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at Shrivenham home signal, and this could hardly have been accomplished on the failing gradient without brake action on the part of the driver and some noise of the wagon buffers closing up.
Further, Chandler suggested that when he eventually came to a stand, 5.21 a.m., he immediately saw (a "fraction later") the headlights of the express, one to 1½ miles away. The train, however, did not enter the section at Marston Crossing, which was two miles away, till 5.22 a.m., and his evidence of such extended visibility is not confirmed, though test showed that had the weather been clear he could have seen the headlights of the express at a range of a mile.
In all the circumstances, I regret that I am unable to accept Chandler's evidence, and I find that he was not really on the alert; while he realised that he was slowing down for so long a period as seven minutes, and may have thought that his train was drawing up to the home signal, it appears that he was pre-occupied in consulting his Service Book with regard to his return journey after relief, and evidently he did not take the trouble even to try to observe this signal, or the distant signal, as was his duty. Indeed, it seems that the situation dawned on him only just in time to permit him to jump from his van and save his life.
If the most favourable assumptions be made in his interests as to the speed of the mineral train, and therefore of the initial velocity of the six vehicles, and if it he assumed that the time of the collision was as early as 5.23 a.m., my considered opinion is that Chandler had at least six minutes in which to take protective action. Had he acted promptly, as the result of having realised, during the long period of retardation, that his train had been drawing away from him, he could have brought the wagons to a stand much earlier by brake action; but even though he failed to do this, he should have been able, notwithstanding the slippery state of the ground, to place a detonator on the rail at least 300 to 400 yards in rear of his brake van, within the time at his disposal after it came to a stand. Although this might not have prevented actual collision, such warning would probably have been effective in mitigating the results.
In my opinion, a considerable measure of responsibility for this accident rests upon Guard H. E. Chandler. He has a good record and served in France during the War; he was gassed in 1917, and was wounded and made a prisoner of war in March, 1918.
12. Signalman W. Head, however, was primarily responsible, as he failed, at 5.15 a.m., to observe that the mineral train, travelling at 10 to 15 m.p.h., had passed his box incomplete; the result was that he accepted the express three minutes later, at 5.18 a.m.
While visibility may have been restricted by mist, smoke, and steam, the simultaneous passage of the down milk empties train slightly retarded Head's observation of the rear of the mineral train, and possibly made it a little difficult and at longer range; but he did not suggest that his view was indistinct, even though his windows were closed. In fact, the box could not be better situated for observation purposes. Further, so far as he was aware, there were no extraneous lights which might have deceived him, nor did he think that the tail light on the milk empties train could have thrown a misleading reflection in the windows of his box; he had never noticed such a thing. Moreover, the milk empties train was carrying the usual single red tail light, whereas the mineral train carried in addition two red sidelights.
The duty of observing the tail light is simple and this serious lapse in respect of such a fundamental matter of safety on the part of Head, a man of long experience. can only be accounted for as the result of momentary lack of care and concentration. He could not recall an occasion on which a train had passed him incomplete, nor could he remember ever having sent an emergency signal. On the other hand, it is to his credit that he realised his mistake so promptly; he acted efficiently, and, by fortunately preventing the entry of the down empty stock train into the obstructed section, for which Enginemen F. Gould and H. J. Howard are also to be commended, he was instrumental in avoiding further serious consequences.
He is 52 years of age, with 34 years' service; he had acted as a signalman for 25 years, and had served at Shrivenham for 17 years. He was referred to as a very conscientious man with an excellent record.
