Commuter dragged after hand stuck in door

[Aictos]

"The dispatcher believed that he had to remain at the dispatch point after he first operated the CD control. This was because the driver’s CD indicator is extinguished when the dispatcher releases the CD switch at the dispatch point and, from past experience, the dispatcher believed that, if he released the CD button without immediately operating the RA control, the train driver might take this as a signal to reopen the train doors."

The bold highlights I've added. "Believed" and "might" clearly show that the dispatcher did not fully understand the operation of the CD/RA panel and safe train despatch.

This actually surprises me as I've never been told that if I don't immediately operate the RA then the driver will take this as a signal to reopen their doors if anything if there is a problem then I've always been told to alert the driver and come to a safe agreement to resolve it.

If anything the only time I would expect a driver to reopen their doors is if there was a problem with a set of doors and the driver had to secure their cab before fault finding what the fault could be, this applies to guards as well.

 

[A-driver]

Why not read the report and these questions will be answered?

41 A passenger near the incident door pulled the PCA about 9 seconds after the train had started moving, when it had travelled about 17 metres. The driver operated an override control 3.5 seconds later and this prevented the PCA causing an emergency brake application. The train continued for about four minutes, until it reached the next station.
42 The driver’s decision to override the PCA had no effect on this incident because passenger A’s fingers were released from the doors shortly before he operated the PCA override. However, overriding the PCA could have resulted in passenger A sustaining more serious injuries if she had remained trapped in the doors, as occurred at Huntingdon (paragraph 34).
43 Override controls are fitted to some trains so that, in appropriate circumstances, the driver can prevent the train stopping at an unsuitable location, such as in a tunnel where it will be difficult to provide assistance to passengers.
44 The railway Rule Book8, and the FCC training notes given to the incident driver during his training9, both instruct drivers that:
l if the PCA is operated, you must, if possible, avoid stopping the train in a place where it might be difficult to deal with the emergency; and
l you must stop the train immediately if the PCA is operated as the train is leaving the station.
45 The Rule Book makes clear that, if a train is leaving a station, the requirement
to stop the train takes precedence over any consideration of unsuitable places
to stop. The training material does not explain this and the incident driver, who had completed his training three months before the incident, believed that he was required to make a rapid judgement call. He had no indication inside his cab of where in the train the PCA had been operated. He decided to continue to Finsbury Park station; this was not a scheduled stopping place for this train, but was the first location at which assistance could be provided relatively easily. He made a general announcement to the passengers, saying that he was aware that the PCA had been operated and that the train would continue to the next station.

I have read the report but put this into a real world scenario, not a bullet point document describing the sequence of events alone.

Train is 1 coach out of the platform doing 15mph when pc is pulled (17m approx 1 car length. )

Alarm goes off. As it is very rare to hear this alarm (I missed a passcom going off on a 377 after about a year of driving them as I had forgotten what the alarm sounded like and was checking every other control in the cab except the override pedal). As it is so rare to hear this and he was a newish driver the thinking time of what is going on etc he took 3.5 seconds to respond-3 and a half seconds is a very long time actually and imagen how much further the train has travelled at 15mph in that time.

After overriding it (which is a reflex to put you, not the train, in control of the situation) he then needs thinking time (as all humans do). By this point (almost 12 seconds after starting to move) it would be quite difficult to know how much of the train is in the platform and take the decision weather to stop or not. Trust me, you play out all sorts of debates/scenarios in your head whilst deciding what to do.

It's easy to look back on it knowing what had happened and say you would stop immediately but we are talking real world here, a lot would be going through his head and as I keep saying, you wouldn't expect to get interlock with someone trapped in the doors so wouldn't immediately think of that. The normal instinctive feeling when a pc is pulled is someone has tried to use it to flush the loo, I have had 3 or 4 activations in my career and all have been accidental involving toilets.

I'm sorry to try and sound like I am casting doubt on non rail workers ability to contribute here as it is really not my intention but until you have sat in the front of a train alone and in control with only yourself to make any decisions in split seconds weighing up experience, rules, location, possible scenarios etc you really can not criticise. Unfortunately the way punctuality is played out by TOCs when it comes to delay attribution a newer driver would very likely feel under pressure not to cause too many delays by blocking the throat of a busy London terminus in the evening rush hour, especially if it turned out that it was just an accidental activation.

Look at all of histories mistakes in any area and it is all too easy to say 'I wouldnt have done it like that' but it is very different at the time.

 

[blacknight]

Why?

There are millions, literally millions, of DOO despatches every year featuring units with doors identical or similar to the iFE doors on the cl365's without incident.

The RSSB recognise the inherent safety of DOO operation/despatch as they don't have a specific Hazard Model within the Safety case suite for the scenario of getting trapped in powered doors and dragged.

If staff had followed procedures that adhered to the Rule Book then this incident wouldn't have happened.

Incident would never have happened at all if passenger had not put hand into a closing door in first place.
If staff are to be held liable for this incident then how can you state that DOO is inherently safe, when at best DOO is only statistically safe when looking at number of accidents when viewed against number of dispatches but is not the loss of one life one to many if it can be avoided.
First rule of risk assessment is there a safer way that task can be carried out answer is yes but it costs.

 

[GB]

To save all this arguing, is it not fair to say that blame can be apportioned to both sides here?

 

[Greenback]

To save all this arguing, is it not fair to say that blame can be apportioned to both sides here?

Fair point. I think this thread may have run it's course.

 

[142094]

Perhaps the real issue is not the Rule Book itself, but the additional 'rules' that each TOC seem to come up with for their operating requirements (e.g. in this case not stopping over points at the entrance to a busy station).

 

[A-driver]

Perhaps the real issue is not the Rule Book itself, but the additional 'rules' that each TOC seem to come up with for their operating requirements (e.g. in this case not stopping over points at the entrance to a busy station).

I don't believe that is FCCs rule actually. It is common sense that of you can avoid stopping there you do. If the train was not stopping at Finsbury then It may have been routed from platform 9 to b road so could potentially block b,c & d roads. I'm not saying that was the problem, just one of many things the driver may have considered at the time.

 

[142094]

I haven't read the RAIB report so only going on previous reports, but in other RAIB reports it has been mentioned several times about the additional rules and regs that a TOC has set down as well as the ones contained in the Rule Book.

 

[Flamingo]

What a nonsense. Clearly you heard something and don't know where the truth is and what the report is all about. It has nothing to do with railway staff but all on the Rolling stock and infrastructure aspects.
Perhaps you might want to read 'Modern Railways" more often to understand a bit more of the "real" railway instead of the "rail enthusiast" railway.

But in a country that is terrorised by Hell n Safety regulations I find it very odd that DOO is allowed, especially in big commuting area's.

Sorry, I don't get time to read "Modern Railways" as much as I should . I probably should show a greater interest in the industry I depend on for my livelihood, but there you go. However, I was sure that McNulty had mentioned something about reducing staffing costs by reducing staffing numbers, maybe I got it wrong. I must check that tomorrow at work. :roll:

But I do agree with your point that it is surprising in an industry that is so safety-conscious as the railways that DOO is allowed.
--- old post above --- --- new post below ---

In any industry, if a staff member has caused a serious incident by ignoring the rules, or implementing them incorrectly, then it is absolutely right and standard practice for them to be disciplined appropriately, possibly with dismissal. And that is never an "easy" option for anyone concerned. Not to do so could have serious consequences in the future, as the effect of the rules becomes eroded.

In most industries (including the railways, in my experience), the usual approach to staff involved in an incident is to consider retraining needs, with disciplinary action being reserved for willful negligence.

The BIG problem with disciplining staff who make mistakes is that staff hide problems, as they are afraid of the consequences. It is much more productive to approach an incident as an excuse to review the relevant protocols and training, as this does not discourage staff from reporting incidents, with the resulting improvement in knowledge and procedures that results from this patway.

 

[BestWestern]

What a nonsense. Clearly you heard something and don't know where the truth is and what the report is all about. It has nothing to do with railway staff but all on the Rolling stock and infrastructure aspects.
Perhaps you might want to read 'Modern Railways" more often to understand a bit more of the "real" railway instead of the "rail enthusiast" railway.

But in a country that is terrorised by Hell n Safety regulations I find it very odd that DOO is allowed, especially in big commuting area's.

Hmm, I'm unsure whether your comment was serious or sarcasm. But in case it was serious, perhaps you have read a different McNulty report to the rest of us. Or perhaps you simply rely too heavily on your chosen railway magazine, which I can assure you is not the full picture of what is 'real'. If you read the report in question, you will find rather a lot of mention of staff reduction to achieve cost savings.

DOO is permitted because it saves the Government money. Simple as that. Sadly, safety is a secondary consideration in such circumstances, whatever the spin doctors might tell you.

 

[455driver]

So non railstaff are saying drivers should stop immediately if a passcom is pulled, yes!

Cant wait for all the threads about "I missed my connection because the train stopped for no reason" or "why are train services always late" etc if this did happen.

Oh there will be lots of driver vacancies as well because drivers will be getting sacked for causing unnecessary delays/ going sick after suffering RSIs from all the delay reports.

If the stupid bint hadnt have stuck her hand in the closing door nothing else would have happened.
Okay there were errors made by the dispatcher and to a lesser extent the driver (anyone saying otherwise that has not been in that position doesnt understand what goes on in those few seconds) AFTER THE INITIAL PROBLEM but the main instigator of all this was the bleedin passenger AGAIN!

 

[tannedfrog]

Also, the way some TOCs go about their business (especially first group) stopping on the point work outside kings cross blocking all the other platforms in the rush hour and racking up all those delay minutes for other TOCs and trains only to find out the pc was pulled by someone thinking it was the toilet flush or whatever really wouldn't go down well with management and would most likely end with you being told next time to find a more suitable location to stop by using the override...

I really feel for drivers if they have to weigh up the risk of management tellings-off against following safety procedures. Are we basically saying profit comes before safety, because "delay minutes" means less profit?
--- old post above --- --- new post below ---

the main instigator of all this was the bleedin passenger AGAIN!

There are and will continue to be many stupid passengers but all railway staff should do what they can to avoid or reduce injuries caused by passengers' stupidity, rather than taking the view that they deserve it

 

[IanXC]

In most industries (including the railways, in my experience), the usual approach to staff involved in an incident is to consider retraining needs, with disciplinary action being reserved for willful negligence.

The BIG problem with disciplining staff who make mistakes is that staff hide problems, as they are afraid of the consequences. It is much more productive to approach an incident as an excuse to review the relevant protocols and training, as this does not discourage staff from reporting incidents, with the resulting improvement in knowledge and procedures that results from this patway.

I could not agree more! In my industry it usually transpires that the longer it takes for a staff member to report an issue, the more it will cost us! Therefore you have to have an environment where staff feel able to report such issues without fear. When someone repeatedly makes such an error the response, of course changes.

So non railstaff are saying drivers should stop immediately if a passcom is pulled, yes!

Cant wait for all the threads about "I missed my connection because the train stopped for no reason" or "why are train services always late" etc if this did happen.

If the stupid bint hadnt have stuck her hand in the closing door nothing else would have happened.
Okay there were errors made by the dispatcher and to a lesser extent the driver (anyone saying otherwise that has not been in that position doesnt understand what goes on in those few seconds) AFTER THE INITIAL PROBLEM but the main instigator of all this was the bleedin passenger AGAIN!

And its all too easy to forget that! I recently wrote a response to a complaint along the lines of "I shouldn't have been given this personal loan because I had XYZ other commitment which meant I couldn't afford it" the fact the applicant did not tell us about this commitment when asked seems to be by the by!

 

[Mojo]

So non railstaff are saying drivers should stop immediately if a passcom is pulled, yes!

No, people (including myself who has worked on the operational railway) are saying that if the train is departing from a station and the alarm is pulled, then the train should be stopped and the reason for pulling the alarm is investigated.

If the stupid bint hadnt have stuck her hand in the closing door nothing else would have happened.
Okay there were errors made by the dispatcher and to a lesser extent the driver (anyone saying otherwise that has not been in that position doesnt understand what goes on in those few seconds) AFTER THE INITIAL PROBLEM but the main instigator of all this was the bleedin passenger AGAIN!

What if this wasn't an intentional act of getting caught in the train doors, but a simple mistake? As unlikely as it sounds, it can happen.

 

[bnm]

The activation of the PCA override is simply to prevent the train brakes applying automatically, allowing the driver to decide where best to bring the train to a stand. It is not indicative of the length of any conversation over the intercom.

O L Leigh

Thank-you for that explanation. If that had been mentioned when you posted your possible scenario, my debunking would've been redundant, and my reply, if any, wouldn't have been on a flawed assumption and I would have posted differently. So whilst my reply was assumptive and, as it turns out, flawed (for which I acknowledge and apologise), it was in reply to a hypothetical scenario. Often with hypothetical scenarios you have to make assumptions to offer a contrary point of view.

There was however no mention of a conversation between the driver and the passenger who operated the PCA in the RAIB report. Conversation or not, it remains so that the train should have been stopped as per the 'Rule Book'.

I'm sorry if my assumption of an operational matter rankled, as you say it did elsewhere on another forum board. Yes, the facts have been laid out, but your 'conversation' scenario isn't one of them, at least not as a fact covered by the RAIB report.

 

[PTF62]

So non railstaff are saying drivers should stop immediately if a passcom is pulled

The non railstaff are saying that drivers should follow the Rule Book, which says that they should stop immediately if a passcom is pulled (and they are still partly in the station).

Oh there will be lots of driver vacancies as well because drivers will be getting sacked for causing unnecessary delays/ going sick after suffering RSIs from all the delay reports.

That comment could be interpreted that drivers are aware of the safety rules, but are deliberately ignoring them. If so, that is shocking.

If the stupid bint hadnt have stuck her hand in the closing door nothing else would have happened.

If the dispatcher had done their job properly then nothing else would have happened.

Okay there were errors made by the dispatcher and to a lesser extent the driver

I am glad you see that.

AFTER THE INITIAL PROBLEM but the main instigator of all this was the bleedin passenger AGAIN!

But the point all the rail staff seem to ignore, is that despite the passengers mistake, if the dispatcher and driver had done their jobs properly the passenger would not have been injured.

Is it unreasonable to expect that people who do safety critical jobs know what is expected of them, and then actually do it?

 

[IanXC]

That comment could be interpreted that drivers are aware of the safety rules, but are deliberately ignoring them. If so, that is shocking.

I think what you are forgetting here is that the rule book is not the only thing governing how rail staff go about their day to day duties. There are other priorities, including those from management and specifically in this case those connected with Delay Attribution.

I manage risk in my job, and whilst it would be exceedingly unlikely anyone would be hurt if I got it wrong the principles are the same. You have to way up the impact of a said thing happening, the possible frequency plus the cost and revenue implications. Don't forget that ultimately if you wanted to avoid all these risks you'd have to close the network completely.

Those posters who have actual rail industry experience might be able to tell us whether this incident is likely to, or make their case that the railways (or FCC/DOO operators) operational assesment of these risks and costs might or should change. Any such change will of course involve assesing competing priorities, which I think some contributors to this thread have forgotten at times.

 

[A-driver]

'PTF62' - you really don't get it do you?! You can't just read the rule book and think you know all about this. There is a lot more to it as myself and others have explained. It isn't black and white and you can not simply say they did not do their jobs properly-they did in the way they thought best under the circumstances. The railways are not always run exactly by the book-other elements are also present. Unfortunately in this case things went wrong but it is not simply a case of staff error. Now please stop trolling.

 

[ian13]

I think what you are forgetting here is that the rule book is not the only thing governing how rail staff go about their day to day duties. There are other priorities, including those from management and specifically in this case those connected with Delay Attribution.

Are you saying that if you were driving a train, and the passcom was activated whilst you were still partly in the station, that you would not allow the emergency brake to apply?

 

[GB]

Why are people still focusing on the passcom area? It was stated quite clearly in the RAIB report that it played no part in THIS incident.

 

[IanXC]

Are you saying that if you were driving a train, and the passcom was activated whilst you were still partly in the station, that you would not allow the emergency brake to apply?

I'm saying that in that situation I would make a judgement call, based on all the facts and instruction from my TOC (a good portion of which we have not seen). The RAIB report explains the potential impact the decision this driver made could have had in other circumstances.

Yes there are questions to be asked in this case, the views of other TOCs staff being particularly interesting, but by no means is this an open and shut case.

 

[E16 Cyclist]

I think its important not just in relation to this incident but in general that we stop the attitude of rail staff blaming passengers and vice versa, it doesn't get anybody anywhere and a lot of the time if you actually work with the passengers even by doing something simple but explaining what is happening can work wonders.

In reality there are three people to blame for this incident and it obviously doesnt take a genius to work out who two of them are, as a driver who operates DOO i'm acutely aware that it can be quite challenging in that your looking at your mirrors or cctv at the same time as checking your signals and then pulling away and it doesn't help when people try and force their way through the doors, its amazing how many indiana jones impressions i've seen and at the end of the day is it really worth it?

It's interesting that in the report it states that while it is contray to the rule book there were a number of FCC drivers who admited they would have done the same thing, part of this i think is it the pressure that is put on drivers to minimise delays although in fairness i've never been criticised for causing a delay when safety has been an issue.

As for the dispatcher, i don't want to go down the road of criticising other grades i've done that job and i know how demanding it can be as you really need your wits about you at times. But saying that at the end of the day that is what they are paid to do. The dispatcher admits they saw the woman and they must have been pretty close to the train at the point when the 'close doors' button was pressed that i cannot understand why 'RA' was given, even if she wasn't at that point stuck in the door she was still in my opinion too close to the train.

Finally putting my union hat on, with train serivces getting busier and busier the liklehood of similar incidents grow all the greater and for busy routes like this maybe it is time to put guards back on trains maybe not for quieter services or at quieter times but this happened in the evening peak and i feel its time resources were put in place to put guards on peak hour services.

 

[GB]

In reality there are three people to blame for this incident and it obviously doesnt take a genius to work out who two of them are,

Three people? I can figure out the obvious two but who is the third because it certainly isn't the driver.

 

[bb21]

I think the thread has run its course as this is clearly just going round in circles. The RAIB report has outlined what happened and made its recommendations. It has been explained by some people in detail why in the circumstances outlined the driver could have thought that the train might have left the station and it would be more appropriate to deal with the incident at the next station, which is what he did. There is nothing more to be gained by people simply pointing fingers at whoever they think should be to blame as that is hardly constructive.

There are however some systematic issues with some of FCC's instructions handed down to drivers and there is no doubt they will be reviewed in light of this incident, together with suitable retraining that might be needed for anyone involved to avoid an occurrence of an incident of a similar nature in the future.