1902


WEST CROYDON 

9th JULY 1902

INVOLVING 


DRIVER HENRY WINTERTON AND HIS


FIREMAN ERNEST WILLIAM WEBB 


Extracted and adapted from the report

P. G. VON DONOP,

 Lt.-Col., R.E.


A passenger train was derailed at about l1 a.m. on the 9th July, near Vest Croydon Station, on the London, Brighton, and South Coast Railway.

In this case, as the 10.30 a.m. down passenger train from London Bridge to Bognor, consisting of an engine and five vehicles, was passing the West Croydon Station signal- box on the down main line, all the vehicles of the train were derailed, with the result that the two lending ones mere thrown over on their sides across the lines. The coupling between the engine and the lending vehicle broke, so the engine kept the rails and ran on into the station without sustaining any damage.

Forty-five passengers received personal injuries, some of them being serious, and at the time of my inquiry seven of these passengers were still detained in hospital.

The engine of the train was a six-wheels-coupled radial tank-engine, running chimney first ; it was fitted with the Westinghouse automatic brake, working blocks on the six coupled wheels, and with a hand-brake working the same blocks.

The train consisted of the following vehicles, attached to the engine in the order given :-
1 third-class carriage,  6 wheels, third-class carriage,  4 wheels, second-class 4 wheels, first-class 6 wheels, 1 brake-van 6 wheels.

The damage to rolling stock and permanent way is given in the Appendix.

Description.

West Croydon Station, near which the accident occurred, is a station on the London, Brighton, and South Coast line from Norwood Junction to Sutton the station is provided with up and down platforms, and the main lines run through them in a direction which is approximately north and south, the down line, on which the train concerned in this accident was running, being on the east side.

The signal-box is on the west side of the line, about 120 yards to the north of that north end of the up platform.

The next signal-boxes to West Croydon in the London direction are St. James' Junction, Normood Fork, and Norvood Junction their distances are as follows :-

West Croydon to St. James’ Junction 53 chains. StJames’ Junction to Norwood Fork 33 chains. Norwood Fork to Norwood Junction 52 chains.

The approach to the station from the north is on a left-hand curve of 16 1/2 chains radius. and the gradient is a gently falling one of in 480.

At a point l80 yards north of the signal-box there is an overbridge carrying a road over the line.

The positions in which the five vehicles of the train were respectively found after accident were as follows:-The leading vehicle was lying on its left side across the up and bay lines at a point about 30 yards north of the north end of the up platform; was thus derailed to the right of the down line, on which it was running, and it was lying just clear of, and nearly at right angles to, that line. The second vehicle was also over turned on its left side, and it was found lying in a slanting direction across the down line, its leading end being to the right of that line and its trailing end to the left of it. The remaining three carriages were standing upright, but each one of them had some of its wheels derailed a short distance to the right of the down line.

The first marks on the permanent way connected with this derailment were found at point just to the north of the West Croydon signal-box, 51 feet distant from the facing far connection on the down line leading to the bay line ; at this point there was a mark on the right-hand rail of a wheel having run across the top of that rail from the inside to the outside, and just opposite this point the inside of the chair supporting the left-hand rail had a corresponding mark on it of a wheel having left that rail and fallen into the four foot way. It seems clear, therefore, that one pair of wheels was derailed at this point to the right of the line.

From this point forward, up to the facing point, wheel marks continued to show regularly on the chairs and sleepers on the right of each rail of the down line, the lines of marks gradually becoming more distant from the rails, as if the derailed wheels were gradually bearing away from them at the facing point itself the marks inside the rail were about 7 1/2 inches distant from that rail the stretcher-bar and connecting rod of the facing point were both cut through just inside the switch-rail, and from this point forward the marks appear on the right of the rails of the bay line instead of those of the down line it is clear, therefore, that at the facing point the derailed wheels, instead of continuing along the down line, bore away to the right in the direction of the bay line. About l5 yards beyond the facing point the left-hand rail of the bay line was badly bent outwards, as if the derailed wheels were at that point being forced back towards the down line. Up to this point the marks on the permanent way appeared to be due to only one pair of derailed wheels, but from this point forward marks appeared both on the bay line and on the down line, SO that it is clear that after passing this spot more than one pair of wheels was off the line. At the point where the left-hand rail of the bay line crossed the right-hand rail of the down line considerable damage was done, the check-rail and wing rail being both cut through, and ahead of this point chairs were broken and sleepers marked both on the bay line and down line, and to a small extent on the up line, right  up to the place where the carriages were found to have come to rest.

The train also was fitted with the Westinghouse automatic brake, working blocks on four wheels of each vehicle. The brakes are all reported as having been in good order. .

At the back of the up platformi.e., on the west side of it, there is a bay platform line, terminating at its southern extremity in buffer-stops it is used for both the arrival and departure of London trains, and it has, therefore, to the north of the station connections with both the up and down lines the latter connection, which is a facing one, is situated just opposite the south end of the signal-box, and the former connection, which is a trailing one, is about 50 yards nearer the station.

Henry Winterton, driver, states : I have been 26 years in the service of the Company, during two or three years of which I have been passenger driver, previous to that I had been driving goods trains for about seven years. On July 9th, I came on duty at 3 a.m. to work till 12.30p.m. I came off duty on July 8th at 2.30 p.m. On the 9th July I WAS in charge of the 10.30 a.m. train from London Bridge to Bognor ; my engine was a six-wheels-coupled radial tank engine travelling chimney first. It was fitted with the Westinghouse automatic brake working the blocks on the six coupled wheels, and with a hand brake working the same blocks. My automatic brake was in good order. At Norwood Fork Junction where I was stopped before arriving at West Croydon, my pressure was 75 lbs., and, as my donkey engine was then still at works I should had about 80lbs. pressure or more at the time of arriving at West Croydon. The guard and I tested the automatic brake before leaving London Bridge, and it was in good order. I was stopped three or four times before arriving at West Croydon, and in all these cases I made use of the  automatic brake, and on all those occasions it acted well. I was thoroughly satisfied with the condition of my brake. I think we were a minute or so late in leaving London Bridge, The only place at which I was due to stop before reaching West Croydon was Norwood Junction. I arrived at Norwood Junction at about 10.45 which was about eight minutes late, the delay being due to my having been stopped by signal. After leaving Norwood Junction I was stopped again Norwood Fork the signal being against me. was delayed about one minute. We left Norwood Fork, and ran through St.James' Junction without stopping, and on approaching West Croydon the signals were all off for me to run into the station. remember passing the West Croydon signal-box. noticed nothing unusual with the running of my train when passing the box. nor was there anything at all unusual when my engine passed the facing point almost opposite that box. We ran through the facing point quite smoothly, and at that time nothing at all seemed wrong with my train. When we were a few yards beyond the facing point, my mate called my attention to the fact that my train was rocking. did not myself look back, but at once applied the automatic brake. At this time steam was shut off. had shut off steam when passing the laundry which is situated about 500 yards from the signal- box, and did not turn steam on again at all. had not applied my brake at all up to the time that my mate told me that the train was rocking. estimate our speed at passing the signal-box at When my mate thought the train was rocking, I at once tried to apply my Westinghouse brake but I found that the air was all gone. my mate had already got the hand brake applied, I then at once reversed my engine and gave her steam, the wheels however skidded, and the engine ran on into the station. At that time it had no carriages attached to it at all. did not myself notice the vehicles behind my engine become detached. Just after my mate had called my attention to the train, the communication hell on my engine began ringing. then went back to the train to assist. Up to the time of leaving my engine had no idea what had been the cause of the accident. After leaving Norwood Fork my train was not checked in any way by fixed signals or hand signals.

Ernest William Webb, fireman, states have been l0 years in the service of the Company, during about three of which 1have been fireman. previous to that had been a labourer, and engine cleaner. On July 9th came on duty with driver Winterton to work the same hours as he did, and had been working with him the day before. was with him on the 10.30 a.m. train from London Bridge to Bognor. Before leaving London Bridge did not notice anything special in connection with the automatic brake. Before reaching West Croydon we stopped think twice on the journey, and on those occasions there was no difficulty in stopping the train, the brake appeared in good order. remember running past the signal-box at West Croydon at that time steam was turned off. It had been turned off when passing the laundry. No brakes were applied to the train at the time of passing the signal-box. should estimate the speed of the train when passing the signal-box at 14 or 15 miles an hour. noticed nothing unusual with the running of the train either when passing the signal-box or when running through the facing point. The first noticed of anything being wrong with the train was at a point about 25 yards beyond the facing point, when at that point I turned round to apply my hand brake. I saw the train rocking about. At that time the carriage next my engine was, think, about five feet from us, and was uncoupled from the engine. It seemed to be off the line on which my engine was running. As looked back towards the train the leading vehicle of it was a trifle to my left. I immediately called my mate's attention to it, and at once applied my hand brake. Immediately had applied my hand brake I looked back again and saw the leading vehicle take a sharp turn to my left, it seemed to sway once or twice, and then the two leading carriages fell broadside. think my engine was about 40 or 50 yards ahead of those vehicles when they fell on their sides. then went back to render what assistance could. From what saw of the derailment could form no opinion as to what was thc. cause of it. Just as spoke to my mate the inter communication bell on the engine began ringing. We had been stopped at Norwood Fork, but the train had not been checked by signals after leaving that point.

 

Alfred Molyneux, guard, states have been 19 years in the service of the Company, during 15 of which have been passenger guard. came on duty on July 9th at 7.45 a.m., to work till 8 p.m. had come off duty on July 8th at p.m. was guard of the 10.30 am. train from London Bridge to Bognor. I have frequently acted as guard to this train before. My train consisted of the following vehicles, attached to the engine in the order given :-

One third class carriage 6 wheels, one third class carriage 4 wheels, one second class carriage 4 wheels, one first class carriage 6 wheels and Brake van 6 wheels.

All these vehicles were fitted with the Westinghouse automatic brake, working blocks on four wheels of each vehicle. The automatic brake was in good order. I tested the automatic brake in the usual way before leaving London Bridge Station, and found everything satisfactory. think that when we left London the pressure was about 60 lbs. did not notice subsequently on the journey what the pressure was. We left London Bridge at 10.31, one minute late my first two booked stops were Norwood Junction and West Croydon. We were stopped by signals at Blue Anchor signal box, and at Croydon up junction, and we stopped again at Norwood Junction Station. On all those three occasions of stopping, the automatic brake was made use of, and it appeared to act well, and I was thoroughly satisfied with condition of the brake. We left Norwood Junction at 10.54 a.m., which was seven minutes late. After leaving Norwood Junction we were stopped again at Norwood Fork signal box, the signal being against us. We were stopped there for two minutes. We left Norwood Fork at 10.58 a.m., and we were not stopped again between there and West Croydon. I myself saw the signals between those two points, and they were all off for us. We were about to stop at West Croydon Station. I can give no information as to when steam was turned off. I noticed that the automatic brake was slightly applied when we were about 200 yards from the signal box. It seemed to me that it checked the train al little, and that it was then released again. The automatic brake seemed to be released just before we reached the signal-box. I estimate the speed of the train between the bridge and the signal- box at about 15 miles an hour. I think 15 miles is the outside limit of the speed at which the train was travelling. As me were passing the signal-box I was looking out from my look-out, window on the near side of my brake-van. The first thing I noticed, was seeing the leading vehicle of the t'rain oscillating, and in a moment the carriage swerved to the right, turned over, and the next one did the same. I noticed that then the automatic brake was suddenly fully applied, and I felt the blocks going on the wheels. I felt the brake going on, but I cannot say how it acted, everything happened so suddenly. 1 could not form any opinion as to what had caused the derailment, but I saw it was something which had happened to the leading vehicleI cannot say when the leading vehicle became uncoupled from the engine. It was when we were passing the signal-box that I looked out, and I did so for the purpose of seeing how me were running into the platform. After the accident occurred I went and rendered all the assistance I could, and I examined the site of the derailment. The opinion I formed after viewing the site of the derailment, was that the engine had spread the rails, causing the wheels of the leading vehicle of my train to drop in between the rails. The derailment occurred just at 11 a.m. We had been due at West Croydon at 10.51 a.m., so that we were then nine minutes late.

Walter Summerfield signalman, states have been 38 years in the service of the Company, during 36 of which I have been a signalman. I am now employed at West Croydon North Box, and I have been employed there for 18 years. 1 came on duty on July 9th at 6 a.m. to work till 2 pm. 1went off duty on the 8th July at 2 p.m.. I remember the 10.:30 a.m. train from London Bridge to Bognor passing my box. The train had been duly offered to me by St. James' Junction signal-box and duly accepted by me at 10.55 a.m. The train arrived at my box at 11.1 a.m.-all my signals were off for it. I had received no warning from the platelayers of any work going on on the line, and there was therefore nothing to prevent my accepting the train. saw the train when it was approaching my box from the bridge. My impression is that the speed of the train when approaching my box was about 30 miles an hour. The speed did not seem to be unusually high for a train that was going to stop at the station. It appeared to me to be about the usual speed at which the trains do run in when they are going to stop. cannot say whether steam had been shut off when the train passed my box, nor can I say whether any of the brakes mere applied. The first knew of anything being wrong with the train was hearing the noise caused by the train running over my lever rods, knew then that something had gone wrong at the facing point. On hearing the noise looked up and at once saw the carriages tumbling over each other. I saw nothing to enable me to form an opinion as to how the derailment had occurred. did not see any workmen on the line near my box and I did not know that any work was going on on the line. The plate layers often do come and warn me when there is work going on on the line, but on this occasion.

Robert Gibbs, signalman, states: I have been 41 years in the service of the Company, during 39 of which I have been a signalman. I am now employed at St. James’ Junction and have been employed there for 27 years. I came on duty on July 9th at 6 a.m. to work till 2 p.m. I went off duty at 2 p.m. on the 8th July. I remember the 10.30 a.m. train from London Bridge to Bognor running past my box. I had offered this train to West Croydon at 10.53 a.m. West Croydon gave me line clear at 10.55 a.m. The train passed my box at 10.59 a.m. I did not stop the train at my box at all. The train did not pass my box at a high rate of speed as it had been stopped at Norwood Fork, but I cannot say what the speed was when it passed box. 
Mr. William Willox states : I am district engineer of the Northern Division, and am in charge of West Croydon. I was on the scene of the accident half an hour after it occurred, and made a careful examination of the site. The first marks I found on the line to account for the derailment were at a point 51 feet from the facing point opposite the signal box. At that point there was a distinct wheel mark on the right hand rail showing that a wheel had passed on that point from the inside to the outside of the rail. There was a corresponding mark on the inside of the left hand rail looking as if at that point a wheel had left the rail and fallen into the four foot. From that point forward up to the facing point there were marks, first on the chairs and then on the sleepers, al these marks being on the right hand side of the respective rails. The marks seemed to run parallel with the rail for a certain distance, and then, as they approached the facing point, they seemed to get further away from th rail. At the facing point the connecting rod and a stretcher bar were both broken. The breakage in these bars was at a point 7 1/2 inches from th stock rail, and just inside the switch rail. From this point forward the wheel marks continued on the right hand side of the rails leading to the bay line, and one of the left hand rails of that line was badly bent. Where the bay line crosses the right hand rail of the down road the check rail and wing rail were both broken, and the wing chairs were broken. Beyond that point again there were a number of chairs broken, sleepers marked, and one rail was bent. The opinion I formed from this examination was that the derailment had occurred at a point 51 feet before the facing point. On looking to ascertain the cause of the derailment I noticed that some of the chairs on the sleepers just in front of the point where the derailment appeared to have occurred had been unspoken. I noticed six chairs under the right hand rail had been unspoken; there of these chairs I noticed were fastened by spike having been driven into the sleeper on the outer lip of the chair; the remaining three were not fastened at all. The first mark of the derailment occurred at a point 4 feet 6 inches beyond the last of these unspoken chairs. I once measured the gauge at the points where the chairs were unspiked, and found that the line was a full 1 1/2 inches wide to gauge. The line at this point is on a curve of 16 1/2 chains radius. At this point the gauge is usually made between 1/8th and a 1/4 inch wide to gauge. It appeared to me that the engine had spread the line making the gauge 1 1/4 inches wider than it had been. I took the super elevation at that point, and found it  1 5/8 inches. This super election is quite as much as I consider it should be, considering that there was a facing point just ahead of it. I ascertained that there had been a working party at work on this portion of the line. I am of opinion that the state in which the line was left was not safe one, and that it was one that necessitated a train either travelling at reduced speed or being brought to a stop. In my opinion it was distinctly a case in which the ganger should have carried out the instructions contained in Rules 253and 251, so that the speed of the train should either be slackened, or the train brought to a stop. In my opinion the train should have been brought to a dead stop before passing over this bit of line, and that would have been in accordance with the regular custom on our line. The ganger in charge of this work was ganger Hackett, who has been 23 years ganger of this section. He has hitherto  proved himself a good reliable ganger, and cannot myself understand why he did not take the necessary precautions. My own opinion is that the primary cause of the derailment was that the leading wheels of the leading vehicle left the rail at a point just, beyond the place at which the chairs had been loosened. consider that the state of the line may have been a contributing cause to the accident. tried the gauge of the line at several points where ganger Hackett had not been at work, and at all these points found the line about half an inch wide to gauge.

Samuel Richard Hill states am platform inspector on the London, Brighton, and South Coast Railway, and have been so employed for about 30 years. At the time this accident occurred was standing on the platform at West Croydon Station, and was watching the 10.30 a m . train running into the station. was standing on the down platform opposite the door of the inspector's office, could not see the train when it passed through the bridge, but could see it just by the signal-box. The first thing 1 noticed of anything having gone wrong was seeing that the coaches were jumping about. The engine appeared quite steady. The leading vehicle was somewhere near the signal-box when first saw it jumping about. The engine appeared to run straight on down its proper road, while the vehicles appeared to turn off in the direction of the bay line, and finally the two leading vehicles were upset. could not form any opinion as to what had been the cause of the derailment. The train was too far of from me at the time. should roughly estimate the speed of the train when it passed the signal-box at about l5 to 20 miles an hour.

Joseph Hackett, ganger, states have been ganger for nearly 23 years, and have been in charge of this section nearly all tall that time. On the 9th July was at work on the line just opposite the West Croydon signal-box. had found that the line at that point was a little bit out of gauge. had found that it was about an inch wide to gauge. usually have the line at that point a little slack to gauge, on account of its being on a curve, but on this occasion I found that it was too slack, and I made arrangements for making it up to the right gauge. In order to do this I withdrew the spikes from six of the chairs supporting the right-hand rail. then adjusted tbe road to the right gauge, and drove in some spikes behind the lips of some of the chairs. drove spikes behind the lips of three or four of the chairs. am sure drove in as many as three, but am not sure whether drove a fourth or not,. This was the state of the road when the 10.30 a,m. train arrived and the accident occurred. About three quarters of an hour after the accident occurred examined the gauge of the line again at this point and found that the line had become a bit wider than it was when had shoved it in. cannot say exactly how much wide to gauge it was. had not taken any steps before carrying out this work to warn drivers as to what was being done because on account of the short space over which was loosening the chairs did not think there was any call for it. am well acquainted with Rule No.253, and know that when owing to repairs it is necessary for a train to travel at reduced speed, have to take steps to warn drivers. did not consider that there was any necessity for a train to travel over the place which was repairing at  reduced speed. was aware that the rail which I was loosening was an outside rail on a curve, and knew that the outside rail of a curve is subject to great pressure when a train runs over it, but did not see any danger whatsoever in what I was doing to the line. distinctly gave thought to the question hether it was desirable to take any precautions, and I was distinctly of opinion that there was no necessity. am in charge of the part of the line at which this accident happened. always inspect this bit of line twice a day, and had inspected it on the morning of 9th July, and it was on that occasion that found that the short length was wide to gauge. In all other respects thought that portion of the line was in good order. have not been able to form any opinion as to what was the cause of the derailment. have often done a piece of work vary similar to this and left the line in the same condition for a train to run over it, as on this occassion, without having a flagman out. I cannot say whether it is customary for every ganger to act similarly. cannot give any precise instance in which have carried out similar work in a similar manner.

George Harbour, permanent way inspector,  stateshave been upwards of 40 years in the service of the Company, and have been permanent way inspector for 16 years. am in charge of what is called No. District, which includes West Croydon Station. Ganger Hackett is employed under me, and is specially in charge of West Croydon. did not know precisely what work ganger Hackett was carrying out on the morning of the 9th July, but since the accident, occurred have heard of the work he was engaged onunderstand that on account of the road not being right to gauge, he was working on it on that morning. have heard ganger Hackett's evidence read over to me, and understand from that the way in which he carried out his work othe morning of the 9th July. am of opinion that, considering the state in which ganger Hackett had left the line, he ought certainly to have had a flagman out. consider that the train should have run over this bit of line, either at a reduced speed, or that it should have been brought to a stop altogether before doing so. I am of opinion that ganger Hackett left the line in an altogether too weak condition. It is not customary on our line to leave a bit of line in a similar state to what ganger Hackett left this bit on this occasion, and if had known that he was going to do as he did, should certainly have taken steps to prevent it. Ganger Hackett has been serving under me for about seven years, he is an energetic man, but have not always approved of the way in which he has carried oat his work. I, at all events, think that he committed an error of judgment on this occasion. I reached the scene of the accident at 1 .m., and on seeing the situation, the opinion I formed was that the derailment was primarily due to the weakness of the bit of line on which ganger Hackett had been at work.

Mr. Edwin Willian Trangmar, states: I am district locomotive superintendent. After the accident occurred the engine was examined by the local foreman, and everything being found satisfactory, it was sent off to Sutton, and it continued in work for the rest of the day. As far as I know, nothing in any way has been found amiss with the engine since that time. Its brake apparatus is in perfectly good order. Immediately the leading vehicle of the train was on to the rails after the accident, its wheels were examined, and they were all found perfectly correct to gauge. The wheels of all the other vehicles in the train were also examined after the accident, and all were found to gauge except those of the second vehicle of the train, both axles of that vehicle were found to be bent, and the wheels to be consequently out of gauge. The wheels of all the vehicles of this train had been examined before the train left London Bridge, and no report had been received of anything being found wrong with any of them. Nothing has transpired since the accident to render it probable, in my opinion, that there was any defect in the wheels before the accident occurred. I visited the scene of the accident after it occurred. I know the point at which it appears probable that the derailment first commenced, and I know the position in which the carriages were found after the accident. I understand that the distance between the point where the derailment first occurred, and the point where the leading carriage eventually came LO rest. was 340 feet. I have heard the evidence given i several witnesses that the speed of the train was about 15 miles an hour. I cannot understand how the train travelled this distance unless it was travelling at a higher rate of speed than that given, or it may have been the train did not become uncoupled till some distance beyontd this point. I have examined thoroughly the Westinghouse brake fittings on the carriages of the train, and found them in good working order. On releasing the air from the train pipe, every brake block throughout the train went securely on to the wheels and remained there.

Conclusion
The cause of this derailment is, I consider, clearly shown in the evidence given by ganger Hackett. Hackett, who is the ganger in charge of this portion of the line, states that on examining his section on the morning of the day on which this accident occurred be found that the line was for a short distance rather wider to gauge than it should have been. (The curve at this point is one of 164 chains radius, and on that account the line is usually kept from one-eighth to one-fourth of an inch wide to gauge.) With the view of correcting the gauge he withdrew the spikes from six consecutive chairs under the right-hand rail, which, it will be remembered, was the outside rail of the curve; the fastenings of the inside rail he did not touch at all. He then adjusted the road to to the right gauge by forcing in the right-hand rail, and drove in a spike behind the lip of son of the six chairs, so as to hold them temporarily in position pending the permanent fixing of them. Hackett is uncertain whether it was three or four of the six loosened chairs which he secured in this manner, but Mr. Willox, the District Engineer who examined the line just after the accident, is positive that only three chairs had been so secured. This was the state of the road when the train ran over it.

Hackett states that he considered that the road was in a perfectly safe condition for the train to run over, and that there was no necessity for checking the train's speed in any way ; he did not therefore send out any flagmen, and he gave no warning of any sort to the signalman ; the train was consequently allowed to run over the line without its speed being checked ; as, however, it was approaching a station at which it was due to stop, its speed was not very high, and the estimates of it vary from 15 to 30 miles an hour.

The point previously described at which the first marks were found on both the right and left-hand rails was situated only 4 1/2 feet beyond the last chair which had been loosened by ganger Hackett, so that the initial derailment of the train occurred immediately after it had passed over the rail supported by those chairs.

After the accident the gauge of the line was examined ; it was found that throughout the length on which the chairs had been loosened the line was a full inch-and-a-half wide to gauge, and it is therefore clear that under the weight of the train the line had spread throughout this portion to the extent of about an inch-and-a-quarter ; at the point where the derailment actually occurred the line was just under half-an-inch wide to gauge. There was therefore a sudden change of gauge amounting to at least an inch just before the point at which this derailment occurred, and as this change of gauge was entirely due to the outside rail there must have been a short length of that rail where its curvature was considerably sharper than that of the remainder of the curve, and a derailment at this point was very probable. The engine, with its comparatively short wheel base, appears to have been able to take this curve, but the leading vehicle, with its longer rigid wheel base. was unable to do so, and a derailment on the outside of the curve consequently resulted.

This accident must therefore, I consider, be attributed entirely to the fact that the train was allowed to run unchecked over a portion of the line which, on account of its being under repair, was in a dangerously weak condition, and for this ganger Hackett is entirely responsible.

Hackett has been in the employ of the Company for 23 years as a ganger, and it is astonishing that a man of his experience should have committed such an error of judgment as he did on this occasion. Hackett stated that he had previously allowed trains to run over lines in a similar condition, but he was unable to mention any specific instance in which he had done so. Both the District Engineer and the Foreman Platelayer under whom Hackett was employed expressed their entire disapproval of his action in the matter, and they assert that it is absolutely contrary to the custom and regulations of the Company to allow trains to run unchecked over lines in the weakened condition which obtained on this occasion. The Company will, however, doubtless take steps to ensure that their regulations on this point are in future strictly adhered to.

From the marks on the permanent way there can be little doubt that this accident originated by one pair of wheels of the train being derailed at the point 51 feet from the facing point leading to the bay line, and from the relative positions in which the vehicles were subsequently found it appears probable that it must have been the lending pair of wheels of the first vehicle which was so derailed. These wheels, which were derailed to the right of the line, i.e., to the outside of the curve on which the train was running, appear to have run along nearly parallel to the rails of the down line, but gradually bearing away to the right on account of the curve of the line, so that when they reached the facing point the left-hand wheel was on the wrong side of the left-hand switch rail and the derailed wheels consequently continued on in the direction of the bay line instead of following the down line. The weight of the engine doubtless tended to pull the leading end of the carriage back to its right line, and this will account for the left-hand rail of the bay line being found to have been so badly bent outwards. But at this point the coupling between the engine and the leading vehicle appears to have broken, and the engine ran on alone into the station. The rear of the lending vehicle would then have been pushed forward by the weight of the vehicles behind it, and as it leading wheels were at the same time being carried away to the right by the rails of the bay line, which was gradually getting further and further away from the down line, it was only to be expected that the leading vehicle should assume the position in which it was found, viz., at right angles to these two lines, and that it should then overturn. The above would also fully account for the derailment of the remaining vehicles of the train and for the positions in which they were found.

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