Simon Brown, rail enthusiast, died on Gatwick Express train, 7 Aug 2016

[whole diary]

[Electric train]

It is entirely possible that there has been a track slew or change of cant since the original structure installation; which might even been compounded several time over the 30 years.  Over the last 20 years there has been a lot of pressure to hand back track in time with no over runs so it is feasible the first thing to be skipped would be a full gauging check

[chrisr_75]

Hang on a minute though......that signal gantry leg is seriously foul of the structure gauge.  I do not condone people hanging their heads out of train windows but that is why the standard structure gauge is what it is.

Nevertheless to quote the RAIB^▸ (Rail Accident Investigation Branch) report "There is a notice above the window “Do not lean out of window when train is moving”", so I suspect the rail industry has covered it's arse with that. Same as no trespassing signs or level crossing signals not stopping people getting mown down by trains, with the rail industry rarely held accountable for such fatalities - I don't think they should carry any blame here either. This guy knew the score better than most, so should've taken a bit more responsibility for his own safety. Basic common sense failure of you ask me.

[grahame]

I'm reminded reading back about this incident that things are not always what they initially seem.  Two historic issues (the motorway pileup at Taunton and a level crossing incident at Moreton-on-Lugg) started off looking as if they were the almost exclusive fault of the deceased, but turned out to be quite otherwise.   In this current case, the initial RAIB^▸ (Rail Accident Investigation Branch) statement indicates a surprise factor ... my goodness - 10 inches is a smaller clearance that I would have guessed). The balance of what mistakes were made is far from clear, and we on the forum posting in public should be mindful of this, and mindful too that the friends and family of Simon Brown may read what we write.

[onthecushions]

So a savvy enthusiast could expect 28" clearance when in fact it was 10.25".

Because of which we shall have every droplight in the country nailed up.

Sub Judice - No Comment

OTC

[LiskeardRich]

And then when they are nailed up we will all be imprisoned on HSTs^▸ (High Speed Train)

[grahame]

And then when they are nailed up we will all be imprisoned on HSTs^▸ (High Speed Train)

Oh come now - I can remember a very long time ago the Ffestiniog locking people in their carriages from outside, and then letting them out at destination by walking along and unlocking. Can't say I felt comfortable with it.  So there is a precedent!

Now that HSTs have central door locking, is there any reason that internal handles can't be fitted?   Even without central door locking southern suburban units like the 4EPBs had internal handles ...

[stuving]

The Railway Group Standard I quoted before, GC^» (Great Central Railway - link to heritage line)/RT5212, was recently withdrawn. There is a complete new set of standards on gauging, as well as two new passenger gauges (PG1 and PG2). Their introduction is covered in RSSB^▸ (Rail Safety and Standards Board) Briefing note 15 BN21:

3 Compliance requirements

GE/RT8073, GE/RT8273, GI/RT7073 and GM/RT2173 come into force and are to be complied with from 05 March 2016 except for the lower sector gauge requirements set out in GM/RT2173 Clause 2.2.4.2 which have a delayed compliance date of 04 December 2021 to align with the LOC & PAS TSI.

After the compliance dates, or the date by which compliance is achieved if earlier, compliance with the requirements set out in GE/RT8073, GE/RT8273, GI/RT7073 and GM/RT2173 are to be maintained. Where it is considered not reasonably practicable to comply with the requirements, permission to comply with a specified alternative should be sought in accordance with the Railway Group Standards Code.

There are no exceptions to the general compliance date specified.

However, the bit I quoted is still there in the replacement, GI/RT7073:

2.2.3 Additional clearances at vehicle window level for new infrastructure
2.2.3.1 The following clearances shall be provided at the level of opening vehicle windows between 2000 mm and 3000 mm above the plane of the rails:
a) 450 mm where passenger vehicles operate with opening windows allowing passengers to lean out.
b) 250 mm where vehicles operate with opening windows for the use of train crew.

GE/GN8573 "Guidance on Gauging and Platform Stepping Distances" is not new, but has been revised and now says:

G 4.3.7   GI/RT7073 sets out a requirement for additional clearances at window level for new  infrastructure. This requirement is maintained to recognise that there is still a significant number of different types of rolling stock operating with opening windows allowing passengers to lean out, but also opening windows in cabs are provided for train crew to look out of the train. Rolling stock with opening windows allowing passengers to lean out include Mk 3 coaches and heritage coaches, typically Mk 2 and Mk 1 coaches. The majority, if not all, of cabs have opening windows for train crew use.

Of course that also applies to clearances to be maintained in existing infrastructure.

[trainer]

I can remember a very long time ago the Ffestiniog locking people in their carriages from outside, and then letting them out at destination by walking along and unlocking.

They still do on their older carriages where there are outward swinging doors, precisely because of the lack of clearance in many places.  It is truly narrow gauge and not just the distance between the rails.

[stuving]

There was another point in that earlier post, a quote from GC^» (Great Central Railway - link to heritage line)/RT2456, and that in full says:

C3.9
Passenger door windows that are capable of being opened (drop lights) shall be locked and the passenger door shall be fitted with an interior door handle that is interlocked with the primary door lock such that it is prevented from being released other than when passengers are intended to board or alight the vehicle. Such passenger door windows shall be fitted with a manually operated  mechanism that will permit train crew only to open the drop light

That section was introduced in issue 2 in 2002, with this implementation requirement:

Compliance with paragraph C3.9 is required by 31 December 2005 for all applicable vehicles that are intended to remain in passenger use after 31 December 2007.

All of the requirements of this document are within the scope of Vehicle Acceptance Body approval. 

After the compliance date, or after the date by which compliance is achieved (if earlier), Railway Group members shall not deviate from the requirements set out  in this document. 

Where it is considered not practicable, or not reasonably practicable, to comply  with the requirements set out in this document; authorisation not to comply shall  be sought in accordance with  GA^▸ (Greater Anglia)/RT6001, GA/RT6004 or GA/RT6006.

Did that happen? Even for these Class 442s and HSTs^▸ (High Speed Train)?

If it had, this would be a staff-only window and a 10" clearance is then appropriate. Even is some people provide themselves with a railway key to open one, they are then clearly doing something that defeats the railways' efforts to protect them (and is probably against the by-laws).

GC/RT2456 was a mandatory standard, but it too has now been withdrawn. According to the briefing note (10 BN38) its requirements are now in GM/RT2100, but I can't find this one there - or anywhere else.

No doubt the RAIB^▸ (Rail Accident Investigation Branch) will enlighten us in due course.

[PhilWakely]

Going off at a slight tangent, but all this talk of loading gauges and locking doors reminds me of a trip I made a couple of years ago on the eastbound California Zephyr from Grand Junction CO to Denver CO.

Those of you who know your railway geography will know that the route of the Zephyr takes you through the Moffat Tunnel at the continental divide in the Colorado Rockies. As we approached the tunnel, there was an announcement over the PA^▸ (Public Address) requesting that we close all windows, vacate the door vestibules and return to our seats. Apparently the tunnel clearance is such that you could stand upright just inside the door, hold your arm outstetched and rest the palm of your hand against the tunnel wall and the length of the tunnel combined with the clearance and lack of ventilation shafts would not be pleasant on the lungs.

[stuving]

From the Rail Accident Investigation Branch reports:

Fatal accident involving a train passenger near Balham, on 7 August 2016.

At about 17:24 hrs on Sunday 7 August 2016 a passenger, travelling on a Gatwick Express service from Gatwick Airport to London Victoria, suffered fatal injuries as a result of having his head out of a window and striking it on a signal gantry near Balham in south London. The train was travelling at about 61 mph (98 km/h) at the time of the accident.

The window concerned was on a door opposite a guard’s compartment in the train; this door was accessible to passengers but it was not intended for passenger use. The RAIB^▸ (Rail Accident Investigation Branch) has found no evidence to explain why the passenger put his head out of the window at that time.

The accident occurred because the passenger’s head was out of the window, there was nothing to prevent passengers from opening the window or putting their head out of the opened window, and because there was less than the normal standard clearance between the train and the signal gantry. Although the clearance was compliant with standards for existing structures, it was less than an industry recommended minimum for new structures where there are trains with opening passenger windows.

An underlying cause was that the process for assessing the compatibility of this train on this route did not identify the risk of the combination of reduced structure clearances and opening windows.

The RAIB has made two recommendations and identified one learning point. One recommendation is addressed to Network Rail, and seeks to improve the industry’s management of the interacting risks between infrastructure and rolling stock. The second recommendation is addressed to relevant train operators with the intention of reducing the risk from people leaning out of opening train windows.

The learning point reinforces the need for regular monitoring and management of structure clearances when those clearances are reduced from normal.

R092017_170525_Balham

There is, in this case, quite a lot more to it than was apparent at the time.

[John R]

There's an interesting observation in the report related to the number and relative sizes of the warning notices on the window in question. Looking at the window of an HST^▸ (High Speed Train) droplight this evening I noted that:-

1. the warning not to look out of the window is by far the smallest
2. several times bigger is the notice to close the window to save energy - not safety related
3. there's a large notice telling people to check that the door is adjacent to a platform before trying to open it, and not to lean on the door

The relative sizes of 1 and 2 appear wrong. As for 3, the only time when this could now be a safety issue is if the TM^‡(resolve) has incorrectly opened using SDO^▸ (Selective Door Opening) (unless the driver has overshot slightly).  So again, the need for the notice and its relative size since SDO was introduced (over 10 years ago) seems doubtful.

 

[LiskeardRich]

The RAIB^▸ (Rail Accident Investigation Branch) has found no evidence to explain why the passenger put his head out of the window at that time.

Because unfortunately that's what the enthusiasts seem to do. Just look for the so-called veg-ex going along dawlish on Saturday and I could put a safe bet most of the sea side has people with heads out the window.
I took a Saturday HST^▸ (High Speed Train) to Newquay last year and a chap got struck by a branch in the face. Fortunately no more than a lesson learnt.

[Red Squirrel]

Reading this thread, I note that some people have set out to blame the victim. That's not how we improve safety.

Psychologist Steven Pinker quotes a warning message that used to appear on portable generators and space heaters sold in the USA:

Mild exposure to CO can result in accumulated damage over time. Extreme exposure to CO may rapidly be fatal without producing significant warning symptoms.

According to Pinker, several hundred Americans every year turned their homes into gas chambers after failing to appreciate the meaning of this. The warning was then changed to:

Using a generator indoors CAN KILL YOU IN MINUTES

This has proved more effective.

Perhaps it would be better if the warning sign by an openable window said something more like:

If you lean out of this window you may strike lineside equipment which could kill you. Equipment may be much closer than you think.

[ChrisB]

Unfortunately, no notice will deter those that think they know better