Passenger trapped in train doors at Newcastle Central station, 5 June 2013

[whole diary]

[Chris from Nailsea]

From the Rail Accident Investigation Branch website:

The RAIB^▸ (Rail Accident Investigation Branch) is investigating an incident at Newcastle Central station, in which a passenger was trapped in train doors, and dragged a short distance, as the train started to move out of the station. The train moved less than one coach length and did not pick up much speed, so the passenger was able to remain on her feet. However, she was shaken and suffered soft tissue damage to her wrist.

At about 17:00 hrs, a 3-car multiple unit train was standing at platform 10 waiting to form train 1P59, the 17:02 hrs Transpennine Express service from Newcastle to Manchester Airport. Shortly before the scheduled departure time, a passenger approached the train from the ticket office end (near field in the photograph), intending to board. The doors on the first (rear) coach were closed, but the rear set of doors on the middle coach was still open.
 

Three-car multiple unit standing at Newcastle Central station platform 10 (courtesy of First Transpennine Express)

These doors were closing as the passenger reached them, so she put her right hand between the door leaves expecting this to cause them to re-open. They did not; closing around her right wrist and trapping it. The train then started to move, forcing the passenger to walk and jog alongside.

As the train started to move, the conductor, who was leaning out of the rear cab window, could not see the trapped passenger due to the curvature of the platform. Passengers on board the train observed what had occurred and pulled the emergency door release which had the effect of applying the brakes. Another person standing on the platform shouted to the conductor to stop the train and the conductor applied the emergency brake.

The incident was not reported to the RAIB until 3 July 2013.

The RAIB^s investigation will examine the sequence of events leading up to the incident, including the dispatch of the train and how the presence of obstructions that are trapped in doors are detected. It will consider how the risk associated with trains departing from the tightly curved platform was assessed and mitigated, and how the incident was reported and investigated by First Transpennine Express.

The RAIB^s investigation is independent of any investigations by the safety authority (the Office of Rail Regulation).

The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.

[readytostart]

Doesn't help that TPE^▸ (Trans Pennine Express) guards have to self despatch at Newcastle on some platforms with very tight curves, should have walked to a point where he/she could observe the whole train though.

[inspector_blakey]

Especially given that, if they're anything like the SWT^▸ (South West Trains) electrics, those Siemens units have a set of conductor's door controls at virtually every door.

[Chris from Nailsea]

The Rail Accident Investigation Branch (RAIB^▸ (Rail Accident Investigation Branch)) has released its report into a passenger becoming trapped in a train door and dragged a short distance at Newcastle Central station 5 June 2013.

The RAIB has made six recommendations.

Summary:

At 17:02 hrs on Wednesday 5 June 2013, a passenger was dragged by a train departing from platform 10 at Newcastle Central station. Her wrist was trapped by an external door of the train and she was forced to move beside it to avoid being pulled off her feet. The train reached a maximum speed of around 5 mph (8 km/h) and travelled around 20 metres before coming to a stop. The train^s brakes were applied either by automatic application following a passenger operating the emergency door release handle, or by the driver responding to an emergency signal from the conductor. The conductor, who was in the rear cab, reported that he responded to someone on the platform shouting at him to stop the train. The passenger suffered severe bruising to her wrist.

This accident occurred because the conductor did not carry out a safety check before signalling to the driver that the train could depart. Platform 10 at Newcastle Central is a curved platform and safe dispatch is particularly reliant upon following the correct dispatch procedure including undertaking the pre-dispatch safety checks.

The investigation found that although the doors complied with the applicable train door standard, they were, in certain circumstances, able to trap a wrist and lock without the door obstruction sensing system detecting it. Once the doors were detected as locked, the train was able to move.

In 2004, although the parties involved in the train^s design and its approval for service were aware of this hazard, the risk associated with it was not formally documented or assessed. The train operator undertook a risk assessment in 2010 following reports of passengers becoming trapped. Although they rated the risk as tolerable, the hazard was not recorded in such a way that it could be monitored and reassessed, either on their own fleet or by operators of similar trains.

As a consequence of this incident, RAIB has made six recommendations. One of these is for operators of trains with this door design to assess the risk of injuries and fatalities due to trapping and dragging incidents and take the appropriate action to mitigate the risk.

Two recommendations have been made to the train^s manufacturer. One of these is to reduce the risk of trapping on future door designs, and the other to review its design processes with respect to hazard identification and recording.

One recommendation has been made to the operator of the train involved in this particular accident. This is related to the management of hazards associated with the design of its trains and assessment of the risks of its train dispatch operations.

Two recommendations have been made to RSSB^▸ (Rail Safety and Standards Board). One is to add guidance to the standard on passenger train doors to raise awareness that it may be possible to overcome door obstruction detection even though doors satisfy the tests specified within the standard. The other recommendation is the consideration of additional data which should be recorded within its national safety management information system to provide more complete data relating to the risk of trapping and dragging incidents.

[Chris from Nailsea]

From the BBC^» (British Broadcasting Corporation - home page):

Train staff 'missed' trapped woman


The train departed from platform 10 at Newcastle Central Station

A train conductor failed to carry out proper safety checks leading up to a woman being dragged along a platform in Newcastle, a report has concluded.

Her hand became trapped in the doors of a First TransPennine Express train she was trying to board last June.

She suffered severe bruising when the train travelled about 60ft (20 metres), reaching a speed of about 5mph.

A report concluded the conductor failed to carry out the required visual checks prior to the train moving off.

The incident happened on 5 June last year and involved a train to Manchester Airport which was departing from platform 10 at Newcastle Central Station.

The Rail Accident Investigation Branch (RAIB^▸ (Rail Accident Investigation Branch)) report said the doors of the train were, in certain circumstances, able to trap a wrist and lock without the door obstruction sensing system detecting it.

Once the doors were detected as locked, the train was still able to move.

Ten years ago the parties involved in the train's design and its approval for service were aware of this hazard but the risk associated with it was not formally documented or assessed, the report said.

The report said the conductor did not notice the trapped woman because he failed to carry out a visual check of the outside of the train as he should have done.

He also failed to properly report the incident.

He was subsequently disciplined by First TransPennine Express.

The RAIB made six safety recommendations, including a review of future train door design.

[Trowres]

The report is worth reading
http://www.raib.gov.uk/cms_resources.cfm?file=/140918_R192014_Newcastle.pdf

I can't help feeling that the BBC^» (British Broadcasting Corporation - home page) report's coverage, in focusing on the conductor's failings, is not representing accurately the RAIB^▸ (Rail Accident Investigation Branch) report, although it does have one sentence on the failings of the safety establishment.

The six recommendations of RAIB? (I have paraphrased - read the report if you want the precise words).
1. Operators should do a risk assessment...
2. The manufacturer should redesign the doors...
3. The manufacturer should review the design process... and hazard assessment
4. The operator (and others) should improve hazard recording and assessment
5. RSSB^▸ (Rail Safety and Standards Board) should recommend to BSI^▸ (British Standards Institute) that it asks nicely for the forthcoming European Standard to include a warning that the safety test doesn't guarantee safety (and it might like to think about changing the standard test).
6.RSSB should think about what extra it needs to know about door trapping incidents.

[ellendune]

The report is worth reading
http://www.raib.gov.uk/cms_resources.cfm?file=/140918_R192014_Newcastle.pdf
2. The manufacturer should redesign the doors...

5. RSSB^▸ (Rail Safety and Standards Board) should recommend to BSI^▸ (British Standards Institute) that it asks nicely for the forthcoming European Standard to include a warning that the safety test doesn't guarantee safety (and it might like to think about changing the standard test).

This standard is at quite a late stage, but it seems to me that by essentially saying that all new trains must be designed to a standard higher than in the draft EN, the EN is holed in the water at a very late stage and if it is approved at this late stage it will have to be publishd in the UK^▸ (United Kingdom) with a large safety notice which will essentially say it is not fit for purpose.