Latest RAIB report - Newcastle Central

[142094]

That's the same as it always has been. However, it is quite often that TPE use 10 instead of 9 and vice versa.

Unless TPE have requested to use a specific platform, then this will be down to the signallers and the platforms that are available. CrossCountry often use platform 12 (which is just about the same layout as platform 10) for an afternoon service so obviously the curvature isn't an issue there - as long as the proper dispatch procedure is followed.

However I also get the feeling that if this was incident had happened overseas more of the blame would have been on the passenger.

 

[ModernRailways]

Unless TPE have requested to use a specific platform, then this will be down to the signallers and the platforms that are available. CrossCountry often use platform 12 (which is just about the same layout as platform 10) for an afternoon service so obviously the curvature isn't an issue there - as long as the proper dispatch procedure is followed.

Indeed! It's quite often that there are two TPEs side by side in 9 and 10. Northern and XC also use 10, 11, and 12. I remember a Northern guard got the driver to assist him with the door closure on 12 as I remember being shocked a service used platform 12

 

[Tomnick]

I wasn't saying the guard should be sacked. I was merely pointing out the difference between the outcomes.

How do you know that the guard would have been sacked if it had been a child trapped?!

 

[ModernRailways]

How do you know that the guard would have been sacked if it had been a child trapped?!

Re-read my post. I said

'If a child was to get caught in the door because the guard didn't re-do any checks their would be all hell let loose and the TOC likely given a hefty fine and the guard sacked'

I never said the guard would be sacked if a child was caught in the doors, but my point was the fact the media (tabloids) would have gotten hold of it and demanded something be done because it was a child and as a result the TOC would likely feel pressured into it. The tabloids hate the railway as is, and this would be a perfect story for them.

 

[Tomnick]

I'd like to think that media pressure isn't a valid reason for failing to follow the proper disciplinary processes, though! It's impossible to state with certainty what the outcome would have been, in either case.

 

[Crossover]

Just another thought here. I haven't read the report in full, but assuming that the guard was dispatching the train from the doors closest to the buffers at platform 10, whereabouts was this woman trying to board? If she had arrived late at the platform, surely the common sense thing to do was to board at the closest set of doors? So where exactly did she try to board? Was that even taken into account?

Edit: Actually scratch that, I've just seen she tried to board through the rear doors of the centre carriage. But the questions still stands, why the hell didn't she try to board at the rear which was closest to the buffers / entrance? I'm sorry but when the alarms are going on a platform configuration like that, you go for the closest doors. It's common sense that possibly shows that she was as much at fault. i wonder if she received a telling off?

If you read down the report, the suggestion is that the doors that the passengers attempted to board through where the rearmost open doors on the set. All the doors on the rear carriage, on the buffers, had auto-closed

 

[dtaylor84]

Unless TPE have requested to use a specific platform, then this will be down to the signallers and the platforms that are available. CrossCountry often use platform 12 (which is just about the same layout as platform 10) for an afternoon service so obviously the curvature isn't an issue there - as long as the proper dispatch procedure is followed.

According to the 'Actions taken' section of the report:

156 First TransPennine Express has reported that it has:
...
e. Stopped operating services from platform 10 at Newcastle Central station (as from 10 February 2014).

 

[LowLevel]

It is amazing the number of people who obstruct the doors assuming they'll just stop. I work class 153 units which will in every likelihood amputate your fingers if they're in the way when the door slams shut - there is no obstacle detection whatsoever on them and it's entirely reliant on my getting my fingers back on the open buttons in time.

 

[kieron]

It is amazing the number of people who obstruct the doors assuming they'll just stop. I work class 153 units which will in every likelihood amputate your fingers if they're in the way when the door slams shut - there is no obstacle detection whatsoever on them and it's entirely reliant on my getting my fingers back on the open buttons in time.

Wouldn't that mean, to the prospective passenger, that the door opens again if there's something in the way as they close?

 

[Crossover]

It is amazing the number of people who obstruct the doors assuming they'll just stop. I work class 153 units which will in every likelihood amputate your fingers if they're in the way when the door slams shut - there is no obstacle detection whatsoever on them and it's entirely reliant on my getting my fingers back on the open buttons in time.

I was going to say something on the lines of some stock you wouldn't want to obstruct the doors on due to the force at which they close - 153's are certainly up there!

 

[ModernRailways]

I was going to say something on the lines of some stock you wouldn't want to obstruct the doors on due to the force at which they close - 153's are certainly up there!

The Paris Metro is similar and no-one tried jumping in whilst the doors were closing. However on one of the lines were the doors were slow and less violent people were jumping in and holding the doors. Maybe people think that because the doors close slowly that means you can jump in because they will bounce back open?

 

[185]

Devils advocate:
Guard should have re-checked doors after pressing door close to ensure all three hazard lights were out. No excuse, everyone has to do it.

but...

FTPE & Northern should employ despatchers and realised that the 'risk assessment' done in 1998 where despatchers were removed from Central was a load of poop. If this was a rural station, no problem. As it is a major station, with a curved platform causing poor signal sighting and platform visibility - that's a second factor and together Ncl Central really needs despatch.

(As for the passengers being stupid comment, all staff, in safety critical situations should treat passengers as being the daftest on the planet to account for every eventuality during station duties.)

 

[HH]

This is the interesting bit (accepting that there is also fault from both passenger and guard):

The large difference between these two frequencies is primarily due to the differences in the assessed likelihood of a trapped passenger on the platform not being able to remove their arm if trapped in the door. The earlier risk assessment estimated this as 1 in 100. The most recent assessment assumes that the person cannot remove their arm. Additionally, the earlier assessment estimated that the likelihood of a trapped passenger being seen before the train moved (thus preventing an accident) was ten times greater than that estimated by the more recent assessment.

How did they arrive at 1 chance in 100 of not being able to remove the arm? I wonder if they took into account the relative strengths of different passengers and the effect of the train moving (making it impossible to get leverage)? OTOH 100% seems to be going the other way; I think they felt they now had to do something.

Is the phrase "ten times greater" meant to obfuscate? From the overall numbers it seems likely that they have moved from 100% likelihood to 1 in 10. Both numbers are dubious; again the first is over optimistic and the second far too low.

My reading is that the first risk assessment was done on the basis of "we don't want to do anything" and the second on "we have to do something". Poor showing by TPE and Siemens on the initial risk assessment, but what was HMRI's role in this? From long and painful experience, it is always the assumptions that need challenging in reports; can anyone really have believed that you would be able to remove your arm 99% of the time (without, it seems, carrying out any tests)?

 

[Tetchytyke]

Guard should have re-checked doors after pressing door close to ensure all three hazard lights were out. No excuse, everyone has to do it.

The hazard lights were out, the badly-designed door mechanism locked despite the obstruction. The RAIB were able to replicate the problem with a different unit, so it is a design fault not a mechanical breakdown. The problem was that the guard relied on the warning lights rather than stepping far enough out on to the platform to see the passenger stuck in the door. At platform 10 you have to step a long way out on to the platform to see the whole train.

I'd agree with you about assuming the public are idiots with a death wish. If you expect passengers to be morons, and check up on them accordingly, you won't go far wrong. I'm astounded that guards are still cutting these sorts of corners, given the Merseyrail guard who cut the same corner and got five years imprisonment because of his mistake.

 

[Quickthorn]

This is the interesting bit (accepting that there is also fault from both passenger and guard):



How did they arrive at 1 chance in 100 of not being able to remove the arm? I wonder if they took into account the relative strengths of different passengers and the effect of the train moving (making it impossible to get leverage)? OTOH 100% seems to be going the other way; I think they felt they now had to do something.

Is the phrase "ten times greater" meant to obfuscate? From the overall numbers it seems likely that they have moved from 100% likelihood to 1 in 10. Both numbers are dubious; again the first is over optimistic and the second far too low.

My reading is that the first risk assessment was done on the basis of "we don't want to do anything" and the second on "we have to do something". Poor showing by TPE and Siemens on the initial risk assessment, but what was HMRI's role in this? From long and painful experience, it is always the assumptions that need challenging in reports; can anyone really have believed that you would be able to remove your arm 99% of the time (without, it seems, carrying out any tests)?

When they did their initial risk asessment, I wonder if they considered that someone with a trapped wrist may be holding something in that hand? Perhaps it never occurred to anyone involved in the testing that a passenger trapped in this way, and holding something valuable to them, might be reluctant to drop that object, even if it results in being dragged along a platform. Certainly, the Railway Group Standards that Siemens would have worked to do not seem to consider this. They require that certain test pieces can be withdrawn from a closed door with less than a specified force, and these test pieces are designed to represent a wrist and an open hand respectively.

However thorough and sophisticated your methodology is to quantify risk, the final answer will only be as good as the inputs.

 

[ModernRailways]

Devils advocate:
Guard should have re-checked doors after pressing door close to ensure all three hazard lights were out. No excuse, everyone has to do it.

but...

FTPE & Northern should employ despatchers and realised that the 'risk assessment' done in 1998 where despatchers were removed from Central was a load of poop. If this was a rural station, no problem. As it is a major station, with a curved platform causing poor signal sighting and platform visibility - that's a second factor and together Ncl Central really needs despatch.

(As for the passengers being stupid comment, all staff, in safety critical situations should treat passengers as being the daftest on the planet to account for every eventuality during station duties.)

Newcastle still has dispatch staff, but fTPE decide not to use it.

Northern don't need it, since they mostly depart from the far platforms which are straight. And there units aren't exactly large so they will be able to see easily.

 

[455driver]

Not sure. Would you expect a lift door to close on your hand?

Would you willingly and knowingly put your hand in the lift door if you knew it wouldnt re-open?

She made an assumption and got it wrong, therefore it has to be somebody elses fault. Why didnt she get in any of the other doors that she had walked past or is pushing a button a bit beyond her?
Yes the guard did it wrong and will no doubt have to explain himself (and he wont do it again thats for sure otherwise it will be P45 time) but I prefer to break the chain of events at the earliest opportunity and not at the last one.

Just another case of the railway having to try and protect itself from the stupid!

 

[bb21]

(As for the passengers being stupid comment, all staff, in safety critical situations should treat passengers as being the daftest on the planet to account for every eventuality during station duties.)

Yes, absolutely. The more I travel around, the more I realise that stupidity has no limit to it. There is only more stupid, never the most stupid. Every time I think I have seen the worst, something else trumps it.

That still does not however mean guards can be relied on 100% of the time. They are trusted to do their jobs professionally, but as humans, they make mistakes, so when personal safety is concerned, I would rather take steps myself to help reduce those risks to a minimum, which may not make much difference under normal circumstances, but I would be much happier in the event that a guard makes a mistake such as in this case, even though it is only a rare occurrence, compared to what might be the case otherwise. I would not like to be the test case, and don't really understand why anyone else would.

 

[Bantamzen]

If you read down the report, the suggestion is that the doors that the passengers attempted to board through where the rearmost open doors on the set. All the doors on the rear carriage, on the buffers, had auto-closed

Even so, the logical choice is if you are running late to head toward the nearest doors, in this case closest to the buffers & try the door release button. By running further down the platform, not only did she risk missing the doors closing, which she did, she also risked slipping or tripping and ending up underneath the train and not being seen by the train or platform crew. It's this kind of reckless behaviour that results in accidents, and trouble for the train crew regardless of any blame on their part.

Whilst the train crew do have a duty of care, passengers equally have a duty not to put themselves at risk or be reckless on platforms.

 

[TimG]

Would you willingly and knowingly put your hand in the lift door if you knew it wouldnt re-open?

She made an assumption and got it wrong, therefore it has to be somebody elses fault. Why didnt she get in any of the other doors that she had walked past or is pushing a button a bit beyond her?
Yes the guard did it wrong and will no doubt have to explain himself (and he wont do it again thats for sure otherwise it will be P45 time) but I prefer to break the chain of events at the earliest opportunity and not at the last one.

Just another case of the railway having to try and protect itself from the stupid!

My point is that she may well have assume it would open as this is the convention set by society. The doors are behaving at odds with what's normal.

 

[HH]

However thorough and sophisticated your methodology is to quantify risk, the final answer will only be as good as the inputs.

Yes. I would also consider the wearing of a chunky watch, for instance; sticking in a bag/briefcase. I'm sure with a relatively small amount of thought we could come up with several other ways that would cause issues compared to testing an arm wearing/holding nothing. It's probably the most important part of the whole process and it feels like it was simply skipped.

 

[Bantamzen]

My point is that she may well have assume it would open as this is the convention set by society. The doors are behaving at odds with what's normal.

Is it though? Maybe with static doors where the worst that could happen is you get a nasty bruise and a bit of a shock if automatic doors fail to open, but on trains the doors have a nasty habit of moving with the rest of the vehicle. And perhaps I'm fixating a bit too much on this, but the report implies that she was carrying her mobile phone in the hand that was trapped. I see it all too often, but people get very distracted by those few inches of LED screen & chips wrapped in plastic. Just like the bloke this very afternoon happily chatting away on his phone whilst crossing a busy junction (with a pedestrian crossing just yards away), totally oblivious to the single decker bus bearing down on him. Only when the driver blasted his horn did he calmly step back into another lane of traffic, obvious that traffic might be coming around a bend to which he did not have sight of...

Maybe I'm being overly cynical here, but many people these days lack basic common sense. And trying to legislate for that is going to be near impossible. Maybe in the future TOCs will have to employ platform staff at every door, to prevent those last minute, distracted by their phone passengers taking risks by launching at closing doors. And even then, a momentary lapse of concentration and someone could come crashing past...

 

[Eng274]

It was never always a design requirement for train doors to have obstacle detection (networker family onwards IIRC). From what I've witnessed a door without obstacle detection will simply stay closed (by air pressure) with the obstacle in place until the doors are reopened, or the obstacle is removed.

I remember a similar issue concerning the design of 'sensitive edge' door sensors was raised on 365s following the incident at kings cross a few years back, I don't recall if a mod was implemented or if it was IIRC deferred to the the next C6.

I wonder if the design on post 2006 builds of 350s had an improved sensitive edge design as the HMRI mandated?

 

[Taunton]

Maybe I'm just becoming intolerant, but over time I just find the RAIB reports increasingly missing the point. Here's a whole series of things which might have been picked up.

Despite the train and crew arriving nearly an hour beforehand, the doors were only released 7 minutes before departure, which for a service expected to be packed meant a large number were left waiting outside. Why was this? It can only lead to unnecessary pushing and shoving to get a seat.

If the train was already full and standing then the final passengers should be expected to walk down the length of it to see if there was more room.

The issue would never have come to light if an uninvolved passenger had not complained, despite it coming to the attention of about half a dozen different people. The TOC controller appeared more concerned to code up the departure delay than to show any concern on hearing that a passenger appeared injured.

The dispatch procedures never envisaged that the platform would be full of passengers waiting for the train on the other side to open up, yet (see first point) this is apparently standard in the peak hour there.

Doing door detection is not rocket science. I recall the 1938 Wirral electric units which occasionally closed on something, they never gave a false positive, nor was there any messing about with edge detectors which must mesh with each other in a certain way. Why has the ability to design things straightforwardly been lost. It seems it was not Rocket Science 75 years ago.

Why ever is the conclusive test of the mechanism, which is to detect trapped limbs, done with a bar rather than real arms and legs.

Why did so many, the operator, the manufacturer, the myriad approval bodies, those who reported on the multiple previous incidents, etc, all see there was a problem with the design of the mechanism in real life, but as long as it passed the theoretical test they did nothing.

The public are used to lift doors etc that regularly close on you when entering and then reopen and don't injure you. Why should the public expect anything different from very similar looking train doors.

The Risk Assessment is now seen as completely baseless and in fact stupid. Is every other risk assessment done by the same organisation going to be checked for comparable stupidities.

The operator also had alternative procedures for dispatch from the middle door, which on a packed train are stated to be impractical. How could they not recognise this on a minimal 3-car peak hour departure.

Although the station is run by another operator who do provide platform dispatch staff, this train operator chooses not to use them. Why. Is there an extra cost charged for use of these dispatch staff. How much is this. Why did the train operator choose not to use them on a known "difficult" platform.

To what extent did management desire for On Time Departure override concerns for safe procedures. If the conductor had gone through the many checks this platform required, which the report states are challenging to complete in 2 minutes, would there have been a reprimand for a late departure.

 

[DDB]

I dislike the term common sense, humans aren't born with a knowledge about the world.
I think that when people use it they actually mean is life experience and everyone's experience is different and can be misleading.

My experience and I think that of most people is that automatic doors don't trap people in them. I travel by train a fair amount and I use a railway discussion forum. I'd not thought about it as I wouldn't try and mix it with plug doors of the stock I normally travel on but I until reading this thread I would have expected sliding type doors to stop closing if they hit an obstruction.

In fact contrary to what some people have said on this thread. That is what these doors were supposed to do (Paragraph 16 of the report).


If I were the conductors employee I would seriously consider dismissing them for not reporting this incident. Mistakes are unfortunate but is vital to learn from them. Failing to report unsafe occurrences are unacceptable.

If I were the regulator I would be inviting the TOC to demonstrate (probably in a court of law) how not using dispatch staff when they are available is making the risk as low as practicable.

Paragraph 124 is pretty damning as well. What is the point in spending all the money it costs to train staff with route knowledge if the knowledge they have to learn isn't what they need to know?

DDB

 

[bb21]

In fact contrary to what some people have said on this thread. That is what these doors were supposed to do (Paragraph 16 of the report).

Does technology work 100% of the time?

If I were the conductors employee I would seriously consider dismissing them for not reporting this incident. Mistakes are unfortunate but is vital to learn from them. Failing to report unsafe occurrences are unacceptable.

Sacking someone for a one-off mistake and poor judgement on whether it should be reported is unlikely to go down well in many ways.

 

[142094]

According to the 'Actions taken' section of the report:

156 First TransPennine Express has reported that it has:
...
e. Stopped operating services from platform 10 at Newcastle Central station (as from 10 February 2014).

Thanks for that - missed it the first time I read through the report. Interesting seeing as there must now be a memo with Network Rail signallers at Tyneside to prevent TPE from using platform 10. Not sure if Northern continue to use plt 10 but wonder what would happen if no other platform was available.

 

[ModernRailways]

Thanks for that - missed it the first time I read through the report. Interesting seeing as there must now be a memo with Network Rail signallers at Tyneside to prevent TPE from using platform 10. Not sure if Northern continue to use plt 10 but wonder what would happen if no other platform was available.

It's not even true, though. There was a fTPE service in 10 last week albeit Not In Service.

 

[muz379]

It is right that the actions of the passenger in this case where reported as a Factor . If for nothing else so that records of passenger actions such as this can be held and used for training staff and deciding on when and where dispatchers are needed to manage the risk from passenger action .

I also think some passenger education posters and information can be deployed , I cant remember where I was but there was painted outlines of people by the edge of the platform showing them as if they would be falling under a train , highlighting the risk of running and slipping or tripping on a platform . There are also the posters about train doors closing 30 or 45 seconds prior to the departure time .

For all those saying the conductor should be sacked I actually tend to agree that someone making such fundamental mistakes and being so fundamentally lax when carrying out safety critical work should not be allowed to carry out that work unless fully retrained , or ideally should be given something non safety critical to do .What he did in failing to the check at a location he knew was actually quite dangerous is not just a minor error of judgement or a mistake , it shows complete disdain for the importance of doing his job properly .

Alas this will not be the case because the employers have to follow the set disciplinary procedure . I can only imagine he will have been seriously disciplined and if anything like this occurs again he will be looking for a new job .

I dont think james street is 100% relevant as a comparison to this case because at James Street the guard knew someone was leaning against the side of his train when he gave the RTS to the driver , At newcastle the conductor did not know someone had their arm stuck when they gave the RTS .

It is concerning the mess that occurred in the reporting of this incident , and the fact that it didn't come to light until some time after the incident . Is this the fault of the conductor for not stating how serious the report was , or was it the fault of the control staff for not asking the right questions (which if they aren't they should be trained to do )

Personally all of the detail and discussion about the design of the doors and the fact that it was possible for something to be trapped in them seems a bit academic to me given that the traction I work(sprinters and pacers) does not have any fancy detecting equipment. The TOC I work for and the passengers that play race the hustle alarm on my trains have to rely on me/dispatchers doing the job properly .

That being said apart from the occasional 155 the traction I work doesn't have an indication inside the unit to tell you the doors have been locked so you have to rely on a visual check of the doors themselves and the hazard lights which means you are also checking the doors have not got anything trapped in them . Also even with the class 185's , even if the door detection circuit is substandard , surely the fact that the conductor is required to do the safety mitigates the substandard sensing system
--- old post above --- --- new post below ---

It's not even true, though. There was a fTPE service in 10 last week albeit Not In Service.

it will be one of them wont it where TPE have committed to avoiding working out of 10 as far as is reasonably practicable . Which basically means nothing has to change .

 

[sbt]

I find it interesting that the discussion seems to have reverted to a 'whose fault' one, rather than 'why did it happen'. This may be unconscious but it does read like a 'Was it the Passengers or the Guards Fault' thread.

As a regular rail passenger I am concerned that the 'Sensitive Edge' did not work and the reasons why it didn't work. If you have one it should work under all reasonable circumstances - a limb inserted at other than 90 degrees to the side of the train is, in my opinion, a reasonable circumstance. Even if the doors didn't automatically reopen it should not have been possible to depart with someones limb between the doors. The design relies on the Sensitive Edge to prevent departure, as well as reopen the doors. If it doesn't work reliably at that task then an older system that allows the doors to close on an obstruction but prevents departure should be used.

I'm also concerned about the way the dispatch process failed. With a less than 100% reliable Sensitive Edge and less than 100% reliable passengers the dispatch process, however conducted, is (almost) the last line of defence against a dragging accident. I don't particularly care if the person trapped was being unwise or not, I don't want to be present at a nasty, possibly fatal accident. I'm also aware, from personal experience, that being between two closing carriage doors is something that can happen without any particularly exceptional foolishness on the part of the passenger. In this case it appears that, even if the Guard had carried it out as designed there was a significant risk of the dispatch procedure not generating the intended result - a safe departure.

What I am most worried about, however, is the non-reporting of the incident. The reporting of dangerous incidents is vital to the safety to all of us who use or work on the Railway. I can only hope that if the other passenger hadn't accidentally raised the alarm the confidential reporting process would have seen the issue raised.

Finally, I expect rail staff (in particular) will want to know how I ended up between closing doors. Its simple - when there are a lot of people boarding a train and you are between the doors when the hustle alarm goes off and the people in front of you suddenly stop, stepping backwards may not be an option. IIRC in one case there was a press of people behind me and in another considerable gap and step down to the platform, something I wasn't going to attempt unsighted and in reverse. A third instance was when I was aboard and the person in front of me stepped backwards to allow someone through, pushing me far enough back for my bag to be caught in the doors and resisting my attempts to get myself, and it, away from the door - the alternative was to fall backwards out of the train onto the platform. Travel long enough on packed trains and something like that will happen to you eventually.