GWR Droplight Fatality Findings

[Krokodil]

If the Do Not Lean Out Of The Window sign was proved to have been visible why was this case ever brought?

The sign was a small one above the window, in yellow, reading "Caution - Do not lean out of window while the train it moving". As the smallest sign there, it didn't exactly stand out among signs illustrating how to open a slam door, how to use the emergency egress, to check if the door is actually platformed, a request to close windows to save energy, and a warning not to open the door while the train is moving - only the last one being a red for "Danger" sign.

Following the incident GWR replaced the sign with much clearer big red sign: "Danger - never place any part of your body out of the window until the train is at a platform".

 

[JKF]

Genuine question: aside from the GWR one and the Southern one at Wandsworth Common, has it happened anywhere else?

Pill station, 1984. Also an HST.

 

[JamesT]

The sign was a small one above the window, in yellow, reading "Caution - Do not lean out of window while the train it moving". As the smallest sign there, it didn't exactly stand out among signs illustrating how to open a slam door, how to use the emergency egress, to check if the door is actually platformed, a request to close windows to save energy, and a warning not to open the door while the train is moving - only the last one being a red for "Danger" sign.

Following the incident GWR replaced the sign with much clearer big red sign: "Danger - never place any part of your body out of the window until the train is at a platform".

And the point of the prosecution was that GWR already knew the sign was inadequate and had promised to replace it with a better one but then failed to do so.

 

[Mainline421]

I appreciate this might be a controversial take, but holding the TOC responsible for this is absurd, especially as there was signage explicitly forbidding it. It’s no different from someone stepping into traffic. Much of the world still operates with droplight windows to this day.

Without wishing to be insensitive, people need to take responsibility for their own actions, even if this doesn’t seem to be the trend in the UK lately. GWR aren't at fault.

 

[Krokodil]

especially as there was signage explicitly forbidding it

The signage wasn't explicit enough. That's why it was changed.

 

[Taplowgreen]

I appreciate this might be a controversial take, but holding the TOC responsible for this is absurd, especially as there was signage explicitly forbidding it. It’s no different from someone stepping into traffic. Much of the world still operates with droplight windows to this day.

Without wishing to be insensitive, people need to take responsibility for their own actions, even if this doesn’t seem to be the trend in the UK lately. GWR aren't at fault.

TOCs need to take responsibility for replacing inadequate safety signage in a timely fashion, when they have promised to do so, which was the whole point of the prosecution.

 

[yorkie]

And millions of people travelled on trains without continuous brakes, without block signalling, before they were mandated.

This is a false equivalence.

A sign is no use whatsoever to those people who don't see it or can't understand it. Or think they know better.

This was debunked earlier in the thread, and again just now:

TOCs need to take responsibility for replacing inadequate safety signage in a timely fashion, when they have promised to do so, which was the whole point of the prosecution.

If anyone has anything to add please ensure it is relevant and based on the reality of the situation. Anything speculative should be posted in the relevant forum section, please.

 

[Tetchytyke]

It's interesting too how many folk want to give GWR a pass, despite it failing to implement a presumably agreed with the regulator tosk assessment approach, while they were all over WCR for doing exactly the same.

I rather thought ORR’s attitude towards the Jacobite was just as ludicrous, to be quite honest. You shouldn’t even need a safety sign to not stick your head out of a window, no matter how fast the train is going.

As for this case, it boils down to the ORR wishing to look important (“somebody died, we need to look like we’re doing something!”) and GWR pleading guilty is cheaper and better for them than trying to defend the case.

 

[father_jack]

Genuine question: aside from the GWR one and the Southern one at Wandsworth Common, has it happened anywhere else?

There's a south Wales enthusiast who was left partly disabled after an incident where there was bellowing going on in Newport tunnel and a sign had been placed incorrectly on the tunnel wall and struck his head.

Pill station, 1984. Also an HST.

Is there any more information about this incident ?

 

[sprinterguy]

I'm amazed we have trains in the 21st century that have opening windows! I thought they were all sealed totally and air con rules?

Other than the Night Riviera sleeper and railtours, there aren't today. This decision and the subsequent discussion relates to an incident that occurred seven years ago.

Though not all stock operating today is air conditioned: There are still large numbers of Sprinter units and EMUs of a similar vintage ventilated by means of hopper vents throughout the passenger saloons.

 

[Annetts key]

I don’t know about your car but in mine there’s a belt that restrains me to a seated position - I am unable to stand and get my torso out of the window, and the window is much smaller than an HST droplight.

I included road vehicles as well as cars. In my car and most road vehicles that I have been in, you can get your head well out of the window even with the seat belt fastened. And considerably more of your body out if you do not have the seat belt tightly fastened or not done up at all. But this is dependent on the actual design of a particular road vehicle and the size and shape of your body.

And I have actually seen with my own eyes, people (who were acting rather jolly, but I have no idea if they were actually intoxicated) leaning out of car windows while the car they were in, was driving along a dual carriageway at 60MPH or thereabouts. And by this, I mean leaning out rather dangerously. I could not tell if they had a seat belt on, as I was concentrating on my own driving.

There’s a lot of comment on the woman being “intoxicated”. The BBC report said she was double the drink drive limit, which is about three pints. That’s not stumbling about vomiting drunk. I also don’t think we know that she put her head out deliberately. The lurch at the end of coaches over trackwork can unsteady you, maybe in an 800 she would have bumped her forehead on the door, rather than going through the open droplight.

Where this happened is straight or gently curving plain line. There is no S&C or pointwork between Oldfield Park station and Keynsham. Twerton is in-between these places. The RAIB report gives the location as being around 108 miles and 36 chains.

About the location it says:

The railway is elevated from the surrounding land on a brick structure. The north side is defined by a vertical brick wall which runs alongside the A36 road. The ballasted area of the railway runs right up to this wall and so affords limited opportunity for the growth of substantial trees. On the south side, where the tree involved was growing, the railway drops down a soil slope to the railway boundary and private properties that back onto the railway. The soil slope has numerous trees growing on it as well as smaller plants and bushes.

And I have travelled this section many, many times and can't think of any trains lurching in this area. The track is CWR / LWR (continuous-welded rail / long-welded) on concrete sleepers (except possibility at the nearby site of the HABD - Hot Axle Box Detector which is at about 108¼ miles) IIRC. The line speed is 100MPH for HSTs.

If you read the RAIB report ("Fatal accident involving a train passenger at Twerton 1 December 2018"), it says that the train was

travelling at approximately 75 mph (120 km/h) at the time.

About the tree, the RAIB report says:

The branch which the passenger came into contact with was attached to a stem that was growing from the stump of an ash tree.

After the accident, Network Rail commissioned an arboricultural consultant to investigate the history of the tree. The consultant’s report identified that the tree involved was an ash tree which had been growing on the embankment approximately 5.5 m from the nearest running rail of the ‘down’ main line.

The report describes how the tree was either felled or coppiced around 1998 and after that seven stems grew out from the stump. Eventually the stump became colonised by two or three types of wood decay fungi which ultimately led to the failure of the stems. The stem involved then fell towards the railway, coming to rest on a chain link fence at the top of the embankment.

From a review of historical aerial photographs and video footage, the RAIB has concluded that the stem involved did not fail before 18 April 2015. However, by 4 February 2017, it had fallen and was resting on the fence with some branches extending out towards the railway line. The photographs and video footage also show that the tree remained largely unmoved in this position until at least late on the afternoon of the day of the accident. Given that the tree had been in this position for at least 22 months without moving significantly, it was not a particularly windy day and the RAIB is not aware of any other events that could have affected its position, the RAIB believes it is likely that it was still in that position at the time of the accident.

Here's a photo of the tree branch. The photo was taken by the Network Rail MOM after the incident


Photo above shows a train stopped at the location of the tree. Some vegetation or branches are very close to the side of the train. Some look to be touching the side of the train. At about the height of the train windows, there is a branch which has had the end broken off.

After alighting from a train carrying out an inspection after the incident

..the MOM saw the freshly broken end of a tree branch at window height, close to the train.

...and found a corresponding section of tree branch on the ballast underneath the tree.

The MOM

recovered the branch. It is approximately 55 cm long and 4 cm in diameter. It was handed to the BTP which was subsequently able to confirm, by way of a forensic examination, that it was the branch that the passenger had come into contact with.

About the passenger who was killed:

Witness evidence confirms that her head was out of the window at the time she sustained the injury.

One of the group of friends opened the window and at least one other friend leant out of the window before the passenger who was injured did so

The toxicology report concluded that the passenger’s blood contained 142 milligrams of ethanol per 100 millilitres. This is nearly twice the UK legal driving limit of 80 milligrams in 100 millilitres of blood. It is generally recognised that this would cause a level of intoxication in the average social drinker which may affect their co-ordination and judgement. However, the actual effect on the passenger involved is unknown.

It also says:

A possible underlying factor was that Great Western Railway’s risk assessment process had not historically identified the risk of passengers or staff being injured as a result of putting their heads out of windows on moving trains. Consequently, Great Western Railway had not provided adequate mitigation measures to protect against the risk.

The RAIB report has four recommendations and two learning points:

One recommendation is addressed to operators of mainline passenger trains, including charter operators, and seeks to minimise the likelihood of passengers leaning out of droplight windows when a train is away from stations. A second recommendation, is addressed to operators of heritage railways and seeks to improve their management of the risks associated with passengers leaning out of vehicles.
The third recommendation is addressed to Great Western Railway and seeks to reduce the potential for hazards associated with its operations being overlooked.
The fourth recommendation is addressed to RSSB and seeks to ensure that its advice on emergency and safety signs reflects the level of risk associated with the hazard being mitigated.
The learning points reinforce the importance of undertaking regular tree inspections and the value of train operators having well briefed procedures for dealing with medical emergencies on board trains.

 

[43096]

I appreciate this might be a controversial take, but holding the TOC responsible for this is absurd, especially as there was signage explicitly forbidding it.

No there wasn’t such signage. It was a yellow caution notice, rather than a red prohibition sign. They are very different.

Without wishing to be insensitive, people need to take responsibility for their own actions, even if this doesn’t seem to be the trend in the UK lately. GWR aren't at fault.

GWR are at fault for the inadequate signage and risk assessment, which was a recommendation in the RAIB report into the similar Balham incident.

 

[Stephen42]

I rather thought ORR’s attitude towards the Jacobite was just as ludicrous, to be quite honest. You shouldn’t even need a safety sign to not stick your head out of a window, no matter how fast the train is going.

As for this case, it boils down to the ORR wishing to look important (“somebody died, we need to look like we’re doing something!”) and GWR pleading guilty is cheaper and better for them than trying to defend the case.

GWR would likely lose the case if they tried to defend in court. The breaches are quoted as ROGS 2006 Regulation 19 (1) and Health and Safety at Work Act 1974 Section 3(1), neither of these require an accident to be caused. The ROGS one is to have an appropriate risk assessment and implement the measures from it. The other is to as far as reasonably practicable not expose non-employees to health and safety risks.

The two relevant actions from the risk assessment were extra staff training and revisions to signage around the doors. Neither of these would be particularly difficult or expensive (so are reasonably practicable) - the target date for all four actions (including two unrelated) was May 2018. The staff tasked with those actions left, the action tracking system did not notify anyone these were overdue or assigned to people who had left. No one had realised in six months after that date before this incident that these items weren't done or being actively progressed. That's slam dunk on the ROGS one, they didn't implement the measures and it was organisational failings below what could be reasonably expected to blame. Similarly the other one the only defence would be the actions wouldn't reduce the risk exposure, but that is undermined by GWR recognising those as appropriate actions in its risk assessment.

Many of the issues uncovered in the investigation would have been present for other safety risks.

I'm actually surprised that corporate manslaughter charges and individual prosecutions of relevant senior staff didn't follow.

The circumstances of this case make any conviction on those charges unlikely. While clearer signage could reduce the number of people putting themselves at risk, for any manslaughter charge would need to prove the actions to alter the behaviour of this group. While it doesn't need to be definite, it does needs to be more than a possibility and reporting suggests the group knew it was a risky activity so would be a tricky bar to clear.

The significant contribution issue wouldn't apply to the windows being there. However the windows not being barred/locked is unlikely to be proved as grossly negligent, as there was a plan to remove stock in a couple of years, a need for passengers to open the windows and no other operators in a similar situation immediately removed their relevant stock from passenger service.

 

[Wolfie]

GWR would likely lose the case if they tried to defend in court. The breaches are quoted as ROGS 2006 Regulation 19 (1) and Health and Safety at Work Act 1974 Section 3(1), neither of these require an accident to be caused. The ROGS one is to have an appropriate risk assessment and implement the measures from it. The other is to as far as reasonably practicable not expose non-employees to health and safety risks.

The two relevant actions from the risk assessment were extra staff training and revisions to signage around the doors. Neither of these would be particularly difficult or expensive (so are reasonably practicable) - the target date for all four actions (including two unrelated) was May 2018. The staff tasked with those actions left, the action tracking system did not notify anyone these were overdue or assigned to people who had left. No one had realised in six months after that date before this incident that these items weren't done or being actively progressed. That's slam dunk on the ROGS one, they didn't implement the measures and it was organisational failings below what could be reasonably expected to blame. Similarly the other one the only defence would be the actions wouldn't reduce the risk exposure, but that is undermined by GWR recognising those as appropriate actions in its risk assessment.

Many of the issues uncovered in the investigation would have been present for other safety risks.

The circumstances of this case make any conviction on those charges unlikely. While clearer signage could reduce the number of people putting themselves at risk, for any manslaughter charge would need to prove the actions to alter the behaviour of this group. While it doesn't need to be definite, it does needs to be more than a possibility and reporting suggests the group knew it was a risky activity so would be a tricky bar to clear.

The significant contribution issue wouldn't apply to the windows being there. However the windows not being barred/locked is unlikely to be proved as grossly negligent, as there was a plan to remove stock in a couple of years, a need for passengers to open the windows and no other operators in a similar situation immediately removed their relevant stock from passenger service.

A very measured and logical response. TY

 

[renegademaster]

Was the fine more or less than what it would cost to do what ORR wanted? And is this kind of thing something that comes out of their insurance or does not following legal instructions force them to pay it out of pocket?

 

[Clarence Yard]

No, the fine was more than the cost of sorting out the warning labels.

It isn’t coverable by insurance so GWR (DfT) will be paying it.

 

[WelshBluebird]

Has anyone got any photos of the different kind of signs being talked about?

Granted its been a while so I may be wrong, but I always thought they had pretty obvious warnings. Similar to those posted in https://www.railforums.co.uk/threads/window-hanging.150830/#post-3064278 but obviously those are about leaning on the door etc. But I could swear they had similar ones for putting parts of your body outside.

Edit - just seen photos of the sign at the time and the one that replaced it on the bbc -
BBC News - Woman killed as she leaned out of train window - BBC News
https://www.bbc.co.uk/news/uk-england-bristol-50067073?app-referrer=deep-link.

I'll be honest do they not just say the same thing? Struggling to see why one would be seen as not good enough but the other is fine. Or at least if a person is going to ignore one of those signs, they arent going to suddenly pay attention to the other one.

 

[Ashley Hill]

TBH a red sign on a pink background wouldn’t have stood out. Unlike the yellow one which clearly does.

 

[Krokodil]

I'll be honest do they not just say the same thing? Struggling to see why one would be seen as not good enough but the other is fine.

One is small, yellow and says "Caution", the other is big, red and says "Danger". It is also backed up by a label on the handle and one below it. The sign reminding you to close the window to save energy has been removed to declutter it.

 

[Deepgreen]

TBH a red sign on a pink background wouldn’t have stood out. Unlike the yellow one which clearly does.

The entire regime of signage and colours on the railway has got out of control. So many signs and labels are just affixed after others and in any available space that there has become a general miasma of various information which does not stand out and is easily blotted out/blurred by the brain (even if not intoxicated). This is a direct result of the steady removal of personal responsibility from people with the inevitable proliferation of signage. The same applies to audible information.

I would welcome a huge and thorough overhaul of the information regime to make it fit for purpose (and 're-nationalisation' provides an opportunity to do so, albeit not overnight), but it won't happen because the removal of responsibility will continue unchecked.

Simply putting notices and announcements about every conceivable action everywhere is not good information provision - it is much more about TOCs being able to claim innocence/immunity in legal cases.

 

[Bikeman78]

That's a very selective statistics, as are many.

How about all the non-125s? How many have been injured but not died?

It's a needless risk. As in, there's no real benefit to keeping these unsafe doors, so it's potential loss of life for at best the odd thrill of a basher. To me it doesn't check out.

They were already being removed by the time of the incident. The first 800s were already in service. Not sure how many HSTs had been withdrawn by that point. There were other TOCs running similar HSTs at the time and I'm not aware of any modifications to those sets.

 

[CC 72100]

There were other TOCs running similar HSTs at the time and I'm not aware of any modifications to those sets.

Indeed I think at the time of the incident, the GWR signage was the same as on all other TOCs.

The Red signage came in (on GWR and other the TOCs) after this event.

So were all TOCs in the same boat and open to the same ORR rulings at the time of the incident, should it have happened on one of their trains instead?

 

[JKF]

Is there any more information about this incident ?

(Filmed at the site of Pill station, someone from my school got paid a small sum in cash to dig the hole!)

 

[slowroad]

Indeed I think at the time of the incident, the GWR signage was the same as on all other TOCs.

The Red signage came in (on GWR and other the TOCs) after this event.

So were all TOCs in the same boat and open to the same ORR rulings at the time of the incident, should it have happened on one of their trains instead?

I know this is a broader issue, but the use of slam doors opened via droplights seems so archaic, even for a 70s train. It’s hard to see how HST’s maintained their modern image with this ludicrous feature. (The answer is presumably “only in Britain” where we were insulated from higher standards in other developed countries.) Aside from the obvious safety issue, the combination with the toilet arrangements was unsavoury - and perhaps also indirectly unsafe. (And then there was noise and the impact on air conditioning…)

I can just about see (with HST developed as something of a stopgap) why automated doors were avoided, but why not fixed windows and internal handles with effective interlocking (not the partially effective solution eventually adopted)? Surely that would have been a reasonable and not too expensive design solution?

 

[Haywain]

from higher standards in other developed countries

Is that the other developed countries across Europe where opening windows are still a thing? And usually larger than a door droplight on an HST.

but why not fixed windows and internal handles with effective interlocking

With CDL internal door handles could perhaps have been brought back (they were there from new) but I guess the safrty aspect of making door handles difficult to get at was preferred.

 

[Bletchleyite]

Is that the other developed countries across Europe where opening windows are still a thing? And usually larger than a door droplight on an HST.

High up so you don't really fully lean out, and with a wider loading gauge so you won't bang your head.

I do despair that the UK failed to adopt the standard RIC folding door with door blocking and autoclose back in the 70s. The HST should absolutely have had these. Indeed the XP64 experimental coach had similar doors but without the safety features, which was ridiculous. Had the UK adopted this proven, safe and universal system many lives would have been saved, including all the ones involving people falling from doors.

 

[FrontSideBus]

Why do they really need prominent warning signs anyway? I mean it's common sense (or at least it used to be!) not to stick your head out of moving trains!

 

[Bletchleyite]

Why do they really need prominent warning signs anyway? I mean it's common sense (or at least it used to be!) not to stick your head out of moving trains!

It's certainly an aspect of the UK that we aren't willing to let Darwinism take its course, which has come from US style litigiousness over time. Most other countries do allow this, i.e. if someone does something obviously stupid and dies then nobody is prosecuted. The UK seems uniquely willing to protect stupid people from their own stupidity, only Australia seems to do this more.

 

[FrontSideBus]

I mean don't get me wrong, I used to do it when we had mk2 and mk3's on the WCML but I never put it out too far and was always on the lookout for stuff and to pull back in quicky. I knew the risks. If I'd have gotten hurt or killed then it really would have been my fault!

 

[Tetchytyke]

The UK seems uniquely willing to protect stupid people from their own stupidity, only Australia seems to do this more.

I don’t even think that is true- look at the Puffing Billy. If a heritage railway here allowed that the ORR would shut them down.