Coulthard, in not attempting to stop the train, clearly did not behave reasonably. With the evidence available, it cannot be determined at which stage of the journey that Coulthard’s behaviour may have become unreasonable. Pascoe (Coroner) determined that Bowden died or was “in a coma at least 6 miles on the down side of the site of the crash”. During this time Coulthard cannot have had any communication with Bowden, nor seen Bowden make any movements, not even make throttle adjustments, in that six miles. It seems incredulous that Coulthard did not notice “the lack of reactions … in accordance with the skill and reputation of a man like Driver Bowden” (Pascoe), a man that Coulthard had worked closely with for thirteen months.
In attempting to make sense of Coulthard’s actions, we can look at what we know about him. We know he was 30 years old at the time of the crash and had been a railway employee for 8 years, half of which he had been a fireman. He joined the railways when he was 22, so one can assume he regarded it as a job, rather than a passion. If it were a passion it is more likely he would have joined upon leaving school.
He and Bowden had been a regular team for 13 months and the fact that Bowden picked him up on the way to work indicates that while they may not have socialised together, they were at least “workmates”.
Coulthard had had at least 6 hours sleep after a day off, prior to coming to work, so fatigue can be minimised as a factor.
We know that Coulthard enjoyed a drink, as on his day off he went to a hotel for lunch, a lunch that took 3 hours during which he consumed “about six 7-oz. glasses” of [presumedly] beer.
Coulthard did not challenge Bowden when it became blatantly obvious that Bowden was not slowing the train. Firemen were subordinate to Drivers; a driver’s decision was absolute, and it took a brave fireman to challenge a driver’s action. Even so, considering that the two men had been working together for 13 months and that they were on friendly terms, it is difficult to see why Coulthard did not ‘remind’ Bowden while there was still time to stop the train.Coulthard had been working
with Bowden for 13 months and we know that Bowden kept Anginine close at hand; it is unlikely that Coulthard cannot have known of Bowden’s heart condition.
It is known that Coulthard faced at least three inquiries: - the investigation of the Victoria Police, the official Victorian Railways inquiry, and the Melbourne City Coroner’s court. When asked why he took no action when he was aware that the driver had not obeyed the signals he said, “I don’t know”. When Coulthard was asked why he did not close the throttle and apply the air brake he replied, “panicked, I suppose, that’s all”. When asked again why he made no attempt to stop the train his reply was, “I thought the brakes had applied”.
Coulthard’s self preservation instinct had diminished to the point that his problem solving skills were severely degraded. His judgement of what to do next had been so impaired that he was incapable of functioning in the appropriate manner.
The question is why, what could have caused such degradation?