Trap and Drag at Bushey (26 March 2018)

[74A]

Surprised this hasn't been mentioned but there was a trap and drag at Bushey. From RAIB website

At around 21:24 hrs on 26 March 2018, a passenger attempting to board a train at Bushey station became trapped in a closing door. The train started and moved around 27 metres before being stopped. The passenger remained upright but sustained a minor injury to their arm.

We have undertaken a preliminary examination into the circumstances surrounding this incident. Having assessed the evidence which has been gathered to date, we have decided to publish a safety digest.

The safety digest will be made available on our website in the next few weeks.

Link https://www.gov.uk/government/news/passenger-incident-at-bushey-station

It doesn't actually say which train was involved but they have a picture of platform 6 which would make it a London Midland service which I believe are guard operated.

 

[northwichcat]

Is this the same issue as happened with a class 185 Desiro at Newcastle that resulted in the RAIB recommending they put yellow teeth stickers on the 185 doors?

 

[yorkie]

It doesn't actually say which train was involved but they have a picture of platform 6 which would make it a London Midland service which I believe are guard operated.

West Midlands Trains (under their "London Northwestern Railway" brand) are the new operator now.

(For completeness, GTR also operate trains - under their "Southern" route brand - through this location, they also have Guards but do not usually call at Bushey (if at all?), so WMT is the likely operator)

 

[pt_mad]

West Midlands Trains (under their "London Northwestern Railway" brand) are the new operator now.

(For completeness, GTR also operate trains - under their "Southern" route brand - through this location, they also have Guards but do not usually call at Bushey (if at all?), so WMT is the likely operator)

Are the Southern Services not DOO dispatch south of Milton Keynes?


Wow dragged 27 metres it's a miracle they didn't suffer serious injury. May have ended up running alongside the train? And these EMUs accelerate rapidly.

Wonder if it was a body part or clothing trapped? Would be surprised if the train obtained door interlock with an arm trapped in a door?

 

[Carlisle]

Are the Southern Services not DOO dispatch south of Milton Keynes?

No, it’s all guarded dispatch north of Clapham Junction.

 

[TEW]

Wonder if it was a body part or clothing trapped? Would be surprised if the train obtained door interlock with an arm trapped in a door?

You would probably not get interlock with an arm stuck in a door, but I would not say it is impossible. But definitely possible with a hand in the door. I've also witnessed a foot stuck in a door and interlock gained.

 

[otomous]

As a driver, a foot trapped in a door and gaining interlock SERIOUSLY worries me!

 

[Mojo]

You would probably not get interlock with an arm stuck in a door, but I would not say it is impossible. But definitely possible with a hand in the door. I've also witnessed a foot stuck in a door and interlock gained.

I am reminded of two recent incidents investigated by the RAIB; one at Newcastle concerning a class 185, in which a whole wrist was stuck in the doors and interlock was obtained (and subsequent testing by the RAIB revealed a wrist somewhat larger than the one of the woman involved could also get trapped and interlock obtained), and also Hayes/Harlington, where a hand was trapped in the doors and the interlock was also obtained.

 

[Mojo]

As a driver, a foot trapped in a door and gaining interlock SERIOUSLY worries me!

From what I can see, the RAIB website doesn’t state what part of the customer was trapped in the door.

 

[whhistle]

You would probably not get interlock with an arm stuck in a door, but I would not say it is impossible. But definitely possible with a hand in the door.

Yorkie beat me to it.

Anyone who is interested in this should read through the Hayes and Harlington trap and drag event.
From what I remember, the driver presumed that if the interlock light was on in the cab, the doors were closed completely and nothing was trapped. Reasonable to presume yes, but the real answer turns out to be a no.
Another part of the investigation is that the trains are older and thus sensors on [the doors] may have greater tolerences than modern units.


The problem, once again, is people.
How do you stop people running and trying to board trains with doors that are closing?
The only way I can think is putting the onus on the person. There's no claim with anyone else. Yes, the guard should be checking but ultimately the responsibility should always remain with the individual.

 

[LowLevel]

Yorkie beat me to it.

Anyone who is interested in this should read through the Hayes and Harlington trap and drag event.
From what I remember, the driver presumed that if the interlock light was on in the cab, the doors were closed completely and nothing was trapped. Reasonable to presume yes, but the real answer turns out to be a no.
Another part of the investigation is that the trains are older and thus sensors on [the doors] may have greater tolerences than modern units.


The problem, once again, is people.
How do you stop people running and trying to board trains with doors that are closing?
The only way I can think is putting the onus on the person. There's no claim with anyone else. Yes, the guard should be checking but ultimately the responsibility should always remain with the individual.

Relying on the interlock light has always been firmly discouraged - our units have had the bulbs removed and the opening covered over to prevent them from being used.

 

[pt_mad]

The problem, once again, is people.
How do you stop people running and trying to board trains with doors that are closing?
The only way I can think is putting the onus on the person. There's no claim with anyone else. Yes, the guard should be checking but ultimately the responsibility should always remain with the individual.

This unfortunately for staff is not the case though. I suppose the balance has to be right. Because if there was no onus to do a visual check and interlock was enough, people might stop looking. So it has to be mandatory that a visual observation is carried out.

The awkward part is say where a bag strap could be trapped, but the person is actually well clear of the train. And whether a member of staff standing up to 11 cars away could be expected to reasonably see a bag strap trapped. Or a driver on CCTV.


Also I've always wondered whether anyone ever gets anything trapped on the inside of the train. Like the doors close and they are standing just inside the door with say a loose sleeve trapped and interlock is achieved and the train moves off?

As there is surely no way the person in charge of dispatch could see or recognise this?
I suppose there wouldn't be any consequences of this as there wouldn't be much chance of an injury.

 

[otomous]

This unfortunately for staff is not the case though. I suppose the balance has to be right. Because if there was no onus to do a visual check and interlock was enough, people might stop looking. So it has to be mandatory that a visual observation is carried out.

The awkward part is say where a bag strap could be trapped, but the person is actually well clear of the train. And whether a member of staff standing up to 11 cars away could be expected to reasonably see a bag strap trapped. Or a driver on CCTV.


Also I've always wondered whether anyone ever gets anything trapped on the inside of the train. Like the doors close and they are standing just inside the door with say a loose sleeve trapped and interlock is achieved and the train moves off?

As there is surely no way the person in charge of dispatch could see or recognise this?
I suppose there wouldn't be any consequences of this as there wouldn't be much chance of an injury.

Common sense would say not. However front line rail staff now have little faith in TOC, BTP, RAIB, RSSB, or CPS to use common sense! It’s guilty til proven innocent, and innocence never warrants an apology!

 

[TheEdge]

Common sense would say not. However front line rail staff now have little faith in TOC, BTP, RAIB, RSSB, or CPS to use common sense! It’s guilty til proven innocent, and innocence never warrants an apology!

Sadly thats how its starting to feel all over the industry. If all the blame can be made to fall on a driver, guard, platform staff or anyone else then I hope you enjoy the feeling of being thrown under a bus...

 

[sbt]

Also I've always wondered whether anyone ever gets anything trapped on the inside of the train. Like the doors close and they are standing just inside the door with say a loose sleeve trapped and interlock is achieved and the train moves off?

As there is surely no way the person in charge of dispatch could see or recognise this?
I suppose there wouldn't be any consequences of this as there wouldn't be much chance of an injury.

I does happen, as I know from personal experience.

My experience as a commuter for 30 years is that the greatest risk is on a packed train as people rearrange themselves after people have got off and on at a station. You may have got on with a reasonable amount of space but people keep moving around to make themselves comfortable that space can rapidly disappear and you, or your bag, can get pushed back quite strongly.

Apart from the time that my bag strap was caught (which I noticed and corrected) there was one time when this rearrangement was a gnats whisker from pushing me out of the door to fall straight backwards onto the platform. In that case I was already on the train when it stopped and it was newly boarded passengers who were pushing back after moving past me. I was teetering on the edge of the floor at the doorway for a moment or two that seemed like eternity before I was able to grab something inside and pull myself back in.

Finally I was once almost caught by the issue with 455 doors that meant that they snapped closed after starting to open if you hit the (still lit) open button after the initial close sequence had started. If I had tried to squeeze through before the doors were fully open I, or part of my baggage, would have been trapped. I was considering reporting it when the RAIB report, and Recommendation to fix this issue urgently, on an incident where someone was, IIRC, hurt as a result came out.

As to injury, can you imagine the result if an exposed item were to catch on something lineside? Or if the passenger, or someone else (as a passenger I may try and behave sensibly but I have no control of 'helpful idiots'), were to foolishly interfere with the door to free the trapped item?

 

[sbt]

The only way I can think is putting the onus on the person. There's no claim with anyone else. Yes, the guard should be checking but ultimately the responsibility should always remain with the individual.

The responsibility should be on EVERYONE. I have lost count of the number of trains I have missed in 30 years of commuting through thinking 'to close' and standing back. Yet I have had several 'near misses' on trapped items, each one making me more careful than the last.

Safety is a layered process, people, including staff, do have lapses. Mechanisms can fail or have designed in faults (see the 455 door problem for details). Third parties can be involved. To assign blame, whether to staff or passenger, without investigation is wrong.

And the bottom line is that what is important is not who gets blamed but who gets hurt. Or, if you believe that getting hurt through your own error removes everybody else's responsibility to prevent that, who gets delayed, exposed to the mess and stress of a serious accident or fatality etc.

There is in society, and especially in the Railway industry[1] and legal system[2], a tendency to look for a single point of blame rather than to look at every accident as a 'Systems Accident' where everybody has to be looked at, blame has degrees, blame may not exist as such and people who may not be 'to blame' may have to change what they do in order to reduce the chances of a recurrence.

---

[1] I think this in large part due to the 'Rules Based' environment of the Railway. The system tends to attract people who pay attention to and obey rules and eject those who don't and as a result the body of railway staff have a higher expectation regarding compliance with rules than the average member of the public. This leads them to have a low opinion of planning intended to reduce accidents to the expected, and normal, proportion of rule breakers (through intent, ignorence or simple lapse) in society.

There is also the issue of [2]. The legal system creates a 'Blame Culture' rather than encouraging a 'Just Culture' - in fact it works strongly against any industries efforts to create a Just Safety Culture.

[2] Sometimes the push of the legal system is required. Sometimes it is unfair, distracting or positively works against safety or it's investigation.

 

[Economist]

I personally think just culture is the way to go, unfortunately society has become increasingly litigious ("where there's blame, there's a claim" springs to mind), so if anything it may go the other way.

The use of just culture encourages staff to be more open and honest, the driver in the 1991 Cannon Street crash didn't co-operate with the official investigation because he feared prosecution. We still don't know, beyond some form of driver error, what exactly caused that crash. If we did, training could be improved to help prevent it in future.

A few years ago, a pilot on an Air New Zealand flight fell into a microsleep for a couple of minutes, he reported himself to the airline. No blame was apportioned and it subsequently was found that the air conditioning within hotel rooms could impact pilots' sleep patterns. Action was taken to rectify this. Both the anonymous pilot and the airline won applause from some lf the more reactionary commentariat on the web.

Unfortunately, the impression I get, is that post-James Street, the CPS view every dispatch-related incident as grounds for a potential prosecution. With there being a lot of political ramifications around DOO, I have yet to see an RAIB report in recent times which brings into question the effectiveness of video screens, which on a sunny day are often unsatisfactory at best.

I do wonder with both this incident and the Notting Hill Gate trap-and-drag as to what the approach by the CPS will be. Hopefully they will appreciate that we rail staff do our best under what, at times, are very challenging conditions.

 

[lammergeier]

I personally think just culture is the way to go, unfortunately society has become increasingly litigious ("where there's blame, there's a claim" springs to mind), so if anything it may go the other way.

The use of just culture encourages staff to be more open and honest, the driver in the 1991 Cannon Street crash didn't co-operate with the official investigation because he feared prosecution. We still don't know, beyond some form of driver error, what exactly caused that crash. If we did, training could be improved to help prevent it in future.

A few years ago, a pilot on an Air New Zealand flight fell into a microsleep for a couple of minutes, he reported himself to the airline. No blame was apportioned and it subsequently was found that the air conditioning within hotel rooms could impact pilots' sleep patterns. Action was taken to rectify this. Both the anonymous pilot and the airline won applause from some lf the more reactionary commentariat on the web.

Unfortunately, the impression I get, is that post-James Street, the CPS view every dispatch-related incident as grounds for a potential prosecution. With there being a lot of political ramifications around DOO, I have yet to see an RAIB report in recent times which brings into question the effectiveness of video screens, which on a sunny day are often unsatisfactory at best.

I do wonder with both this incident and the Notting Hill Gate trap-and-drag as to what the approach by the CPS will be. Hopefully they will appreciate that we rail staff do our best under what, at times, are very challenging conditions.

Couldn't have put it better myself, good post. Further evidence of the CPS' gung ho attitude can be found in the Martin Zee case, cleared by the company and ORR but prosecuted using some obscure law by the CPS. Until this attitude falls away then a just culture is a long way off.

 

[pt_mad]

The responsibility should be on EVERYONE. I have lost count of the number of trains I have missed in 30 years of commuting through thinking 'to close' and standing back. Yet I have had several 'near misses' on trapped items, each one making me more careful than the last.

Safety is a layered process, people, including staff, do have lapses. Mechanisms can fail or have designed in faults (see the 455 door problem for details). Third parties can be involved. To assign blame, whether to staff or passenger, without investigation is wrong.

And the bottom line is that what is important is not who gets blamed but who gets hurt. Or, if you believe that getting hurt through your own error removes everybody else's responsibility to prevent that, who gets delayed, exposed to the mess and stress of a serious accident or fatality etc.

There is in society, and especially in the Railway industry[1] and legal system[2], a tendency to look for a single point of blame rather than to look at every accident as a 'Systems Accident' where everybody has to be looked at, blame has degrees, blame may not exist as such and people who may not be 'to blame' may have to change what they do in order to reduce the chances of a recurrence.

---

[1] I think this in large part due to the 'Rules Based' environment of the Railway. The system tends to attract people who pay attention to and obey rules and eject those who don't and as a result the body of railway staff have a higher expectation regarding compliance with rules than the average member of the public. This leads them to have a low opinion of planning intended to reduce accidents to the expected, and normal, proportion of rule breakers (through intent, ignorence or simple lapse) in society.

There is also the issue of [2]. The legal system creates a 'Blame Culture' rather than encouraging a 'Just Culture' - in fact it works strongly against any industries efforts to create a Just Safety Culture.

[2] Sometimes the push of the legal system is required. Sometimes it is unfair, distracting or positively works against safety or it's investigation.

Some great points. Especially about the public perhaps having less of a desire to obey rules than rail staff, generally because rail ops are totally rule based so staff live to strict rules and procedures.

That's perhaps another part of it. That if the public make a mistake, a bad judgement or deliberately disregard safety during a dispatch, unless they are hurt, there are no consequences for them. Yet if a member of staff did this and was reported, they'd face action and have to explain themselves. Because they are at work.
If someone jumped a door and got stuck, but wasn't hurt, you can report it but there won't be any consequences for that member of the public so they probably see it as fair game otherwise there wouldn't be as many do it.

Likewise they can be drunk and unsafe and yet there won't be any likely consequences for tjem unless they carry out criminal acts. They can swear at staff. But obviously staff members couldn't behave in the same way or even speak rudely to the public nevermind swearing. They have to take it.

Mind you, regarding what you said about post James Street. There was another incident at Bishops Stortford which was documented in another thread in detail. The person suffered life changing injuries. No criminal action was taken and the civil action by the injured party was dismissed at the hearing.

The judged ruled words to the effect of when the person in charge of dispatch (think it was driver) did the train safety check, the doors and dispatch corridor were clear. So he or she started the train. An incident occurred shortly after but it fell on the individual who chose to act as he did.

So there's some reassurance there.

 

[Economist]

If the dispatch corridor is clear at the time of the check, then the staff should have no case against them, though the CPS did still bring charges against Martin Zee. Part of the problem with that case was that the monitors didn't show much of the platform and the injured party was moving quickly.

Another problem with the monitors is image quality, particularly on a sunny day. It's entirely possible to think that you may be able to everyone, however you can't, sometimes people magically appear from the shadows and you realise that if that person hadn't moved, you'd have never known they were even there. It's the "unknown unknown" so to speak. Personally, I've been instructed by training staff (who were involved in the investigation of a dispatch incident) that it's really important to be not just doing your job but to be seen to be doing it too. I make sure that I'm in a position to be picked up on CCTV doing my checks an should be so long as the CCTV covers the immediate cab area on the platform.

With the monitors, it's entirely feasible that a driver or guard could think the dispatch corridor is clear when it isn't. The monitors will probably be in working order, so it all depends on picture quality which isn't recorded and can't be replicated easily at all. Even a photograph of the monitors won't show an accurate representation of the quality. So it all comes down to the question of how bad does a picture have to be before you lock a train out from the rear?

I'd be interested to hear whether the guards at Bushey use monitors or simply look along the train.

 

[OxtedSignaller]

Safety digest from RAIB has been released today

https://www.gov.uk/government/publi...s-and-dragged-at-bushey-station-26-march-2018

1. Important safety message
This accident demonstrates the importance of staff responsible for the dispatch of trains conducting a thorough final safety check after the passenger doors have closed. They should always remember that in certain circumstances it is possible for the door control system to detect the doors as closed when someone is trapped in them.

2. Summary of the accident
At around 21:24 hrs on 26 March 2018, a passenger was dragged along the platform by a train departing from Bushey station. Her forearm was trapped by an external door of the train and she was forced to walk, and then run, beside it to avoid being pulled off her feet. The train reached a maximum speed of around 9 mph (14 km/h) and had travelled around 27 metres before being brought to a stand...

 

[tsr]

From the linked report:

West Midlands Trains informed RAIB on 23 April 2018 that London Midland had, in addition to the above actions arising from the urgent safety advice, taken the following actions in response to the recommendation:
...
- developed a competence management system for its senior conductors and added platform train interface visual assessments

It's seriously worrying that no such actions had previously been taken to ensure that trains were worked competently by conductors. I wasn't even aware before this that there were TOCs that didn't have a competence management system for safety critical staff. Obviously visual assessments of the PTI are also crucial, to observe visibility risks, hidden hazards, routes which passengers could take around the platform, signal sighting and so on. How on earth did LM get away with not doing any of this?

 

[Intermodal]

Some very interesting points and pictures of the RAIB managing to gain interlock with a (rather large) forearm trapped within the door. It seems like a forearm is possibly one of the most likely parts of the body to become trapped. Perhaps this piece of engineering needs revisiting?

 

[Adlington]

It seems like a forearm is possibly one of the most likely parts of the body to become trapped. Perhaps this piece of engineering needs revisiting?

You mean the forearm??

 

[CC 72100]

From the linked report:



It's seriously worrying that no such actions had previously been taken to ensure that trains were worked competently by conductors. I wasn't even aware before this that there were TOCs that didn't have a competence management system for safety critical staff. Obviously visual assessments of the PTI are also crucial, to observe visibility risks, hidden hazards, routes which passengers could take around the platform, signal sighting and so on. How on earth did LM get away with not doing any of this?

Indeed - I thought that a Competence Management System for such colleagues was one of the fundamental requirements of running a safe railway?!

That said, one Saturday night I was on the last Northbound LM local out of Euston. By the time we got to my station, the train was 5/6 minutes down due to extended dwell time and making sure that everyone was away from the train before giving 2 - fair enough, complete common sense. Imagine then my surprise at seeing the train depart the station with the Guard not watching it out. Perhaps there was a widespread - originating from the lack of CMS - underappreciation of PTI risk?

 

[Economist]

It seems in many ways to be similar to the Hayes and Harlington incident but with a guard rather than DOO, the exceptions being the guard saw the passenger (but not realising they were in contact with the train) and that the guard stopped the train.

Things like this are precisely why, as a DOO driver, I wait until everyone is behind the yellow line before departing. I make it totally clear to everyone on board, especially after departing from a terminal station that this will be the case. I'd say the vast majority follow the instructions, a minority don't. I wait for those who don't.

It isn't always very popular, I do receive complaints from time to time but for me it's the only way of doing things. If I do have to take any action (such as waiting, calling for people to stand clear, or reporting problematic monitors) I note it ln my schedule card which I keep hold of for many months.

 

[CC 72100]

It seems in many ways to be similar to the Hayes and Harlington incident but with a guard rather than DOO, the exceptions being the guard saw the passenger (but not realising they were in contact with the train) and that the guard stopped the train.

Things like this are precisely why, as a DOO driver, I wait until everyone is behind the yellow line before departing. I make it totally clear to everyone on board, especially after departing from a terminal station that this will be the case. I'd say the vast majority follow the instructions, a minority don't. I wait for those who don't.

It isn't always very popular, I do receive complaints from time to time but for me it's the only way of doing things. If I do have to take any action (such as waiting, calling for people to stand clear, or reporting problematic monitors) I note it ln my schedule card which I keep hold of for many months.

Or Liverpool St James street, in terms of assuming the behaviour of the individual involved:

The conductor stated that he believed the passenger reached the doors after the body side light associated with the vehicle the passenger was attempting to enter had extinguished. However, the CCTV shows that she had arrived just before the doors were fully closed.

The conductor stated he then believed the passenger was close to, but not in contact with, the train and that he instructed the passenger to stand clear of the train. However, the passenger stated that she did not hear any instruction and remained at the doorway with her forearm trapped.

The conductor then closed the door to his cab and the interlock light illuminated when this door was fully closed.

 

[pt_mad]

Or Liverpool St James street, in terms of assuming the behaviour of the individual involved:

The conductor stated that he believed the passenger reached the doors after the body side light associated with the vehicle the passenger was attempting to enter had extinguished. However, the CCTV shows that she had arrived just before the doors were fully closed.

The conductor stated he then believed the passenger was close to, but not in contact with, the train and that he instructed the passenger to stand clear of the train. However, the passenger stated that she did not hear any instruction and remained at the doorway with her forearm trapped.

The conductor then closed the door to his cab and the interlock light illuminated when this door was fully closed.

It's often sensible to go the extra step and keep the train in the platform until all passengers are well clear of the train, potentially behind the yellow line. For the staff's own reassurance as much as anything. The fact remains that this isn't necessary as far as RSSB rule books stipulate and there is no requirement for passengers to be well back from the train, only that they are clear of doors and no contact with the train. Which is too close for my liking.

Second of all at some point it would be far better imo if the industry bit the bullet as far as train technology was concerned, and made sure that interlock lights and exterior hazard lights extinguishing does mean (at some point in the future) that doors are sealed without obstruction or obstacles trapped.

I believe this may be the case on the new MerseyRail trains .Can someone say whether that's the case for sure?

Was it envisaged when the exterior hazard lights were introduced for interlocking that they would indicate that nothing was trapped? Should imagine it could have been. What do they indicate now? That a door cannot close or has not closed. But they may extunguish when a door appears to have closed when in fact it hasn't successfully as there is an obstruction. So potentially they indicate when a door is definitely open, or that central locking has been released, or that passenger alarm has been activated. But they don't indicate whether a door is definitely closed, just that it may be closed.

 

[CC 72100]

It's often sensible to go the extra step and keep the train in the platform until all passengers are well clear of the train, potentially behind the yellow line. For the staff's own reassurance as much as anything. The fact remains that this isn't necessary as far as RAIB rule books stipulate and there is no requirement for passengers to be well back from the train, only that they are clear of doors and no contact with the train. Which is too close for my liking.

Behind the yellow line and clearly showing no intent to interfere with the movement of the train (attempt to board, wave someone off by running alongside it right next to it etc.) is my personal standard. If I've got doubts about someone I'll go and ask them. If they don't respond to any shouting to stand clear, I don't move the train and go and investigate. Probably helps that most stations I deal with are staffed, although I have self-dispatched slam door stock in darkness before.

Was it envisaged when the exterior hazard lights were introduced for interlocking that they would indicate that nothing was trapped? Should imagine it could have been. What do they indicate now? That a door cannot close or has not closed. But they may extunguish when a door appears to have closed when in fact it hasn't successfully as there is an obstruction. So potentially they indicate when a door is definitely open, or that central locking has been released, or that passenger alarm has been activated. But they don't indicate whether a door is definitely closed, just that it may be closed.

A whole variety of things, depending on traction, and not all door related!

 

[nuts & bolts]

West Midlands Trains (under their "London Northwestern Railway" brand) are the new operator now.

(For completeness, GTR also operate trains - under their "Southern" route brand - through this location, they also have Guards but do not usually call at Bushey (if at all?), so WMT is the likely operator)

The Tring terminators under London Midland called at Bushey as they do with the current operator.