BROMLEY JUNCTION 

13th NOVEMBER 1981

INVOLVING 

HORSHAM DRIVER CYRIL BROCKHURST 

& SELHURST DRIVER N.A. MARSHALL

ADAPTED FROM THE REPORT BY

P.M. OLIVER MAJOR

EVIDENCE-BROMLEY JUNCTION
Driver C. D. Brockhurst signed on duty at Horsham at 05.30 after normal rest and feeling perfectly fit. He worked Class 405 units Nos. 4725 and 4742 from Horsham to Victoria after a satisfactory brake test and then the same stock from Victoria to Beckenham Junction after a further satisfactory brake test had been carried out at Victoria with Guard Parle. When returning with the 08.23 train 2K44, from Beckenham Junction towards Victoria, the stop at BirkBeck Station was quite normal and he received a green aspect at the Platform Starting Signal, CA243. Brockhurst said that, after receiving a green flag signal from Parle, he opened the motors to the series position in anticipation of slight slipping due to fallen leaves on the rails on the rising gradient to Bromley Junction; consequently his speed was slightly slower than usual.
Brockhurst said that he had a good view of Signal VC746, the signal protecting Bromley Junction on the Up Bromley line, and it was displaying a Green aspect. He particularly remembered this, as on every previous day that week that he had worked the 08.23 from Beckenham Junction. the signal had displayed a Red aspect. He estimated his speed on passing the signal as being between 30 and 35 mile/h. After he crossed the bridge over the London Bridge to Norwood Junction lines he saw another Up train, the 08.22 from West Croydon, closely approaching Bromley Junction but that the junction points, No. 368, were correctly set for the passage of his train. He immediately closed the controller and made an emergency application of the brake. When he realised that a collision was inevitable. he released the driver's safety device and, when satisfied that it had operated, moved to the offside of his cab immediately before the nearside of the cab collided with the offside of the leading coach of the other train. 
He estimated that the speed of his train at the moment of impact was about l 5 mile/h.
Brockhurst said that he was unable to leave his cab as the nearside door was obstructed by train 2K44 and the offside cab door and the guard's communicating door had both jammed as a result of the collision. He noted that Driver Marshall from train 2K44 applied a track-circuit operating clip on the Down Bromley line after which he came to Brockhurst's cab and learnt that the latter was trapped but unhurt. He said that Marshall, after ensuring that the guards of both trains were protecting the rear of their respective trains, obtained a crowbar from his own train and released him through the guard's compartment communicating door.
Guard E. J. Parle was riding in the guard's compartment in the fifth coach of train 2R66. He noted that Signal CA243 was displaying a Green aspect before he gave Driver Brockhurst a 'right away' signal with his green flag to leave Birkheck Station. 
The progress of his train was normal until he was thrown forward by a fierce brake application, this was quickly followed by the impact of the collision.
Parle said that, on realising that an accident had occurred. he immediately alighted and placed a track-circuit operating clip on the adjacent Down Bromley line. He then went forward to the head of the train where he discovered that Brockhurst was unhurt but trapped in his cab. He checked with Driver Marshall that he would carry out full protection forward and his guard would protect the rear of train 2K44, and then made his way back along the Up Bromley line to carry out detonator protection at the rear of his train. On his return to the scene of the accident and having been assured by a member of the railway staff there that 
the traction current had been turned off, Parle assisted with the detraining of passengers from his train.
Guard H. S. Dhanoa booked on at Selhurst Depot at 06.11 and joined Driver Marsball to carry out both electro-pneumatic and Westinghouse air brake tests on Class 415 Unit 5007 before leaving to work the empty stock to Selhurst Station and thereafter working the 06.57 service to Holborn Viaduct. followed by the 07.35 to West Croydon. Dhanoa said that, after 
changing ends, they left West Croydon on time as train 2K44 for Victoria. He was riding in the rear guard's compartment and he clearly remembered noting that the Starting signal, JC95, at the London end of Norwood Junction Up Local Platform was displaying a proceed aspect together with a junction indicator for the Up Crystal Palace Spur, but he could not be certain what aspect. He did not see the Bromley Junction Signal, VC744, but, on approaching the junction, he felt what he thought was an emergency brake application being applied by his driver and then almost immediately he was thrown back in his compartment 
by the impact of the collision, slightly injuring his right arm.
Dhanoa observed that the train was on the Crystal Palace side of signal VC744 and that the front three coaches were derailed. 
On alighting from the train he started to make his way forward but Marshall. who was also on the trackside, saw him and signalled to him to go back. He therefore walked back to Signal VC744, which he checked was showing a Red aspect, telephoned the signalman, who confirmed both that the traction current was off and that protection had been given, and then put down three detonators, 20 yards apart, from the signal towards Bromley Junction. He then went back to his train to assist in detraining the passengers and conducting them along the trackside to Crystal Palace Station.
I questioned Dhanoa at some length concerning Driver Marshall. He considered Marshall had been behaving perfectly normally during his driving of the various trains that morning and he did not notice anything unusual when they met whilst changing ends at West Croydon prior to working train 2K44. Marshall did not discuss any personal problem with him nor, after the collision, did he comment on the aspect being displayed in Signal VC744 as the train approached and passed it.
Driver N. A. Marshall confirmed that he had booked on duty at Selhurst Depot at 06.26 on Friday, 13th November, having booked off duty at 13.00 the previous day. He considered that he was fit to drive but admitted he had a lot of personal and domestic problems at the time. He was due to collect his wife and newly born first child from hospital later in the day, the baby having been delivered with difficulty on 7th November. He had been visiting his wife in hospital each evening and not getting to bed until about 10.30 each night. In addition, his mother was very ill in Bournemouth and he had received telephone calls from 
his father each evening to let him know her condition.
On the night before the accident Marshall said he went to bed at 23.00, but had a poor night's sleep as he was suffering from a mild migraine and also had a wisdom tooth that was troubling him. When he got up at 04.45 on the Friday morning he took two 'Equagesic' tablets to help get rid of his migraine-he had been prescribed these over a year previously by his doctor for his intermittent migraine attacks and still had a small number left. Marshall said that his doctor did not issue any warning when he prescribed the tablets. but equally he had not informed his doctor that he was a train driver. At about 07.30, whilst at Holborn 
Viaduct, he took two more 'Equagesic' tablets and then at about 08.20, at West Croydon, he used some 'Superdrug Toothache Solution' mouth wash to relieve his toothache; he subsequently discovered that this solution contained 0.5 per cent chloroform.
Marshall was adamant that, despite his personal worries, his lack of sleep and the medicines that he took, he felt all right and quite capable of driving competently. The driving of the trains from leaving Selhurst Depot until arriving at West Croydon, as described by Guard Dhanoa, were, in his opinion, quite normal and without incident. He left West Croydon with train 2K44 on time at 08.22 and also left Norwood Junction Up Local Platform on time with the Starting Signal, JC95, clearly displaying a single Yellow aspect with a position '1' junction indicator. Marshall said he passed through JCY3 junction points onto the Up 
Crystal Palace Spur leading to Bromley Junction at about 20 mile/h; shutting off power at the normal position for sighting Signal VC744 which he expected to find displaying a Red aspect to protect the junction whilst the 08.23 Beckenham Junction to Victoria train, 2R66, preceded his to Crystal Palace, as booked in the working timetable. Marshall said that he was satisfied that when the signal came into his view it was displaying a single Yellow aspect and thus he reopened his controller to accelerate the train up to the maximum permitted speed of 20 mile/h through No. 368 points at Bromley Junction.
On closely approaching the junction, Marshall observed that No. 368 points were set for a train from Beckenham Junction and he immediately realised that he must have passed Signal VC744 at Red. He immediately released the Driver's Safety Device in order to make a full emergency brake application with the minimum delay hut failed to bring the train to a stand until his cab was just short of the switchblades of the junction points. Almost immediately Marshall felt his train surge forwards, his coach tipping towards the nearside cess and coming to a halt still leaning over.
Marshall said that, on seeing that a collision had occurred, he promptly applied a track circuit operating clip to the Down Bromley line, which appeared to be fouled and telephoned the signalman at Victoria Signal Box to inform him of the collision, request the isolation of the traction current on all lines and ask for the emergency services to be called. He then arranged for the two guards to carry out protection in rear of their trains and, seeing that passengers were getting out of his train, he telephoned the signalman again to confirm that the current had been isolated.
I questioned Marshall at length as to why he had passed signal VC744 at Red which he readily accepted he must have done, but he was unable to produce a definite answer. He agreed that his personal problems were tending to distract his concentration and that he might have retained the sight of Signal JC95 showing a single Yellow aspect in his mind. He was quite satisfied that the fact that he was using his sun visor and that the sun was tending to shine from behind him into the lenses of the signal did not cause him to mistake the aspect. In particular, had the sun caused a 'phantom' and more than one aspect appeared to be illuminated he would have immediately stopped and telephoned the signalman. The only effect of the sun could have been to have caused the Red aspect to appear less brilliant than at other times. At the time of the accident he thought he was thoroughly alert and in full control of his train, but he now accepted that this could not have been the case, although he was unable to say why this was so.
I also questioned Marshall as to whether, in his opinion, the provision of AWS (Unit 5007 was not fitted, but the ground equipment at Signal VC744 was operational), had it been available, would have alerted him and prevented him passing the signal at Danger. He accepted that AWS, which he was using for about 25 per cent of his driving hours at the time of the accident, was in general of positive assistance to the driver. Had his unit been fitted with AWS, however, whether the signal was displaying a single Yellow aspect or a Red aspect, he would have received the same warning, namely a horn and a black indication turning to a yellow and black indication on the depression of the cancellation button. He found it difficult to say whether he would have examined the aspect of VC744 more closely and possibly discovered his mistake or, being under the impression that it was displaying a single Yellow aspect. he would have cancelled the A WS without looking further at the 
signal.
I questioned Marshall further about his taking of the 'Equagesic' tablets. He said he was unaware that when the instructions on a medicine bottle stated "2 Tablets, 3 or 4 times a day" it meant that the maximum dose should be two tablets every six hours and thus he had taken double the prescribed dose on the morning of the accident. He said that on previous occasions he had taken a similar dose without any ill effects. Marshall said that he was aware of Section A, Clause 1.2.2. of the Rule Book dealing with the taking of intoxicating liquor or drugs whilst on duty but he did not drink nor did he consider that 'Equagesic’ 
tablets came under the class of drugs referred to in the rule. Marshall said that he had not seen the "Drink and Drugs-not a good mixture. Have no doubts, Ask your Doctor" poster, nor the similar pamphlet issued by the Safety Advisory Service, until after the accident. To the best of his knowledge the poster appeared in all Mess Rooms on about 26th November 1981. Finally, Marshall said he had been back to see his doctor since the accident and the latter had said that, if he had been told that Marshall was a locomotive driver, he would have informed him of the effects of the tablets.

Dr. M. I. Andrews, the Senior Medical Officer, Southern Region, said that he had investigated the medical aspects of Driver Marshall's case with particular reference to his taking 'Equagesic' tablets prior to the accident. On the manufacturer’s data sheet, which is the standard method of advising the medical profession on the prescribing of various drugs, it is stated 
This product rarely causes drowsiness hut patients receiving this medication should not drive or operate machinery unless the drug has been shown not to interfere with physical or mental ability". Doctors prescribing such drugs in many cases, however, did not either warn the patient verbally or request the pharmacist to place a written warning on the bottle containing the drug.
Dr. Andrews stated that the effect of a person taking four tablets within about 3 hours, twice the prescribed dose, could vary from no side effect at all to obvious drowsiness. As far as Marshall was concerned the drug would have had an enhanced effect on him of which he would not have been subjectively aware. due to his very short night and the fact that he slept badly. 
Marshall's state of health was normal when Dr. Andrews examined him, as was his visual acuity and colour vision.
Signalman G . F. W . Twilley was on duty on No. 3 panel controlling the Bromley Junction area of the new Victoria Signal Box on the morning of the accident. He gave preference to the 08.23 train from Beckenham Junction over Bromley Junction, as shown in the Working Timetable, and set the route from Signal VC746 to VC742, noting that the indication for Signal VC744 remained Red. Shortly after he noted that No. 368 points were indicating that they were out of correspondence and almost immediately he was telephoned from Signal VC744 to be told that a collision had occurred, whereupon he immediately sent the 
'emergency alarm' signal to Norwood Junction Signal Box. Shortly after he was telephoned from the telephone at No. 368 points, told that there had been a collision and requested to summon the emergency services; he immediately sent the emergency alarm to Beckenham Junction and the regulator called the emergency services. He protected the area of the collision by replacing all protecting signals to Red and using reminder appliances.
Twilley confirmed that he and not Signalman Taylor, who was supervising his duties, had set the route for train 2R66from Signal VC746 to Signal VC742 and that neither he nor Taylor had previously set the route from Signal VC744 to Signal VC742 for train 2K44 and then changed their minds. He pointed out had they done so, Signals VC744 and VC746 would have been held at Danger for two minutes before the other route could have been set.
Signalman I. J. R. Taylor confirmed that he was supervising Twilley on panel No. 3 in Victoria Signal Box on the morning of the accident and, in general, confirmed Twilley's evidence. Taylor said that, immediately after the accident, Selhurst Electrical Control telephoned to advise them that there was a dead short in the Crystal Palace area, was informed that there had been a collision and the controller in turn confirmed that he had discharged all current in the Crystal Palace-Bromley Junction area.
Before the collision the signalling equipment in the Bromley Junction area had been working satisfactorily and Signals VC744 and 746 had been operated manually and not in the automatic mode. Taylor was also emphatic that the route had been set for train 2R66 between Signals VC746 and VC742 in accordance with the Working Timetable and that at no time immediately prior to the accident had the route been set from Signal VC744. cancelled. and then altered.
Mr. C. S. French, the head of the Rules and General Section, South Eastern Division, was travelling from West Croydon to London Bridge in train 2K44 on the morning of the accident. He was seated next to the window, facing forward on the nearside of the first compartment of the leading coach and, after a steady run up the bank from Norwood Junction, as if the driver had the route clear for him through Bromley Junction. he saw Signal VC744, showing a Red aspect from shortly before or just as the driver's cab passed it. Almost immediately there was a grinding noise and the train came to a halt with his coach 
leaning over towards the cess. After discovering that a collision had occurred, he obtained confirmation from Victoria Signal Box that the traction current had been isolated and then assisted in the detraining of passengers until the emergency services arrived.
Signal and Telecommunications Supervisor L. D. Bond, on being told of the collision. went direct to the Crystal Palace Relay Room, arriving there at about 09.40. He checked No. 368 point relay, finding it was in the 'normal' position, and then proceeded to Bromley Junction to inspect the S&T equipment and assess the damage to it. He examined No. 368 points on the ground and found that the right hand switch, which should be closed when the points are set 'normal'. had been run through, although the facing point lock in the point machine was still intact. The stretcher bars and other connections were bent, and he was able to see clearly where the wheels of the train coming up the Crystal Palace Up Spur had scraped metal off the switch blade and distorted it from the closed position. He checked Signal VC744 and found it was displaying a Red aspect; in his opinion its brilliance was what one would normally expect and was not affected by the sunlight.
Later Bond tested the cables leading to Signals VC744 and VC746 and found that these were satisfactory in all respects. The next morning he checked the aspect sequences between Signals JC95 and VC744 and found that they were correct in accordance with the control table.

Technician Officer P . J. Scon was called to the operating floor of the Victoria Signal Box when the accident occurred and noted all the indications on the panel in the Bromley Junction area. Of particular significance, No. 368 points were indicated as 'out of correspondence', and the route indication lights of the short section of track circuit between Signal VC744 and the points were not illuminated. Both these indicated that the route through Bromley Junction had been set for train 2R66 on the Up Bromley line and not set for train 2K44 from Norwood Junction up the Crystal Palace Spur. Further confirmation of this and the fact that train 2K44 had passed Signal VC744 at Danger was given since the description of 2K44 was still in the berth track of Signal VC744 while that for 2R66 was in the berth track of Signal VC742, having advanced beyond the junction.
Mr. R. Remnant, the New Works Assistant associated with the commissioning of the new Victoria Signal Box and Mr. P. H. I. Green, the Assistant Divisional Signal Engineer, Central Division, had collaborated in carrying out a series of additional tests of the signalling, the former in the signal box and the latter in Crystal Palace Relay Room. The tests had to be carried out in this manner because trains were running into Crystal Palace Station and thus it was virtually impossible to carry out tests purely on the local panel. The main testing was to prove that the approach locking on Signals VC744 and VC746 was correct and that the approach locking and route holding on No. 368 points was correct. Mr. Green confirmed that, from the results of the tests carried out by him or on his behalf, the signalling at the time of the accident was functioning correctly and that Signal VC744 was displaying a Red aspect when passed by train 2K44.
Mr. Remnant explained that he was responsible for testing the interlockings from the panel in the signal box as each interlocking, housed in a relay room, was commissioned. With the Crystal Palace commissioning on 9th August 1981 there had 
been one or two minor faults, but the two routes involved in the accident, from Signal VC744 to Signal VC742 and from Signal VC746 to Signal VC742, had been completely trouble free. He was not aware of any faults in the area between then and the accident apart from one instance of a high resistance contact in the Signal VC744 circuit in the relay room-a safe side failure.
Mr. Remnant pointed out that among the tests which were carried out following the accident was the lamp and controls feature between Signal VC744 and Signal JC95. The control is such that Signal JC95 will only clear if there is a Red aspect showing in Signal VC744 or if the route ahead of the latter signal has been set. This control was found to be correct and this gave further proof, as the route ahead was not set, that Signal VC744 was passed by train 2K44 when it was displaying a Red aspect.

CONCLUSION

The direct cause of this collisions was the passing of the signals protecting Parks Bridge and Bromley Junctions respectively at Danger.
The reason why Driver Marshall drove past Signal VC744 at Danger is, in my opinion, more easy to explain. He was short of sleep, having only gone to bed at 23.00 the previous evening and having got up at 04.45 after a poor night’s sleep resulting from a mild migraine and a wisdom tooth that was troubling him. He then proceeded to take two 'Equagesic' tablets twice in under three hours, double the dose prescribed by his doctor, and, in addition, he had considerable personal and domestic problems. 
His mother was seriously ill in hospital and his wife and newly born first child, which had been born with complications on 7th November. were due to be collected from hospital later in the day. I have little doubt that the combination of worries, lack of sleep and an overdose of an analgesic-cum-tranquiliser medical drug, albeit a mild one, was sufficient to reduce his normal state of alertness so that he was unaware that he was passing Signal VC714 at Danger. As stated by Dr. Andrews, the fact that Marshall considered at the time that the drugs had had no effect on his alertness is no indication of his real state. as they might well have had an effect of which he would not have been subjectively aware.
The situation as regards AWS was similar to that of Driver Hazard at Parks Bridge Junction, namely the unit which Marshall was driving, EPB No. 5007, was not fitted with AWS, although the line on which it was running and, in particular, Signal VC744 was fitted. Marshall was not sure that the AWS, if operating, would have alerted him that he was approaching the signal at Red. 
He said he was under the impression that the signal was displaying a single Yellow aspect and thus he might have reset the AWS without looking further at the signal. as the warning of a horn and the visual indication of a black and yellow aspect, on his pressing the acknowledgement (cancellation) button, was the same for both Yellow and Red signal aspects. Obviously it is not possible to prove that, had AWS been operational on the line concerned, Marshall would not have passed Signal VC744 at Danger but 1firmly believe it might have. 

REMARKS AND RECOMMENDATIONS

The Automatic Warning System

These two accidents must join the list of other accidents on the Southern Region which would in all probability have been avoided had the signals and trains concerned been fitted with AWS. The subject of AWS on the Southern Region, or rather the delay in fitting it. has been dealt with by several Inspecting Officers in their Reports of Inquiries into collisions on the Southern, the last of which was by Major C. F. Rose in his Report on the collision that occurred on 19th December 1978 between Hassocks and Preston Park, where he set out the history of AWS on the Region up to the end of 1978. I do not need to reiterate the background up to 1978, but to briefly set out the current position. 

Of the 850 route miles remaining to be fitted with AWS track equipment at the end of 1978, 652 route miles have been fitted or will be fitted within the next two years. This will still leave 198 route miles to he completed and 1 am assured by the British Railways Board that a high priority is being given to completing this, despite the current financial limitations with which they are having to contend. While Major Rose recorded that the full planned provision of A WS would be achieved by 1985, the situation at the time of writing this Report is that all the routes on the Southern Region, due to be fitted with AWS in accordance with the Board’s signalling principles, will be fitted by the end of 1986 with the exception of the Paddock Wood to Strood line (21 route miles) and the Ashford to Minster line (26 route miles) which will be completed in 1987. While this represents a slippage in the programme agreed with Major Rose, I am satisfied that the programme 1 have outlined above represents the best 
possible one that can now be achieved and that all the Chief Officers at the Board and in the Southern Region fully appreciate the vital importance of ensuring that no more delays occur. 

As is illustrated by this Report, the AWS problem is not only confined to the track equipment but also to the fitting of the train-borne equipment including the audible and visual warnings in the cab. I am assured by the Chief Mechanical and Electrical Engineer of the Southern Region that the fitting of this equipment is well up to schedule and all locomotives, DMU, DEMU and EMU to he retained in service beyond the end of 1985 will have been fitted before that date. While I have no reason to question this statement, which was given in good faith, I consider it essential, in the event of any serious delays in the withdrawal of older classes of rolling stock from service beyond the end of 1985, that such stock should also be fitted with AWS. With all drivers relying increasingly on the assistance given by AWS, it would be even more dangerous than in the past for drivers to be denied the use of this important safety aid when it was in use virtually universally.

Dangers from Alcohol and Medical Drugs78. Following my Inquiry into the collision that occurred at Chinley North Junction. in the London Midland Region, on 14th February 1978, I recommended that the leaflet, issued originally in 1975, warning train crews and other operational railway staff of the dangers of mixing alcohol and medical drugs also the necessity of informing one's doctor of one's job if drugs were being prescribed. should be re-issued forthwith and thereafter at regular intervals and to all new recruits on entering railway service. This pamphlet was re-issued throughout British Railways, with the exception of the Southern Region, in 1980. I have been unable to discover why no action was taken by the Region to re-issue the pamphlet in accordance with the instructions of the then Director. Industrial Relations. British Railways Board. I am glad to state. however. that immediately after the Bromley Junction collision the leaflet was re-issued to all the appropriate staff on the Southern Region and I was assured that reminders would in future be issued at two yearly intervals. I strongly recommend, particularly with the current reorganisation within British Railways that steps be taken both at Board and Regional level to ensure that the dangers from alcohol and medical drugs are drawn to the attention of all appropriate staff at regular two yearly intervals.