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Near miss with an access ramp at Norwood Junction station (RAIB)

voyagerdude220

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In the section headed "Actions reported as already taken or in progress relevant to this report", paragraph 132 states:

That doesn't exclude the possibility they were redeployed to other duties, however.
Thanks, I didn't read that bit.

== Doublepost prevention - post automatically merged: ==

The report indicates that dispatch did take place - "The train driver is entirely responsible for the safe dispatch of the train from a station and station platform staff have no role in the dispatch process" (para 35)
My meaning of "dispatch" was a formal process involving both platform staff and the train Driver. Not self dispatch by the Driver alone.
 
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Krokodil

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this was probably because the driver was distracted as they were making a mobile phone call at the time the train departed.

They were doing what?!
 

Tetchytyke

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It doesn't make good reading.

Some select highlights:

72. However, phone records obtained by RAIB established that the driver’s personal mobile phone was switched on for the duration of their shift and that five phone calls of lengths from 33 seconds up to 25 minutes were made or received while they were driving various trains

74. RAIB determined that these phone calls were being used by the driver to deal with personal issues of a potentially distressing nature.

76. The driver was involved in two incidents in the year preceding the Norwood Junction accident that also could be attributed to distraction.

77. The driver had their first incident in July 2024 when they passed a signal at danger (SPAD). ARL’s investigation found that the driver was habitually cancelling warnings issued by the automatic warning system (AWS, which provides an audible and visual warning to a driver on the approach to certain infrastructure features, such as signals and selected speed restriction changes) and not modifying their driving behaviour in response to the warnings received.

79. The driver’s second incident occurred in May 2025 where they had a ‘failed to call’ (FTC) incident at a station. The ARL investigation showed that the driver had lost concentration due to personal issues and had not slowed the train sufficiently for the station stop.

84. Phone records were no longer available for the period covering the July 2024 SPAD. However, records obtained by RAIB show that the driver’s phone was on for the duration of their shift when the FTC incident occurred in May 2025. Although no records of phone calls being made during the incident were found, records show that the phone was switched off immediately before the driver was met by their manager.

RAIB have the legal power to access phone records, unlike the TOCs, so only RAIB would find out if a driver was lying about their mobile phone use.

132. The driver of train 9D18 ceased driving trains for ARL.

I should think not!
 

sharpener

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It doesn't make good reading.

Some select highlights:

......
The working of the station has some worrying concerns as well. IMO they should have retired the ramps that were physically compatible with one class of train but did not block the door operation, it seems the later ramp could have served for both and removed one source of error.

Once the need to block the door operation was recognised, good practice would at least be to have some form of mechanical keying on the ramp. Introducing this retrospectively might not be practical, however it shouldn't need RAIB to point out the obvious need for labelling the ramps with the train types they were intended for.

And the whole business of having 3 different classes with driver self-despatch for one and platform staff despatch for the other two must be an ongoing source of confusion, especially with contract staff. Though in this case their training and behaviour seems to have not been at fault.
 

Posa

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Always found it puzzling that they have London Overground employed and trained safety critical dispatch staff on the platform but they only dispatch Southern trains.

If they are there they should dispatch everything and then this incident wouldn't have occurred.
 

Tetchytyke

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Always found it puzzling that they have London Overground employed and trained safety critical dispatch staff on the platform but they only dispatch Southern trains.
The station is operated by TfL and so the staff are TfL staff (well, employed by TfL's Overground concessionaire). The only trains that require staff despatch are the Southern Class 377s. It isn't particularly uncommon.

If they are there they should dispatch everything and then this incident wouldn't have occurred.
The other two types of train, the 378 and the 700, are driver-despatch using on-board monitors. That's not unusual either.

The working of the station has some worrying concerns as well. IMO they should have retired the ramps that were physically compatible with one class of train but did not block the door operation, it seems the later ramp could have served for both and removed one source of error.
GTR were the ones who removed the ramp for the 378 and replaced it with another ramp for the 377, though. And the staff weren't trained on the different types of ramp so, because the 377 ramp fit into the 378 lugs, they didn't know it was wrong. The only difference between the two ramps was the 378 ramp had the extended arms to prevent the doors closing.

Perhaps the 377 ramp should have the arms too, it would certainly make sense, and would prevent this happening again.

But the station working doesn't particularly concern me. The simple fact is that the driver didn't see a huge yellow ramp and a staff member in hi-viz in the gap between the white and yellow lines when he closed the doors and still didn't see them when he decided it was safe to set off.
 

ainsworth74

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It doesn't make good reading.

Some select highlights:
Seems to be becoming a bit of an issue in the industry mobile phone usage whilst driving. Bromsgrove in 2020 where a freight went through some buffers in a siding and fouled the mainline causing an XC 170 to strike a glancing blow* and then Kirkby in 2022 when a Merseyrail 507 lost an argument with the buffer stops. Both were caused by drivers being distracted by phones. And now this one where mobile phone usage played a role.

So three times where it's gone so wrong that it's caused accidents (with us getting lucky all three times that no-one was seriously injured or killed). How many times is it happening that go undetected or where whatever goes wrong isn't serious enough to attract attention?


*Though I did and still do have a lot of sympathy for the Bromsgrove driver as they were driving almost immediately Boris announced the first lockdown and were worried about childcare during what could fairly be described as unprecedented times! Shouldn't have done it of course but I'm still sympathetic.
 

RailwayRookie

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If they are there they should dispatch everything and then this incident wouldn't have occurred.
Having the driver operate DOO at every other station and then change to being dispatched by platform staff at one could also lead to an incident.

If the driver forgets the arrangement and self dispatches safetly but without the platform agent saying they could? Its a reportable safety incident for no reason.


Arguably the DOO system isnt the problem as this incident and others cited in the report all have factors beyond an "insufficient method of working". You know like being on the phone.

Im sure someone will argue that the DOO system wasnt effective as the driver didnt see the hand signals or baton on the cameras, but he also didnt see the access ramp so the problem is with the driver not the method.

But the station working doesn't particularly concern me. The simple fact is that the driver didn't see a huge yellow ramp and a staff member in hi-viz in the gap between the white and yellow lines when he closed the doors and still didn't see them when he decided it was safe to set off.
They do mention this in report. Sorry i dont still have it open to give the paragraph, but they say its not unusual for platform staff to be there to stop people touching the train as it leaves.
 

Mattplans

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A bit confused about the Southern dispatch situation. I thought the whole point of relieving guards was so drivers could dispatch themselves. Why are they being dispatched by station staff at NJ? Is this necessary at every station?
 

Tetchytyke

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Sorry i dont still have it open to give the paragraph, but they say its not unusual for platform staff to be there to stop people touching the train as it leaves.
It's not unusual for the platform staff to be in the despatch corridor but you'd expect the driver to notice them and check that there wasn't a reason why they were in the despatch corridor. Unless, of course, the driver was on their phone and not paying attention...

Seems to be becoming a bit of an issue in the industry mobile phone usage whilst driving. Bromsgrove in 2020 where a freight went through some buffers in a siding and fouled the mainline causing an XC 170 to strike a glancing blow* and then Kirkby in 2022 when a Merseyrail 507 lost an argument with the buffer stops. Both were caused by drivers being distracted by phones. And now this one where mobile phone usage played a role.
RAIB go into it in quite a lot of detail later on in the report and mention those incidents as well as a trap-and-drag at Hayes and Harlington being caused by mobile phone usage.

I thought this paragraph was quite pointed:
118. In 2024, RSSB published the report from an updated research programme, T1280 ‘Evaluating the effectiveness of control measures for unauthorised presence of mobile smart devices within the driving cab’. Updated surveys revealed nearly 40% of drivers did not think they would be caught using a mobile device while driving, and 18% of drivers thought mobile devices do not affect performance. The report also shows that drivers and managers do not want any form of in- cab monitoring, instead preferring to influence behaviour through education. The recommendations made in the report were to have better policies and risk assessments focusing on more checks and monitoring and updating training and awareness processes. Currently, this has not filtered out to the wider industry beyond awareness of the recommendations.
 

ainsworth74

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RAIB go into it in quite a lot of detail later on in the report and mention those incidents as well as a trap-and-drag at Hayes and Harlington being caused by mobile phone usage.

I thought this paragraph was quite pointed:
Oh yes that is rather pointed isn't it?

Definitely feels like something that is going to need to be looked at more seriously. We're getting bright red warning lights now with four separate incidents that could have ended much much worse than they did (and Hayes and Harlington didn't exactly end well, but it could certainly have been even worse).
 

Posa

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Having the driver operate DOO at every other station and then change to being dispatched by platform staff at one could also lead to an incident.

If the driver forgets the arrangement and self dispatches safetly but without the platform agent saying they could? Its a reportable safety incident for no reason.

But that's exactly what happens with the Southern stoppers from p1 that are dispatched at Norwood.

Also Overground are dispatched from Euston and Liverpool Street and then doo the rest so it's not unheard of on the Overground

I'm not excusing the driver being on the phone.

But if there are safety critical staff, why are they not used? a second pair of eyes is always more safer than one.
 

RailwayRookie

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But that's exactly what happens with the Southern stoppers from p1 that are dispatched at Norwood.

Also Overground are dispatched from Euston and Liverpool Street and then doo the rest so it's not unheard of on the Overground

I'm not excusing the driver being on the phone.

But if there are safety critical staff, why are they not used? a second pair of eyes is always more safer than one.
Apologies my post was meant to be more of a question than a flat out statement.

Would the Euston and Liverpool Street situations also be because of relative busyness or perhaps someone having to be there already to TRTS the train to the signaller?

As you say though its not totally out of course to do it. There are many other things that should have been done differently that would have made the the whole dispatching point moot.
 
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I don't doubt that the other recommendations should be implemented, but:

That's wild. Making a mobile phone call, work or otherwise, while departing a station is surely advised against?
The report also says that "RAIB determined that these phone calls were being used by the driver to deal with personal issues of a potentially distressing nature" - so maybe he shouldn't have been at work at all. Unfortunately he initially denied having used his phone at all - but police enquiries (from the network or phone isn't stated) disproved this.
 

Horizon22

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Thanks, I didn't read that bit.

== Doublepost prevention - post automatically merged: ==


My meaning of "dispatch" was a formal process involving both platform staff and the train Driver. Not self dispatch by the Driver alone.

"Dispatch" can be conducted in about 10 different ways. Driver doing DOO dispatch is included with this.

== Doublepost prevention - post automatically merged: ==

Having the driver operate DOO at every other station and then change to being dispatched by platform staff at one could also lead to an incident.

If the driver forgets the arrangement and self dispatches safetly but without the platform agent saying they could? Its a reportable safety incident for no reason.

Why? This happens around the country day in, day out at some operators. Every station has local dispatch arrangements due to the specific infrastructure constraints.
 

td97

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I don't doubt that the other recommendations should be implemented, but:

That's wild. Making a mobile phone call, work or otherwise, while departing a station is surely advised against?

Clearly the driver making a phone call is worrying but so is the number of organisations involved meaning too many cracks for things to fall through.

I've read the report and as others have already said, there are numerous concerning bits which it highlights.

Hopefully the Driver is no longer employed on the Railway if they were indeed using their personal phone whilst driving the train.

Also to be pedantic, the OP refers to "unsafe dispatch" but I don't think despatch took place.

From my reading of it, it seems like it goes beyond the use of a mobile phone. It says for this incident, the on call manager couldn't see any evidence of phone calls but evidence beyond this says they did. Presumably this was records from the phone company (which also showed the phone being turned on at a time the driver had said it was off. So not only was it likely against policies, but it makes out that the driver was also economical with the truth, with it

They were doing what?!
There's no doubt about it - the driver was using his phone incessantly during his shift that morning, including during the ramp dispatch incident.
Then afterwards, he cleared call logs and switched off the device upon knowing he was being summoned to the on call manager, and then lied about the status of the device during driving duties.
The RAIB's investigation has uncovered this as a blatant, dangerous lie.
 

saltywalrus

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But that's exactly what happens with the Southern stoppers from p1 that are dispatched at Norwood.

Also Overground are dispatched from Euston and Liverpool Street and then doo the rest so it's not unheard of on the Overground

I'm not excusing the driver being on the phone.

But if there are safety critical staff, why are they not used? a second pair of eyes is always more safer than one.
If I had to guess; it's more straightforward for the driver to use the same DOO procedure at every stop, rather than having to remember which stations are DOO and which are dispatched by platform staff.

The platform staff can still be a second pair of eyes with DOO - they are still able to keep watch for danger and alert the driver using the "stop" hand signal, which is exactly what happened in this case. Except the driver was too distracted by their phone to notice. (edited per sharpener's point that the driver could not see the dispatcher on the cameras)

Seems to be becoming a bit of an issue in the industry mobile phone usage whilst driving. Bromsgrove in 2020 where a freight went through some buffers in a siding and fouled the mainline causing an XC 170 to strike a glancing blow* and then Kirkby in 2022 when a Merseyrail 507 lost an argument with the buffer stops. Both were caused by drivers being distracted by phones. And now this one where mobile phone usage played a role.

So three times where it's gone so wrong that it's caused accidents (with us getting lucky all three times that no-one was seriously injured or killed). How many times is it happening that go undetected or where whatever goes wrong isn't serious enough to attract attention?


*Though I did and still do have a lot of sympathy for the Bromsgrove driver as they were driving almost immediately Boris announced the first lockdown and were worried about childcare during what could fairly be described as unprecedented times! Shouldn't have done it of course but I'm still sympathetic.
Definitely - and given how many RAIB reports have been put out emphasising the danger of phone distraction, I doubt there is anyone of the railway that is ignorant of the risk - so at this point it is an issue of some people thinking that they can get away with it.

Obviously such willfully negligent behaviour is cause for immediate dismissal, but given how these incidents keep reoccurring that doesn't seem to be enough of a deterrent alone. Is there any prospect of criminal prosecution for phone usage whilst driving? Reckless endangerment maybe?
 
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sharpener

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The platform staff can still be a second pair of eyes with DOO - they are still able to keep watch for danger and alert the driver using the "stop" hand signal, which is exactly what happened in this case. Except the driver was too distracted by their phone to notice.
No, the report says (with reconstruction pic) that the platform staff's raised arms are mostly out of shot when viewed on the screen in the cab.

Seems to me that (as with prisons) it should be possible to detect a switched-on mobile phone with a comparatively simple bit of electronics, if not actually to jam it as well. The softly softly approach clearly hasn't worked and with the same problem on the roads it probably isn't going to.
 

saltywalrus

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No, the report says (with reconstruction pic) that the platform staff's raised arms are mostly out of shot when viewed on the screen in the cab.

Seems to me that (as with prisons) it should be possible to detect a switched-on mobile phone with a comparatively simple bit of electronics, if not actually to jam it as well. The softly softly approach clearly hasn't worked and with the same problem on the roads it probably isn't going to.
Ah, my mistake, have edited my previous post. Still, DOO is deemed to be a safe procedure regardless of if a station is staffed or not. The benefits of involving another person in the dispatch process at some stations is outweighed by the complications introduced by requiring the driver to switch between two different procedures at different stops.
 

cats_five

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Seems to be becoming a bit of an issue in the industry mobile phone usage whilst driving.
<snip>

I think it's an issue on the roads as well with all types of vehicle except, maybe, buses where the passengers could see if the driver was using a mobile phone.
 

Krokodil

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Seems to me that (as with prisons) it should be possible to detect a switched-on mobile phone with a comparatively simple bit of electronics, if not actually to jam it as well. The softly softly approach clearly hasn't worked and with the same problem on the roads it probably isn't going to.
Wouldn't that affect the GSM-R?
 

TrainOnLine

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I think it's an issue on the roads as well with all types of vehicle except, maybe, buses where the passengers could see if the driver was using a mobile phone.
It's the flimsy excuse of "personal issues" post event that really irks me. The cynic in me thinks they're told to say this by the union.

There is zero tolerance on mobile phone usage. The only time authorised should be for safety critical comms if needed as a last resort
 

saltywalrus

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No, the report says (with reconstruction pic) that the platform staff's raised arms are mostly out of shot when viewed on the screen in the cab.

Seems to me that (as with prisons) it should be possible to detect a switched-on mobile phone with a comparatively simple bit of electronics, if not actually to jam it as well. The softly softly approach clearly hasn't worked and with the same problem on the roads it probably isn't going to.
I doubt a system to track/jam staff phones would be simple or inexpensive at all, not to mention it would prevent safe usage of mobile phones for emergency communication and presumably prevent passengers from using their phones as well.

It's the flimsy excuse of "personal issues" post event that really irks me. The cynic in me thinks they're told to say this by the union.

There is zero tolerance on mobile phone usage. The only time authorised should be for safety critical comms if needed as a last resort
Maybe, but ideally the reason stated by the staff for using their phone shouldn't make a difference; it should always be treated as wilful gross negligence which knowingly endangers the lives of potentially hundreds of people.
 

fishwomp

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There is zero tolerance on mobile phone usage. The only time authorised should be for safety critical comms if needed as a last resort
Zero tolerance but zero awareness?

The management have no right to access phone records - and the delete calls option seems sufficient *except* when an incident has to be investigated by RAIB to get the operator logs - means the only enforcement is after the potential worst has happened.

Unless cabs are routinely going to have video monitoring, how can it be known ... I don't see that happening without industrial relations blowing up, except were that to be accepted without question as necessary after something really bad happens.

With trains having on-board wifi too, challenge is not just phone signals - but also how to prevent drivers, yet enable passengers in the front seats to still use wifi calling. Equally, how to prevent watching junk on the internet or any distraction.

It's entirely dependent on the professionalism of the drivers at the moment - and some have been found lacking. That's no reflection on what will be the vast majority of safe drivers who are true professionals.
 

Tetchytyke

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Seems to me that (as with prisons) it should be possible to detect a switched-on mobile phone with a comparatively simple bit of electronics, if not actually to jam it as well.
The trouble is that many of the safety systems in a cab run on the same technology as mobile phones (e.g. GSM-R).
I doubt there is anyone of the railway that is ignorant of the risk - so at this point it is an issue of some people thinking that they can get away with it.
I don’t think it was a coincidence that RAIB drew attention to a report which showed that 40% of drivers believed they could use a mobile phone without detection and 18% of drivers think they can use a mobile phone without it affecting performance.
 

Watershed

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I think the question of in-cab CCTV needs to be reopened, just as in the aviation industry with in-cockpit CCTV.

Yes, no-one likes being "watched" whilst doing their work but when you are in charge of the safety of hundreds of people and could affect the safety of thousands, I think that has to be balanced against your right to privacy.

Of course there isn't remotely the will to tackle issues like these properly so instead we see sidestepping of the issue. Education is all well & good but I'm sure every driver is aware of the risks and yet some still choose to do it.

As with the lack of complete TPWS fitment which may well now have claimed someone's life, this is a latent danger that has been staring the industry in the face for decades but it doesn't seem like it is being addressed with the urgency it deserves.
 

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I don’t think it was a coincidence that RAIB drew attention to a report which showed that 40% of drivers believed they could use a mobile phone without detection and 18% of drivers think they can use a mobile phone without it affecting performance.
We've come to accept that driving a car with hands-free phones is 'ok' unless you have an accident. In a car you need the hand more than when driving a train - for steering obviously, and in a typical urban driving scenario you're more likely to have other eejits in cars, pedestrians, etc etc, and more signs and traffic lights - several times a minute - although the stopping distances are shorter..

We've probably just accepted that if you can't beat it, you have to accommodate it as safe as you can, in a car. Is that going to be necessary for trains - bluetooth, limits on where/when/speeds etc etc.. - or blanket bans that aren't enforced if they can't be detected?
 

GordonT

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I think it's an issue on the roads as well with all types of vehicle except, maybe, buses where the passengers could see if the driver was using a mobile phone.
It would depend on the mindset of those bus passengers who were in situ. We are now in a culture approaching towards the almost omnipresent phone and unfortunately some passengers would form the view that the bus driver was probably speaking to his/her depot controller and (wrongly) form the opinion that was fair game. Worse still some passengers might not perceive any problem with the phone being used.
 

Tetchytyke

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We've come to accept that driving a car with hands-free phones is 'ok' unless you have an accident.
We have, but that’s largely because the distraction from a hands-free phone isn’t very different to the distraction from having a conversation with a passenger.

There’s a reason why access to the cab is more tightly controlled than that; worth noting that a “guest” in the cab was cited as the primary distracting factor in a recent overspeed incident at LNER.
 

Wolfie

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No, the report says (with reconstruction pic) that the platform staff's raised arms are mostly out of shot when viewed on the screen in the cab.

Seems to me that (as with prisons) it should be possible to detect a switched-on mobile phone with a comparatively simple bit of electronics, if not actually to jam it as well. The softly softly approach clearly hasn't worked and with the same problem on the roads it probably isn't going to.
The likely issue with your second para is having a detector which is sensitive enough to detect a phone in the driving cab but not in the passenger seats immediately behind it. That also, rather importantly assumes that no work issued phones or other equipment based on mobile phone technology are in use.

A similar issue would arise with any use of jammers - anything which jammed passenger's phones would definitely be problematic.
 

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