier's experience, he suggested that he should have graduated through a lower class box " because it did seem in a way unfair to put a porter-signalman with a few weeks’ experience out on the Main line."

 

 

Porter-Signalman Hillier's tour of duty at Purley Oaks was from 6 a.m. to 3 p.m. When he opened the box at 5.58 a.m. the weather was foggy, but he could see the near end of the platform awning about 200 yards away  Fogmen had been called out and arrived at his Up Distant signals at 7.20a.m. Weather conditions deteriorated, and by 8.30 am., the fog had become so dense that he could no longer see the station or platforms. A train register book is not kept at this box, and Hillier could not recollect the train from Liitlehampton which preceded that from Haywards Heath. He remembered, however, accepting the latter, but, as he did not receive " Line-Clear " from South Croydon Junction and was unable to lower

Starting signal No. 19, he brought the train nearly to a stand at Home signal No. 18 before allowing it into the station up to the Starter. Owing to the fog, he could not seethe train after it had passed him, and whilst it was standing at the piatform. In consequence,he forgot it, and, when a few minutes later Neary spoke to him, he glanced at his Home signal instrument No. 18, and, seeing the upper tablet was showing " Locked " and the lower " Blank," he jumped to the conclusion that it had failed.

Hillier referred to previous failures and, without waiting to think, he used the release key to reset the instrument. “I just turned round (from the telephone) and looked at the instruments and though 1 had stopped something, and immediately, freed the instrument .. . . at this time No. 19 Starting signal was section locked.” He then transmitted the " Out-of-Section" signal to Purley North and accepted the Tattenham Corner train on the 3-3-1 bell code immediately it was offered to him by Neary a few moments later. Shortly afterwards, at about 8.35 a m . , South Croydon Junction accepted the Haywards Heath train on the bell code 3-1 and plunged, thus freeing Starting signal No. 19. Hil!ier did not appreciate that this acceptance related to the Haywards Heath train and lowered his Up Main Home, Starting and Distant signals for the Tattenham Corner train, which he had never offered forward to South Croydon Junction.

As a result. the Haywards Heath train, which had ihen been standing in Purley Oaks station for 6 to 7 minutes, moved forward and operated Treadle F, which changed instrument 19 from " Locked " to " Free." Hillier noticed this and thought at first that platelayers had struck the treadle. thus freeing the instrument, but realising it was too foggy for them to be working, he assumed that the rod had simply fallen through, so he lifted it and replaced the tablet to " Locked " without returning the signal to danger. In the meantime, the Tattenham Corner train was approaching and ran through Purley Oaks under clear signals. Hillier saw the headcode as the train passed and realising that it was from Tattenham Corner, while South Croydon Junction had accepted the train on hell code 3-1, he rang up Signalman Walder and told him that a branch train was coming, to which Walder replied "All right."

In effect, Hillier's explanation for falsely assuming the failure of his instrument was that he had overlooked the Haywards Heath train (obscured by fog) having regard to the heavy pressure of traffic. In one hour, 13 trains are booked on the Up Main, 12 on the Up Local, with 13 on the Down lines, a total of 38 trains, for which that number of plunges are required and 90 to 100 bells, besides the pulling and replacing of the signal levers for each. As to his competence, he said " in the normal way, I was at home in that box “ ; but on this occasion “ I could not see further than the other side of the tracks, looking directly out.” He added that while he usually made use of the Switch Hook, " I do not know whether I actually did this time “ when acknowledging the " Entering Section " signal for the Haywards Heath train ; “ It is quite possible that in offering the train to South Croydon, I may have been at the other end of theframe and ringing on bells far away from the instrument . . . . I am afraid1 must have overlooked it (the switch hook)." Hillier said that he had not been worried previously and had nothing on his mind ; his health had been good and he finished duty at 3.0 p.m. on the previous day.

Signalman E. Walder, like Signalman Neary, is a man of long exberience and has been at South Croydon Junction for 11 years, with a total service in this capacity of 35 years. He said he had been offered a train from Tunbridge Wells by Selsdon (on the Oxted Branch) at 8.21 a.m., but he did not accept it at first because he was not expecting it to arrive for several minutes and he wished to keep his Junction working clear for as long as possible, especially as he could not accept Main Line trains under the Warning Arrangement on account of the fog. He had had the Littlehampton train described on the Up Main at 8.17 a.m., and he therefore accepted it when offered by Hillier at 8.23 a.m. ; it passed the station box at 8.274 a.m.

In the mean time, the Haywards Heath train had been described at 8.24 a m . and Hillier offered it on the 3-1 code at 8.26: a.m. Walder, however, did not accept this train, as he decided to work to the booked order and accepted the Tunbridge Wells train instead at 8.29 a.m., after he had received "Line. Clear " for it from South Croydon Station. The latter passed his box at about 8.32 a.m. and when South Croydon Station cleared the block at 8.35 a.m., Walder accepted .the Haywards Heath train, which, as previously noted, Hillier had offered 89 minutes earlier. Walder did not, however, con- sider that there had been undue delay because the working of trains through the Junction was always interfered with during fog. Walder lowered his Up Main Home, but he thought it was two or three minutes before he was able to lower his Distant which is controlled by South Croydon Station Box. At 8.36 a m . he received the '' Entering-Section r' bell signal, and a few moments later Hillier told him that the Tattenham Corner train was approaching on the Main Line. Walder didnot comment on this because it was not unusual for the order of running to be altered. About a minute afterwards, however, he heard the noise of the collision and took immediate steps to block all lines and put all his signals to Danger. Heinquired from Hillier whether the Tattenham Corner train had passed signals at Danger and Hillier replied “ No,it was all my fault."

Signalman Hillier is 29 years old and has been in the Company's service for I1 years, of which he spent over five in the Army, including three as a prisoner of war after capture at Tobruk. He rejoined the Company in May, 1946, and having first been employed as a leading shunter and then as an acting ticket collector, he applied in March, 1947, for the appointment &Porter-Signalman at

Purley Oaks and was accepted. He commenced training at once, and after four weeks he was tested and passed by Inspector E. G. Akehurst on 12th May. After another week as second man, he took over full charge, working a shift from 6 a.m. to 3 p.m. and 3 p.m. to midnight on alternate weeks for four weeks whilst the two regular signalmen went on a fortnight's holiday in turn. He then reverted to his normal duty of Porter at Purley from 8 a.m. to 2 p.m. and Signalman at Purley Oaks from 2 p.m to 4 p.m. Five weeks before the accident he again resumed full time duty as signalman, in place of Slgnalman Beadle, who was ill. He had thus had nine weeks' previous experience of heavy traffic, including the morning and evening peaks, and 14 weeks of normal duty, involving two hours per day in the signal box during the slack period. He had also performed Sunday duty as a signalman on nine occasions. Prior to the morning of the accident, he had not had any experience of working a signal box in fog.

Inspector Akehurst, an ex-signalman who has 32 years' service, for the last nine in his present capacity, had recommended Hillier for training as a signalman after being asked by his Divisional Superintendent whether he could do so. Akehurst considered him to be "perfectly suitable" and a man above the average. He was'quite confident that Hillier was competent to take full charge after he had tested him on 12th May. During the test, he watched him working the frame and instruments for an hour or so, and then gave him the usual examination in Rules and Regulations. Akehurst said that failures of apparatus were discussed and how to deal with them. He made a particular point of impressing on Hillier the care to be exercised in using the release key. For instance, he told him " to treat it as a red hot poker and handle it as such."

Akehurst did not agree that the appointment was a mistake, and he had been impressed with Hillier's " steady manner." He was “quite prepared to accept him as a signalman to work any turn in the box at any time,” and he considered that Hillier fully understood his duties. He pointed out that " it is left to the man to decide when he is ready to take over" as a signalman, and that no man is examined and passed unless he has expressed his willingness. The previous failures of equipment should not have influenced Hillier ; nor would a train register necessarily have acted as a reminder. He did not feel that the fog or telephone messages should have put Hillier " of his balance " ; but that " he was prompted by the signalman at Purley that he was delaying traffic, which caused him to take the action he did on the spur of the moment."

On three occasions during the week of the accident, apparatus at Purley Oaks had failed while Hillier was on duty. On Monday, 20th October, Down Main Treadle D only reacted inter- mittently to the passage of trains and did not free instrument No. 36, so that Hillier had to use the key to release the backlock on this starting signal lever. Assistant Lineman Daniels attended to the treadle and set it somewhat finer. On Thursday morning, 23rd October, the same treadle failed again, due t6 being set too fine. It operated, in fact, as the result of vibration, probably caused by trains passing on adjoining tracks, and thus released the backlock incorrectly, allowing the instrument to change to " Free " when it should have remained at " Locked "-a danger-side failure. This was attended to, but,on the morning of the accident Down Local Treadle B failed to release instrument No.40 after the passage of a train. Hillier took correct action in this case, and did not clear the block to South Croydon Junction until he received the " Out-of-Section " signal from Purley North. In connection with the reporting of these incidents, he stated that failure forms exist but are not used for treadle failures (which are entered in a book provided for the purpose). He had used one form since he had been in the box for a failure of rotation locking between Home and Starter ; but he could not remember the circumstances or date.

Hillier's usual procedure was to telephone (eight rings) to the Lineman on duty (one of three) ; most of the failures in his experience were on the safety side, preventing the release of backlocks. Inspector Akehurst thought that one such failure actually occurred on 12th May when he was examining Hillier in the box ; but from what he had heard generally from the 200 signalmen under him, he was of opinion that the incidence of these failures was not worse than pre-war, and that e three cases mentioned above were coincidence. Mr. Boucher, the Assistant Engineer for Signals and Telegraphs, also thought that they were exceptional in such a short period, and said that the whole equipment had been overhauled between 15th April and 18th May this year. It appeared, however, that he was not being invariably informed of such incidents, though Inspector A. F. Kadwell reported that, since the overhaul, the Lineman’s attention had been called to two failures of apparatus on the Local lines, but to none on the Main lines. 

CONCLUSION

There is no doubt that the Tattenham Corner train was running under clear signals, and the late Motorman H. Goldsmith was in no way responsible for the accident. In the first place,thetrainwas improperly allowed to leave Purley, and secondly, to enter the Purley Oaks-South Croydon Junction section. Judging by the severity of the collision, its speed must have been 40 to 45 m.p.h. when it over took the Haywards Heath train, travelling at 15 to 20 m.p.h. while passing South Croydon Junction Home signal after check by the Distant at Caution 

The primary cause appears to have been that Porter-Signalman H. D. Hillier of Purley Oaks entirely forgot the Haywards Heath train while it was in the station for six or seven minutes obscured from his view by fog. It is difficult to account for what transpired, but responsibility must rest upon him for his most irregular use of the key to release his Sykes instrument No. 18 thus destroying the protection afforded by the Lock-and-Block system to this train which was standing at Starting signal No. 19.

This followed Signalman Neary's telephone inquiry as to the position on the Up Main, upon which Hillier jumped to the erroneous conclusion that his instrument had failed, a very serious error on his part, particularly in fog. His confusion of mind must have deluded him into thinking that he alone was right and his instrument wrong ; thus his series of blunders were set in motion, the first being his transmission of the " Out-of-Section " signal for the Haywards Heath train, and then the release of the block to Purley North.

Nor were subsequent warnings of any avail in the absence of visual reminder of the train. Having used his key to cancel the front lock on Signal No. 18 and to free that instrument, which correctly registered " Locked," he was able incorrectly to accept, and lower signals Nos. 18, 19 and 17 for the Tattenham Corner train. Although he could not see or hear the Haywards Heath train start from a e station, he observed instrument No. 19 change from " Locked " to " Free " when the actuation of Treadle F released the backlock on the starting signal leper, but this did not warn him that something was wrong. He again falsely assumed that this second instrument had also failed, and re-set it to " Locked " without returnmg the signal to Danger.

He did not appreciate the significance of Signalman Walder's 3--1 bell signal acceptance, and assumed that this applied to the Tattenham Corner train, although that train had been offered to him by Neary only a few moments before on the 3-3-1 bell signal, and he had not offered it to Walder. Even when Hillier saw the headcode and informed Walder that the Tattenham Corner train was approaching, he was not reminded of the position, and it was not until Walder spoke to him after the collision that he realised his mistake  He frankly and immediately admitted it, and expressed deep regret.

Hillier's breakdown in instrument manipulation in this emergency must, 1 think, have been due tp some failing to appreciate the danger of irresponsible use of the key, and it occurred in the face of the most stringent Instructions, reinforced by the Superintendent of Operation in July, 1946. I know of no other Instruction which gives warning that improper use of apparatus may incur dismissal, and the Company at once took the view that he should be employed on other work.

The relevant Instructions provide for the sw~tch-hookbeing placed over the Sykes instrument plunger when the " Train-Entering-Section" signal is acknowledged, but Hillier presumably failed to do this when he acknowledged this signal for the Haywards Heath train. When he used the key his block indicator was in the raised position, as it had been so placed when the switch-hook was turned over the plunger by Signalman Walder at South Croydon Junction at the time he refused to accept the Haywards Heath train. Although Hillier therefore operated his signals for the Tattenham Corner train, the Haywards Heath train, which he had overlooked, started from Purley Oaks platform, and, as already mentioned, he thereupon failed to appreciate the significance of the freeing of instrument No. 19.

The recent failures of treadles referred to in Hillier’s evidence, and in particular that on the previous day when instrument No. 36 incorrectly changed from " Locked " to " Free," a danger-side failure, may have influenced him. It was also the first time he had worked in fog during his brief experience
of five months as a signalman. There were men of long service in the boxes on either side of him, and Signalman Neary's telephone reminder obviously surprised him and appears to have led him
to think that he was delaying traflic. In the circumstances, all that could have been expected of him was to do nothing until he had consulted the box on either side ; but there is, of course, the natural desire of a signalman to rely on his own initiative rather than on his colleagues. Presumably, however, he would have been told to ring up the man on duty on the platform to ask if a train was standing there awaiting the lowering of Starting signal No. 19.

Although Hillier was considered to be fully competent to take charge of Purley Oaks box, the circumstances of this accident led me to think that both he and Inspector Akehurst, who tested and passed him, overestimated his ability to work alone in a Main Line box under the stress of heavy traflic in adverse conditions, such as fog. I realise that Inspector Akehurst has many years’ signalling experience, and that signalmen even of long service have in the past misused the release key. But it seems to me that Hillier was allowed too rapidly to assume duties with too much responsibility, and the Company's Officers have assured me that the extent of training and the methods of examination and instruction will be reviewed ; as also the placing of men of short experience in Main Line boxes, even if used only as block posts, where peak traffic is as heavy as at Purley Oaks.

Having regard also to the sequence of three treadle failuresduring the week of the accident, to which should be added a fourth, namely that of Treadle E, which actually occurred during my inspection at Purley Oaks on 27th October, the question of insistence upon reporting such incidents by signalmen to the Traffic Department, as well as direct to the lineman, appears to require further emphasis ; by this means all in authority should be kept aware of the extent of such failures, and of the efficiency of maintenance. It should be added, however, that the Company’s statistics showed that,on this section of line, there had been no deterioration in the general standard of reliability, in spite of difficulties in obtaining staff and material. 

 

CONCLUSION

There is no doubt that the Tattenham Corner train was running under clear signals, and the late Motorman H. Goldsmith was in no way responsible for the accident. In the first place,thetrainwas improperly allowed to leave Purley, and secondly, to enter the Purley Oaks-South Croydon Junction section. Judging by the severity of the collision, its speed must have been 40 to 45 m.p.h. when it over took the Haywards Heath train, travelling at 15 to 20 m.p.h. while passing South Croydon Junction Home signal after check by the Distant at Caution 

The primary cause appears to have been that Porter-Signalman H. D. Hillier of Purley Oaks entirely forgot the Haywards Heath train while it was in the station for six or seven minutes obscured from his view by fog. It is difficult to account for what transpired, but responsibility must rest upon him for his most irregular use of the key to release his Sykes instrument No. 18 thus destroying the protection afforded by the Lock-and-Block system to this train which was standing at Starting signal No. 19.

This followed Signalman Neary's telephone inquiry as to the position on the Up Main, upon which Hillier jumped to the erroneous conclusion that his instrument had failed, a very serious error on his part, particularly in fog. His confusion of mind must have deluded him into thinking that he alone was right and his instrument wrong ; thus his series of blunders were set in motion, the first being his transmission of the " Out-of-Section " signal for the Haywards Heath train, and then the release of the block to Purley North.

Nor were subsequent warnings of any avail in the absence of visual reminder of the train. Having used his key to cancel the front lock on Signal No. 18 and to free that instrument, which correctly registered " Locked," he was able incorrectly to accept, and lower signals Nos. 18, 19 and 17 for the Tattenham Corner train. Although he could not see or hear the Haywards Heath train start from a e station, he observed instrument No. 19 change from " Locked " to " Free " when the actuation of Treadle F released the backlock on the starting signal leper, but this did not warn him that something was wrong. He again falsely assumed that this second instrument had also failed, and re-set it to " Locked " without returnmg the signal to Danger.

He did not appreciate the significance of Signalman Walder's 3--1 bell signal acceptance, and assumed that this applied to the Tattenham Corner train, although that train had been offered to him by Neary only a few moments before on the 3-3-1 bell signal, and he had not offered it to Walder. Even when Hillier saw the headcode and informed Walder that the Tattenham Corner train was approaching, he was not reminded of the position, and it was not until Walder spoke to him after the collision that he realised his mistake  He frankly and immediately admitted it, and expressed deep regret.

Hillier's breakdown in instrument manipulation in this emergency must, 1 think, have been due tp some failing to appreciate the danger of irresponsible use of the key, and it occurred in the face of the most stringent Instructions, reinforced by the Superintendent of Operation in July, 1946. I know of no other Instruction which gives warning that improper use of apparatus may incur dismissal, and the Company at once took the view that he should be employed on other work.

The relevant Instructions provide for the sw~tch-hookbeing placed over the Sykes instrument plunger when the " Train-Entering-Section" signal is acknowledged, but Hillier presumably failed to do this when he acknowledged this signal for the Haywards Heath train. When he used the key his block indicator was in the raised position, as it had been so placed when the switch-hook was turned over the plunger by Signalman Walder at South Croydon Junction at the time he refused to accept the Haywards Heath train. Although Hillier therefore operated his signals for the Tattenham Corner train, the Haywards Heath train, which he had overlooked, started from Purley Oaks platform, and, as already mentioned, he thereupon failed to appreciate the significance of the freeing of instrument No. 19.

The recent failures of treadles referred to in Hillier’s evidence, and in particular that on the previous day when instrument No. 36 incorrectly changed from " Locked " to " Free," a danger-side failure, may have influenced him. It was also the first time he had worked in fog during his brief experience
of five months as a signalman. There were men of long service in the boxes on either side of him, and Signalman Neary's telephone reminder obviously surprised him and appears to have led him
to think that he was delaying traflic. In the circumstances, all that could have been expected of him was to do nothing until he had consulted the box on either side ; but there is, of course, the natural desire of a signalman to rely on his own initiative rather than on his colleagues. Presumably, however, he would have been told to ring up the man on duty on the platform to ask if a train was standing there awaiting the lowering of Starting signal No. 19.

Although Hillier was considered to be fully competent to take charge of Purley Oaks box, the circumstances of this accident led me to think that both he and Inspector Akehurst, who tested and passed him, overestimated his ability to work alone in a Main Line box under the stress of heavy traflic in adverse conditions, such as fog. I realise that Inspector Akehurst has many years’ signalling experience, and that signalmen even of long service have in the past misused the release key. But it seems to me that Hillier was allowed too rapidly to assume duties with too much responsibility, and the Company's Officers have assured me that the extent of training and the methods of examination and instruction will be reviewed ; as also the placing of men of short experience in Main Line boxes, even if used only as block posts, where peak traffic is as heavy as at Purley Oaks.

Having regard also to the sequence of three treadle failuresduring the week of the accident, to which should be added a fourth, namely that of Treadle E, which actually occurred during my inspection at Purley Oaks on 27th October, the question of insistence upon reporting such incidents by signalmen to the Traffic Department, as well as direct to the lineman, appears to require further emphasis ; by this means all in authority should be kept aware of the extent of such failures, and of the efficiency of maintenance. It should be added, however, that the Company’s statistics showed that,on this section of line, there had been no deterioration in the general standard of reliability, in spite of difficulties in obtaining staff and material. 

 

 

REMARKS

Lock-and-Block signalling apparatus is designed to afford complete protection, but it is necessary to provide some means for interrupting the normal sequence of operations. For example, a train which has been accepted may have to be cancelled ; in certain circumstances shunting operations affect other movements ; and provision has to be made for correcting failures of treadles to release backlocks. It is for such reasons, and others varying according to the locality, that a key is provided .sb that instruments may be legiti'mately re-set. The problem resolves itself into limiting the use of the key for essential purposes and preventing the signalman resorting to it at the wrong time. The Company accordingly has issued the strictest possible warnings against the misuse of this releasing device, and safety of operation naturally depends on the maintenance of a high standard of discipline.

The accident would not have occurred had colour light signalling and track circuiting been installed between Battersea Park and Coulsdon. as was the Company's intention. It was proposed to commence this work in 1940, but, like many other schemes, it had to be postponed on account of the war. Approval, however, has recently been given for this modernisation to proceed, and I understand that the Company's plans are well in hand. The present signalling in this area has been in use for over 50 years, and it is probably tme to say that no other mechanical system could have coped so efficiently with such heavy main line and suburban electric services. It is essential, however, that more modern equipment should be provided to deal with increased traffic and to afford even greater safeguardsagainst human error. It will also have the advantage of easing the man power position.

The over crowding of the two trains, and especially the leading coach of the second, undoubtedly increased the number of casualties. When traffic is running out of course due to fog, some overcrowding is inevitable. On this occasion, for example, the Haywards Heath train, which was moderately well loaded on leaving Coulsdon, was filled with local passengers when it was stopped by signal at Purley Oaks. The main causes of overcrowding are shortage of rolling stock, high concen- tration of traffic at peak periods, and insufficient line capacity. The last named will be assisted by the new signalling, and relief in respect of the others must depend on improved allocation of resources.

 

RECOMMENDATIONS

(a) Although Signalman H. D. Hillier acted in this instance without due sense of responsibility, his failure in the prevailing circumstances seems to have resulted from insufficient experience of the Sykes signalling system. In addition to reviewing their methods of training and examination, the Company should consider the propriety of placing men with short experience in charge of Main Line

(b) Stringent as the Instructions already are about using the release key, further consideration also appears desirable with the object of ensuring that the signalmen in the boxes on either side should be asked to advise and co-operate in any case of doubt. Alternatively,where applicable,the signalman concerned should be obliged to consult the platform staff before a Home signal, and/or Plunger, lock is freed.

(c) Greater emphasis appears to be necessary as regards signalmen reporting all failures of equipment to the Traffic Department, apart from the lineman being advised. This should facilitate the full recording of every failure, and ensure that all in authority may gauge the efficiency of maintenance 

 

 

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