29th JANUARY 1989




extracted and adapted from the report by

A J Davis

H.M. Principal Inspecting Officer of Railways 

An accident which occurred on Sunday 29 January 1989 in Merstham Tunnel, in the Southern Region of British Railways.
At approximately 00.52, the 00.15 'Gatwick Express' passenger train from London, Victoria Station, travelling at a speed of about 70 mile/h, struck some of the components of a new signal bracket structure which were being conveyed on an engineer’s train. Six passengers were slightly injured but, after hospital examination and treatment for shock, cuts and bruising, all were discharged the same day. After examination of the line by civil engineer's staff, normal working was resumed at 04.13.

Summary of the accident
1 Components of a signal bracket structure were being conveyed by an engineer's train from Three Bridges to Balham in connection with the Waterloo area resignalling scheme; they were loaded on to a bogie bolster wagon, designated a 'Salmon'. In the course of the journey part of the load, consisting of two rolled steel joists(RSJs),became displaced and over hung the wagon side towards the six-foot space and outside the loading gauge limits. The RSJs were struck by the Gatwick Express as the two trains passed each other in Merstham Tunnel.
The trains involved and damage sustained
2 The 00.15 Victoria to Gatwick Airport passenger train, identified as 2A18, and known as a Gatwick Express, was a push-pull unit formed by a Class 7311 electro-diesel locomotive propelling six bogie vehicles of passenger stock. The formation was: 
Leading Driving motor luggage van (DMLV) No 68509 
Trailer second handbrake (TSH) No 72643
Trailer first handbrake (TFH)  No 72507
Trailer second handbrake (TSH)  No 72620
Trailer second (TS) No 72710 
Trailer second handbrake (TSH) No 72621
Trailing Electro-diesel locomotive No 73204 

Note Electro-diesel locomotives normally draw current from the third rail supply. They are, however, equipped with a diesel-generator set which enables them to operate, albeit at reduced tractive effort, over non- electrified track or when the third rail supply has been interrupted for any reason.
3 All exterior damage to the vehicles was on their right-hand (ie six-foot) sides.
DMLV 68509 Shoe fuse-boxes smashed. Power cable torn on leading bogie.
TFH 72507 Broken motor-alternator set. Cracked lower step board. Grazed paintwork on bodyside underskirt.
TSH 72620 Minor paintwork grazing above both bogies.
TS 72710 Broken traction rod on trailing bogie. Bodyside gashed below No 3 window. 

TSH 72621 Three windows smashed and their frames crumpled.
Bodyside panels gashed and holed in four places above and below the windows. Internal luggage racks and panelling damaged. 
(All the passengers who were injured were travelling in this vehicle.) 
The engineer’s train was the 23.44 Three Bridges to Balham, 7Z15, of Saturday 28th January. It was marshalled as follows.
Electro-diesel locomotive No. 73118
Converted ferry van (ZSX) No. DB786901
Converted ferry van (ZSX) No. DB787000
Converted ferry van (ZSX) No. DB786974
(These three vehicles acted as additional brake force) 
Brake van (ZXW) No. DS55476
15 ton diesel-electric crane (YOB) No. DRT81338
Crane match wagon (QSB) No. DS70276
'Salmon' bogie bolster wagon (YMB) No. DB996546
Trailing ‘Bass’ open wagon (ZDA) No. DC110274
The Salmon wagon was loaded with the component parts of a new signal bracket which were secured with webbing straps, while the Bass wagon contained some miscellaneous small items.
5 The last two wagons showed signs of damage from being struck on their right-hand sides.

DB996546 Underframe and floor damaged, also a toolbox in the centre of the wagon.
Winch point damaged about three-quarters of the length of the wagon from the leading end and the third webbing strap was broken. In the area of this strap, a length of RSJ was found unsecured and displaced to the right-hand side, some 30" to the direction of travel. The load on the rear portion of the wagon also showed signs of having been struck and had moved approximately two inches out of position.
DC110274 Leading door hinge and hinge pin struck and damaged. A rope-securing cleat on the third door from the leading end had been driven through the bottom plank of the door. Rear corner post bent and both bottom welds fractured. Rear end plate bent and its door securing pin damaged. 

Injuries to people
6 Six passengers in the fifth coach, TSH 72621, were injured, mainly by fragments of glass from the broken windows and by luggage thrown from the racks. All were taken by ambulance to New East Surrey Hospital; none was detained after receiving treatment.
The signal structures for the Waterloo area resignalling scheme (WARS) were fabricated at the British Railways area civil engineer's steelwork shop at Brighton and taken, in sections, by rail to the sites at which they were to be erected. The structure involved in the accident was one of several which had been made over a period of some months; all the sections being transported on Salmon wagons. Because of their heights above rail level, each load was designated as an exceptional load requiring examination by an inspector specifically qualified to do so. 

8 Steelwork Shop Supervisor K Cresswell told me that he was responsible for the fabrication and despatch of steelwork from the area civil engineer's steelwork shop at Brighton. He said that in the twelve months prior to the accident he had despatched 
the components for eight or nine structures for WARS on Salmon wagons. The steelwork involved in the accident had been loaded on the morning of Friday 20 January by his chargehand, a crane with driver and two fitters.
9 Mr Cresswell described the way in which the various parts of the signal bracket were positioned on the wagon. The stanchion was loaded on the leading end and secured with four webbing straps while two straps secured the cantilever arm on the trailing 
end. The smaller components, which included the RSJs and steel gratings which were to form the walkway on the cantilever, were placed between the larger sections. On assembly, the RSJs would form inclined struts supporting the cantilever. He said that the wagon was provided with a six-inch high timber edging and the walkway gratings were contained within the shallow well formed by it. The RSJ struts were stacked on top of the gratings and were above the level of the timber edging; a single webbing strap was passed over the struts to secure both them and the gratings underneath them.
Mr Cresswell added that the gratings, which were a proprietary product, arrived at Brighton after the wagon had been loaded with the rest of the components. He had, therefore, to remove the struts, load the gratings and then replace the struts on top of them before they could be secured in position. 
10 Having satisfied himself that the load was secure, Mr Cresswell telephoned the control point at Brighton Station to request that it be examined by an "Exceptional Loads" Inspector. When, on the following Wednesday, Area Movements lnspector Robb arrived to carry out his examination, Mr Cresswell assisted him in measuring the load although, he said, he was not usually involved in such inspections; his responsibility ended when he had seen a wagon loaded and secured. He told me that of similar loads previously despatched, three included RSJ struts and all had been accepted as adequately loaded and secured. He admitted 
that he had not received any formal training in dealing with exceptional loads but said that he had gained his knowledge by experience over a period. He considered that every load that he dealt with was an exceptional load and said that all of them were examined by a member of the "Traffic Department".
11 Area Movements Inspector S C Robb told me that he had been advised on the Tuesday that there was a load to be examined in the engineering depot at Brighton. He attended to it on the following day, satisfying himself that it was within the limits prescribed and that the load was secure. His evidence generally confirmed Mr Cresswell's description of the load but he said that, in addition to the side timbers, a piece of wood had been placed across the wagon and that one end of the small items, including the struts, were resting upon it and were not lying flat on the floor of the wagon; this portion of the load had been secured with one webbing strap only. The lower end of the walkway gratings and the RSJ struts were firmly held against one of the wagon's bolsters and the webbing strap had been pulled tight to hold them down on to the cross timber that had been added.
12 Mr Robb said that he had added further timber dunnage (packing) to wedge the load and make it more secure but he had not fixed these timbers down to the wagon floor. He considered that the load was stable and incapable of moving, being satisfied that it was within loading gauge limits and adequately secured, he signed the wagon labels, advised the steelworks supervisor accordingly and arranged for it to be marshalled into its train.
13 Mr Robb told me that he had completed a three-day exceptional loads course during the previous year and that he had attended earlier courses. The most recent course was purely theoretical and had dealt with the principles of loading; he had gained a mark of 98% in the test held at the end of the course. He commented that he would have liked the course to have been longer and to have had a practical element included.
14 Depot Supervisor P Dunn, one of the supervisors from Three Bridges Depot, told me that the bogie wagon carrying the steelwork had been taken to Three Bridges from Brighton on the Friday prior to the accident to be marshalled in the engineer’s train that was to deliver it to the site of work. He had seen it in the yard and had checked the webbing straps holding the load to ensure that they were secure. One or two needed tightening slightly but, he said, this was a common occurrence after a loaded wagon had been moved. He said that, although the load was secure, he noticed that the timber beneath the walkway gratings was bending slightly. This was a piece of 2" by 2" wood which was resting on the longitudinal side timbers of the wagon but Mr Dunn did not consider that it was adequate so he reinforced it with a piece of 3" by 2" timber; this he wedged in by hand alongside the original. Neither of the timbers was fastened to the wagon but were held in place by the weight of the components lying on them and by the tension in the single strap securing that part of the load. Mr Dunn confirmed Mr Robb's description of the manner in which the gratings were laid on the wagon; they were on the floor with one end only supported on the timber 
15 Trackman G Talley was detailed as the Acting Guard of train 7215, the 23.44 Three Bridges to Balham into which Salmon wagon D8996546 was marshalled. He said that his first task on reaching his train was to examine the vehicles to ensure that the handbrakes were released, the couplings tight and that none of the vehicles had been labelled by the carriage and wagon examiners as unfit to run. He also checked the security of the loads by pulling on the webbing straps to satisfy himself that they were adequately tight. His evidence regarding the load on wagon D8996546 confirmed that of Mr Robb and Mr Dunn. Mr Talley then carried out a brake test, lit the train's tail lamp and instructed his driver that he could move the train to the exit signal from the yard.
16 Mr Talley spoke on the telephone to the signalman in Three Bridges Signal Box to obtain information about the route that his train was to take and then advised his driver accordingly before taking up his travelling position in the rear cab of the locomotive. He said that it was the normal practice for the guard to ride there in order that he could observe the load during 
transit. On this particular train, however, a number of box vans had been marshalled next to the locomotive and the only way that he could see along the length of his train was to lean out of the side window of the cab. He told me that he was unaware of anything untoward with his charge until the train was stopped by signals in Coulsdon Station and he was advised of the accident. He added that the train had ridden normally and he had no recollection of it having been jolted at any time during the journey from Three Bridges.
17 Driver D Davis was at the controls of electro-diesel locomotive No 73118 hauling train 7215 from Three Bridges. He told me that the maximum permitted speed of his train was 45 mile/h, it being limited by the engineer’s crane that was in its formation, but that he had not exceeded 40 mile/lh at any stage of the journey. He confirmed Mr Talley's statement that the 
journey had been free of untoward occurrences and could not add anything further.
18 At the controls of the 00.15 Victoria to Gatwick passenger train, 2A18, was Driver P Rood. He was in the driving cab of DMLV No 68509 and told me that he had left Victoria a few minutes late and stopped, as booked, at Clapham Junction, Selhurst, East Croydon and Purley Stations. The journey was perfectly normal until, as he passed a train travelling towards London on the adjacent Up line in Merstham Tunnel, there was "a loud bang" and he saw the reflection of an electric arc being drawn from the conductor rail; at that time, he said, he believed his speed was between 70 and 75 milelh. He realised that something had struck the front of his train and immediately applied the brake; he also started the diesel engine to ensure that he could retain electrical power. When his train’s speed had been reduced to about 20 mile/h and it was evident that it had not been derailed, he decided to proceed in order to clear the tunnel before stopping to examine the train and to inform the signalman of the occurrence, using a signal post telephone.
19 Mr Rood told me that, having obtained an assurance from the signalman that the Up line had been blocked, he went back to examine his train. He found that the leading end shoe fuse-box of the DMLV was missing and that the fuses were hanging on their leads; the trailing end fuse-box was damaged but intact. The third, fourth and fifth vehicles had suffered minor damage only but the sixth, TSH 72621, had a number of windows broken and its bodyside was extensively holed. The rest of the train and the propelling locomotive appeared unmarked.
20 He boarded TSH 72621 to check on the well-being of the passengers; one woman had sustained cuts around her ankles and another had something in her eye. Mr Rood met up with his guard, Conductor Bergmeier and an off-duty driver, Mr R Wadey, in the coach and , between them, helped passengers into other coaches. Mr Wadey then assisted Mr Rood in securing the damaged shoe fuses before the train went forward to Redhill Station where it was met by an ambulance and a number of police officers.
21 While at Redhill Station, a passenger awaiting a train engaged Mr Rood in conversation and remarked that a goods train had passed through the station "with something loose sticking out the side". Later, when shunting his train at Redhill before returning to Stewarts Lane Depot, Mr Rood noticed that the route indicator associated with a ground shunting signal (position light type) between the Down and Up lines had been dislodged and was lying on its back; this he reported to the signalman.
22 Conductor M Bergmeier, the guard of the 00.15 Victoria to Gatwick train, confirmed Mr Rood's evidence, adding that there had been eight passengers in the most severely damaged vehicle, TSH 72627. He said that he was riding in the leading vehicle when he heard the sound of a crash and saw a bright flash. He checked the first two vehicles in the train and, finding nothing untoward, made his way forward to the driver's cab, by which time the train was drawing up to a signal outside of :he tunnel.
23 Signalman J A Baker was on duty in Three Bridges Power Signal Box operating the panel controlling the area between Salfords and Horley. He told me that he was made aware of the accident at 00.55 when Mr Rood called him from a signal post telephone located immediately to the south of Merstham Tunnel advising him that his train had struck something from a passing engineer's train and asking for the adjacent Up line to be blocked. Mr Baker did so and also advised his colleague, who was operating the Purley section of the control panel, of the incident; his colleague then took steps to stop the engineer's train and 
instruct its crew to carry out an examination of it. Mr Baker said that the train crew reported back that they had lost a girder that was part of their load. He also told me that some time later he was advised that a theatre-type route indicator associated with a ground position light signal on the Down line at Redhill had been damaged.
24 Area Movements lnspector D S Morgan was advised of the accident at approximately 01.l5. He told me that he went to Redhill Station and made arrangements to examine Merstham Tunnel. He walked through the tunnel accompanied by a man from the Civil Engineering Department and, about half- way through, they found small pieces of aluminium and broken glass; they also noted damage to some signalling equipment mounted in the four-foot way. About 25 m further towards the London end of the tunnel they found a metal girder lying across the rails of the Down line; its ends were bent and some of its paint 
coating had been chipped off.
25 Mr T Knight, Regional Trains Inspector, showed me the broken webbing strap which had been used to secure the walkway gratings and the RSJ struts to the wagon, and explained that the strap had a breaking load of five tonnes. He explained that the broken ends of the strap showed signs of progressive failure with the inner strands being stretched before final fracture. This, he considered, indicated that the struts had slipped down over the side of the wagon and had then been struck by the passing train and had cartwheeled. He was supported in this view by Rolling Stock lnspector Strzetuszewski who had also examined the two 
26 Mr Knight explained some details of the three-day safe loading courses attended by those whose duties involved the approval of unusual loads. They were introduced following an accident in Linslade Tunnel, London Midland Region, in 1981, in which a section of prefabricated track became displaced from a load. Each course, he said, had its principles based upon the section of British Railways working manual for train staff which deals with the loading of all types of wagon and is known as the 'Green Pages'. He explained that the working manual is a guide in respect of unusual loads and that the most important aspect of the course is for trainees to learn to recognise the ways of ensuring that loads can be conveyed safely. The courses were very intensive and totally theoretical; up to 1987, practical work was included but it was felt that too much time was wasted by taking the trainees away from the classroom and travelling to yards in which suitable loads could be found. A video presentation had been substituted and was considered to be more appropriate to the type of instruction given.
27 Regarding the loading of the Salmon wagon involved in the accident, Mr Knight said that he was satisfied that it was correctly loaded although he did consider the load to be inadequately secured. He felt that the timber dunnage on which one end of the gratings was resting was probably there for convenience during slinging; he considered that there should have been two pieces of timber, one under either end of the bundle so that it lay flat and not raised at one end. He was also of the opinion that two straps should have been used to secure such a load. He added that if an inspector was unsure of the security or size of a load 
because of its unusual nature or if there was a need for reassurance he, Mr Knight, was always available to provide advice and assistance.

28 The RSJ struts became displaced from the load being conveyed on Salmon wagon D5996546 marshalled in the 23.44 Three Bridges to Balham engineer's train in the course of its journey. One of these hung over the side of the wagon and struck and damaged a ground position light signal at Redhill. I conclude that, as a result, the strut was dragged along at the side of the wagon until, as the 00.15 Victoria to Redhill train passed the engineer's train in Merstham Tunnel, the strut struck and damaged the leading vehicle and then cartwheeled alongside, damaging other vehicles in the passenger train.
29 1 also conclude that the load was inadequately secured, relying upon the wedging action of timber dunnage, not firmly affixed to the floor of the wagon, and a single webbing strap only for stability. It is probable that the vibration of the wagon during its journey caused the struts to slide sideways and over the side of the wagon.
30 Nevertheless, it is evident that all concerned with the loading, securing and inspection of the wagon and its load were of the opinion that they had carried out their duties to the best of their abilities. I conclude, however, that the training given to British Railways' staff in respect of unusual loads needs to be further reviewed in the light of this accident.

31 Large structures such as gantries and brackets intended to support signals are unusual loads for which no fully comprehensive loading instructions exist. Nevertheless, those charged with the responsibility of checking such loads must be entirely familiar with the principles regarding loading, the positioning of dunnage and securing. British Railways must ensure that these matters are fully addressed in both theoretical and practical elements of their training courses for loaders and load inspectors. I further recommend that the duration of each course be extended so that more thorough instruction, particularly in 
respect of practical experience, can be provided.
32 1 am pleased to report that British Railways have subsequently reviewed their loading instructions. Now they state that smaller items, such as the struts and gratings which have figured largely in this report, should, wherever practicable, be loaded in vans or in high-sided wagons.
33 A matter for comment, although not contributing to the accident, is the travelling position of the engineer's train guard, Trackman Talley. While I accept that it is normal practice on freight trains for the guard to ride in the rear cab of the locomotive, Mr Talley was unable to observe the load during transit except by leaning out of the cab window. To lean out of a moving train, particularly looking backwards, is a dangerous and foolhardy practice and, in any event, the train included a brake vehicle in which Mr Talley should have ridden. I recommend, therefore, that if it is necessary to marshal vans as additional brake force in 
trains conveying loads which must be observed during transit, a separate brake van is provided and the guard instructed to ride in it.  

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