Passenger accident at Hayes & Harlington station Report

[edwin_m]

It seems to me that the driver didn't see that the passenger had a hand STUCK in the doors. I reckon DOO trains should have an external PA system fitted, a few speakers along the outside of the train in order to tell people to stand clear of the train, because otherwise if you are 4-8-12 coaches away from a passenger vigorously hammering the door buttons etc, they can't hear you shouting at them. They'll stay there touching the train if you don't move thinking you are going to re-release the doors.

Good idea. Some trams have external PA so why don't trains? There are probably speakers fitted already to ensure the opening and hustle tones are audible outside the train.

 

[40129]

This is exactly what they have on the Washington Metrorail where drivers frequently make announcements to people waiting on the platform. Two things to note however. First: Metrorail is ATO so drivers can make announcements before the train stops. Second: IME Washingtonians are more inclined to take notice of announcements than their British counterparts

 

[313103]

Wasn't there a similar one at Newcastle a while back, but due to a guard error?

And wasn't there another, worse, incident involving the guard making a serious error at Liverpool James Street?

Go figure...

Tell me what you know about the James Street incident?
--- old post above --- --- new post below ---

Aye, the latter incident resulted in the death of the victim. I shall say no more on the matter.

And you fail to mention the Guard was imprisoned, so that was conveniently left out!

 

[theageofthetra]

Out of interest which depots who operate similar stock have not seen this report in an official notice case?

 

[Via Bank]

Here's a proposition. Why are DOO trains not fitted with body-side cameras which then feed into an image processing system to detect obstructions in the PTI, in the doors, etc.? This is the kind of task that computer vision is ideal for. You could, in fact, have an interlock that refuses to let the train go if anything is detected in front of the yellow line.

The interlock on train doors also needs to be looked at. Clearly the system on the Networker series units is not adequate (there was a similar incident at West Wickham recently, and the lady involved - caught by her backpack strap - suffered life changing injuries.) And there was a similar incident involving a class 185 unit at Newcastle in 2013 - in this case, a conductor was on board.

 

[HH]

The interlock on train doors also needs to be looked at.

It does (and I think everyone would agree, regardless of what they think of DOO) and the interesting thing is that the newer tube trains seem to more sensitive and automatically won't move if doors aren't OK.

Does anyone know anything about their systems?

 

[tony6499]

When you read the whole report it makes interesting reading , especially the drivers past and present competency history, hopefully the lessons from this accident will be learnt by all.

And by the grace of god the lady wasn't seriously injured or even dragged under.

 

[ComUtoR]

especially the drivers past and present competency history,

Can you expand on that comment. I'm not sure what your trying to highlight.

 

[Phil.]

No, you could predict this would stay very clear of pointing out risks with DOO. And, shock horror, it did.

As I posted in an earlier reply, the R.A.I.B. doesn't seek to apportion blame, it merely reports the facts and in many cases makes recommendations. That's what accident reports do.
As much as train crew want to read a report by the R.A.I.B. saying that driver only operation is inherently dangerous it ain't gonna happen.

 

[ComUtoR]

As I posted in an earlier reply, the R.A.I.B. doesn't seek to apportion blame, it merely reports the facts and in many cases makes recommendations.

I agree to a point. They do apportion blame in a sense and they also make conclusions based on evidence presented and not always facts. Many reports admit that there is a lack of evidence and they will make educated conclusions.

 

[bnm]

It's interesting to note that of the eight 'trap and drag' incidents the RAIB have investigated in the past 10 years, four were on DOO and four were on services where there was an additional member of staff involved in the despatch procedure.

That does rather suggest that, for these types of incidents, DOO is no better or worse a method of operation. Despite what is often often said on this forum. That DOO is more dangerous.

 

[Matt Taylor]

Can you expand on that comment. I'm not sure what your trying to highlight.

Three incidents in under three years is a huge red flag and would be enough to bring an end to someone's driving career at certain employers and the training plan following these incidents was still in place at the time of this accident.

 

[W230]

Three incidents in under three years is a huge red flag and would be enough to bring an end to someone's driving career at certain employers and the training plan following these incidents was still in place at the time of this accident.

Not where I work it isn't (depending on the incident obviously).

 

[Harbornite]

And you fail to mention the Guard was imprisoned, so that was conveniently left out!

So what?

 

[ComUtoR]

Three incidents in under three years is a huge red flag and would be enough to bring an end to someone's driving career at certain employers and the training plan following these incidents was still in place at the time of this accident.

In 9yrs (2002 - 2011) of driving he was clean

January 2011 - the driver contravened the company’s professional driving policy in two separate incidents when he took full power when starting on a single yellow signal at Reading depot and Reading West station.

Can you explain the context of this. I know many places where taking full power against a single yellow is pretty meaningless. Did he stop at the red correctly ? Did he pull full power then drop into coast and hit the correct 20mph 200yrds from the signal ?

November 2011 - the driver received an unsolicited brake application due to failing to cancel an in-cab vigilance device

Missed the DSD. How many Drivers miss the DSD. We have a location where it is a very common occurrence. Not exactly a Safety of the line incident and more a common driving incident. I don't even think it is on many of our Drivers records its that common.

and was also involved in another incident in failing to call at Slough station.

Not the best thing to do and is a concentration and unconscious competency issue.

As a result of the two separate incidents the driver was placed on a ten-month Competence Development Plan (CDP).

You see how badly Drivers are treated and the undue pressure we are put under. A 10 month CDP for a fail to call and a missed DSD. That's pretty insane.

Following another personal matter, the ten-month CDP was extended by a further month to October 2012.

He has things going on in his personal life that clearly affected his driving and his plan gets extended !

lJuly 2013 - the driver failed to call at Winnersh station and was placed on a twelve-month CDP

He had a fail to call in 2011 and then 20 months later he had another fail to call. The same incident twice is not great and would need to be looked at further but none of those incidents are serious breaches of safety and are incredibly common across the network. To call it a huge red flag is very unfair and without context even more so. I know Drivers whose records are worse by a long margin.

If you read up on human factors and the volume of data on incidents you will see that you can have a few incidents in a short spell due to the pressure mounted upon you and the fear of having another incident.

The RAIB report isn't there to make inferences.

 

[Carlisle]

This is exactly what they have on the Washington Metrorail where drivers frequently make announcements to people waiting on the platform. .

Standard on many DOO trains in Germany too

 

[GB]

In 9yrs (2002 - 2011) of driving he was clean



Can you explain the context of this. I know many places where taking full power against a single yellow is pretty meaningless. Did he stop at the red correctly ? Did he pull full power then drop into coast and hit the correct 20mph 200yrds from the signal ?



Missed the DSD. How many Drivers miss the DSD. We have a location where it is a very common occurrence. Not exactly a Safety of the line incident and more a common driving incident. I don't even think it is on many of our Drivers records its that common.



Not the best thing to do and is a concentration and unconscious competency issue.



You see how badly Drivers are treated and the undue pressure we are put under. A 10 month CDP for a fail to call and a missed DSD. That's pretty insane.



He has things going on in his personal life that clearly affected his driving and his plan gets extended !



He had a fail to call in 2011 and then 20 months later he had another fail to call. The same incident twice is not great and would need to be looked at further but none of those incidents are serious breaches of safety and are incredibly common across the network. To call it a huge red flag is very unfair and without context even more so. I know Drivers whose records are worse by a long margin.

If you read up on human factors and the volume of data on incidents you will see that you can have a few incidents in a short spell due to the pressure mounted upon you and the fear of having another incident.

The RAIB report isn't there to make inferences.

Summed up pretty nicely...well done!

To class a missed DVD or AWS as well as being placed on a development plan due to outside factors as operational incidents is in my opinion weak at best.

 

[G136GREYHOUND]

Summed up pretty nicely...well done!

To class a missed DVD or AWS as well as being placed on a development plan due to outside factors as operational incidents is in my opinion weak at best.

In 20 months he'd stopped at how many stations ? 20,000 plus ? And cancelled a DSD every minute of driving for 20 months ? Say 1500 times a week ?

 

[Via Bank]

I am rather more worried by the RAIB's report that the driver was using his mobile phone whilst driving the train. If that doesn't betray a rather cavalier attitude to safety and attention when driving I don't know what will.

 

[bnm]

In 9yrs (2002 - 2011) of driving he was clean
He had a fail to call in 2011 and then 20 months later he had another fail to call. The same incident twice is not great and would need to be looked at further but none of those incidents are serious breaches of safety and are incredibly common across the network. To call it a huge red flag is very unfair and without context even more so. I know Drivers whose records are worse by a long margin.

The salient point though is those drivers you know with worse records haven't (presumably) been subject to ORR and RAIB investigation following a serious safety of the line incident. Its perfectly understandable, and a mark of a thorough investigation, for the RAIB to scrutinise a drivers record to identify patterns and gain evidence that could lead to better understanding of human factors.

Where the RAIB have slightly failed is not investigating the train operator's handling of the drivers Competence Development Plan. It appears they're may have been deficiencies there too.

 

[bb21]

Here's a proposition. Why are DOO trains not fitted with body-side cameras which then feed into an image processing system to detect obstructions in the PTI, in the doors, etc.? This is the kind of task that computer vision is ideal for. You could, in fact, have an interlock that refuses to let the train go if anything is detected in front of the yellow line.

Retrofitting would be expensive, but is not impossible to incorporate into newer stock.

As for your last point, Clapham Junction, et al, will grind to a halt in the peaks.

 

[philthetube]

It does (and I think everyone would agree, regardless of what they think of DOO) and the interesting thing is that the newer tube trains seem to more sensitive and automatically won't move if doors aren't OK.

Does anyone know anything about their systems?

The Underground S stock trains have sensitive edge technology fitted on the doors which seems to work very well, and now it is bedded in does not cause problems,this will stop the train moving off with something the thickness of a pen in the doors ans also prevents someone with anything caught in the doors, coat string etc. being dragged I will try to explain how it works

The doors shut firmly, with no give.

There is a groove in one of the door rubbers and a tongue in the other, when the doors are closed the tongue sits in the groove, there are two wires? running through the tongue and if the tongue is compacted then they touch and break a circuit which prevents motoring and the drivers door closed indication, this would not necessarily prevent someone being dragged by something like a scarf but if the train begins to move then it tightens in the doors, if it does not pull out and compacts the tongue which again cuts out the motors and also causes a brake application and sounds a warning in the cab.

I cannot understand why it is a requirement for all new stocks to be fitted with it, whether for DOO or guard operation, and I would have thought it would have been a relatively easy retro fit for any older electric stock with tight closing doors, but that is my opinion.

If anyone feels they can explain it better then please do.

 

[ComUtoR]

The salient point though is those drivers you know with worse records haven't (presumably) been subject to ORR and RAIB investigation following a serious safety of the line incident.

Its not the point at all. The report simply shows his record. It doesn't state whether this is a good or bad record. It is merely reporting what is listed and what has been gained from interview. It is people who read the report making conclusions about how good or bad a Driver he is.

Its perfectly understandable, and a mark of a thorough investigation, for the RAIB to scrutinise a drivers record to identify patterns and gain evidence that could lead to better understanding of human factors.

I have read many many RAIB reports. I am fully aware of what they contain and the reasons why.

Where the RAIB have slightly failed is not investigating the train operator's handling of the drivers Competence Development Plan. It appears they're may have been deficiencies there too.

No they haven't. You are misunderstanding the purpose of the report. The report lists a set of facts and an evidence trail, nothing more. It is not the job of the RAIB to investigate competency management. There may be deficiencies but FGW appear to have followed the procedures laid out. Again, nothing has been mentioned of how good or bad their procedure was, what the content of the plans were and how the Driver was monitored following each of his incidents. You are drawing a conclusion about deficiencies.

The problem with these reports is their clinical nature and that they are not meant for open discussion, especially by those who have little or no knowledge about procedures, policies, rules, regs, standards etc etc. I can say, because I have a point of reference, that the Drivers record is relatively good. I can say that his CDP was typical of the industry approach (in length) and I know the points where the RAIB may have missed some vital evidence (as its not shown in the report) Just like 455, I can see where the industry is ignoring the DOO risks.

 

[bnm]

I know the points where the RAIB may have missed some vital evidence

Aren't the RAIB open to evidence from any source?

If you know they've missed something vitally important that may alter their conclusions and recommendations don't you have a duty to set the record straight?

 

[SpacePhoenix]

I would have thought it would have been a relatively easy retro fit for any older electric stock with tight closing doors, but that is my opinion.

I doubt that it would be easy to retrofit, I'd imagine that it would mean new doors. If the doors are hollow on the inside then that might provide the room to fit whatever is needed

 

[dviner]

I doubt that it would be easy to retrofit, I'd imagine that it would mean new doors. If the doors are hollow on the inside then that might provide the room to fit whatever is needed

The door rubbers with wire components would probably be relatively easy to retrofit, however, the subsequent "tightening" of the doors as you move off may be more problematic.

 

[Wolfie]

It does (and I think everyone would agree, regardless of what they think of DOO) and the interesting thing is that the newer tube trains seem to more sensitive and automatically won't move if doors aren't OK.

Does anyone know anything about their systems?

my bold

Something which caused chaos when the 09 stock was first introduced on the Victoria line...

 

[philthetube]

The door rubbers with wire components would probably be relatively easy to retrofit, however, the subsequent "tightening" of the doors as you move off may be more problematic.

Trains with "plug" doors have tight fitting doors anyway, I think it should be easy to link to the circuit which currently causes the motors to drop out, though not necessarily to a braking circuit. I would have thought it was worth investigating anyway.

 

[Bromley boy]

Trains with "plug" doors have tight fitting doors anyway, I think it should be easy to link to the circuit which currently causes the motors to drop out, though not necessarily to a braking circuit. I would have thought it was worth investigating anyway.

As with everything with the railway I suspect it boils down to cost.

The doors fitted to older stock such as networkers will be compliant with the rules in force at the time of manufacture. They will now be "grandfathered" so that there is no requirement for them to be updated in light of new regs. There is simply no incentive for TOCs/ROSCos to invest significant sums and take stock off track to update fully compliant systems.

 

[edwin_m]

As with everything with the railway I suspect it boils down to cost.

The doors fitted to older stock such as networkers will be compliant with the rules in force at the time of manufacture. They will now be "grandfathered" so that there is no requirement for them to be updated in light of new regs. There is simply no incentive for TOCs/ROSCos to invest significant sums and take stock off track to update fully compliant systems.

True, but the report did say the Networker door concerned was tested against the current standard (not in force when it was introduced) and complied.