HST door-opening incident from 1990s

[ralphchadkirk]

Fighting and restraining people enough to throw them out of a train door would likely leave very specific contusion and fracture patterns.

 

[PG]

Indeed - and there were some incidents on ECML north of Newcastle and south of Berwick. A mate was tasked by examining these incidents in BR days - using the new database for accidents that was in then. Amazingly - alcohol featured strongly - in one unfortunate case at , or near Alnmouth - the toxicology report was the highest ever recorded blood /alcohol rate ever recorded in records. One idea was ****ed carry on drinkers - had issues lurching to the buffet car 2/3/4 hours into a journey. Certainly - "events" were reduced over the years....

Going on the assumption that a fair few of these folk were 'a bit the worse for wear' - is it possible that feeling not to clever they decided to [insert word of choice] vomit out of the window and perhaps leant out too far succumbing to the combined effects of 100+mph and the slipstream?... although you'd imagine there would be some vomit splattered on the windows/carriage side behind them that would have been noticed?

 

[lastladporter]

Fighting and restraining people enough to throw them out of a train door would likely leave very specific contusion and fracture patterns.

it would depend on many factors i suppose, if the victim was intoxicated , the size of victim to assailant or assailants, if the victims were stunned by, say, a blow to the head rendering them unable to struggle. And even if someone was to struggle whilst been thrown out by a window,there was nothing to grip onto except the door pull bars, everything was easy clean surfaces, nothing to dig your nails into , no upholstery to tear. and would anyone have been looking for that stuff then?
as i posted earlier it would be more acceptable (the findings) if there were witnesses, i seem to remember that there were a few suggestions of foul play in the newspapers.
this was played down at the time but it would be wouldnt it? scaremongering?
as i posted earlier it was really when a senior conductor ,whilst working, so i guess not drunk ," fell out of his hst" , that i really took notice.
dont get me wrong , i suppose the newspapers sensationalised the storys then as now.
but i tell you what, bringing an almost empty hst home late at night certainly put me on my toes in those days.
anyway im sure the deaths were thoroughly investigated , and weather the conclusions were right or wrong , im sure the electronic locking doors have saved a few lives since, accidental or not.............................

 

[321Clss93]

Would the HST drivers following the ones from which people fell out have been able to spot all those bodies lying beside the track at speed? Would they stop the train immediately and radio in or something, or would some of the bodies go unnoticed for a while on those long desolate stretches? I'm just thinking what the protocol would be for locating someone who disappeared from a train, especially if their family were not aware of them travelling at that specific time. It's not like there's an individual passenger headcount at the start/end of a journey in the same way as airliners.

 

[ChiefPlanner]

Would the HST drivers following the ones from which people fell out have been able to spot all those bodies lying beside the track at speed? Would they stop the train immediately and radio in or something, or would some of the bodies go unnoticed for a while on those long desolate stretches? I'm just thinking what the protocol would be for locating someone who disappeared from a train, especially if their family were not aware of them travelling at that specific time. It's not like there's an individual passenger headcount at the start/end of a journey in the same way as airliners.

Put it this way - train drivers often (unfortunately) spot things like this - any train found with a door open in transit - will have the normal principles applied of a following - or train in the opposite direction - "examine the line" for which full guidance is given to the well trained train crew. Often an extra check would be carried out by calling out locally based staff - in my day the on call Station Manager ....

 

[lastladporter]

back then train staff were asked to keep an eye out for a body if a door was seen open and a passenger suspected or a posibility of one fallen out .When i worked on out stations (when all stations had porters or railmen) i was once asked to go check the line for a possible blonde haired little girl lying in the 4ft , yellow vest on i approached gingerly and was so relieved to find a labrador and not a child.the p-way staff removed the dogs body as they always did then.
back then it was the job of the p-way staff to collect the body parts, and they were given the next day off when it was human.
i dont know how anyone would know for definate if someone was missing ,especially back then, that stuff all happened before mobile phones were common , and even proving which train they were on if a body bounced into the shrubbery and wasnt seen straight away could, i imagine, prove tricky as cctv wasnt common then , i cant imagine all the bodys would just stop dead (no pun intended) when falling at speed. i suppose if they left personal effects on a seat/table or someone remembered seeing them get on or buying a ticket, credit card receipts (though cash was king back then) and ticket time of issue would all tell the tale. ticket checking platform staff were also the norm until around about the late 80s early 90s .

 

[PG]

The Railways Archive
http://www.railwaysarchive.co.uk/docsummary.php?docID=393
has a copy of the HSE report from 1993 on Passenger Falls from Train Doors
http://www.railwaysarchive.co.uk/documents/HSE_TrainDoors1993.pdf
Having waded through this it appears that the vast majority of instances involved deliberate opening/misuse by passengers.
It does however say:

233 The most important failure mode identified, and that posing the clearest risk, is where a lock handle is misaligned so that the lock bolt can jam in the fully retracted position, combined with a door that can stick in its frame. This combination has been found on trains in service, reproduced in laboratory conditions, and the lock jamming effect carefully measured. In this situation the door appears from inside the carriage to be properly closed. A very slight pressure applied to a door in that condition could cause it to open; a passenger leaning on it would be likely to fall out.

I thought the eventual conclusion was that the door latches were found to be jamming if not properly lubricated resulting in the doors in question being closed but not locked?

They did find that latches could jam and result in doors being closed but not locked but that this was not due to not being properly lubricated, more to do with the tolerances required during fitting and/or maintainence of the locks combined with doors that when closed were a tight fight into the frame (and this isn't a criticism of fitters). Incidentally the report came up with a figure of under 1.5% of locks jamming.

TRANS PENNINE
THE MAGAZINE OF THE PENNINE RAILWAY SOCIETY

No.74 - Winter 1990

NOTES FROM THE COMMITTEE TAMWORTH DEATH TRAP

In less than one year 5 people have been killed falling from moving trains in the Tamworth area. In no instance has there been found a defect on a door and BR can offer no explanation. The area has been dubbed the "Tamworth Triangle".

This seems to have been down to the way BR investigated incidents prior to the HSE report - the lock would be removed from the door in question and sent to Derby for testing, whereas in some cases testing in-situ would reveal a fault, albeit one in which the handle was visibly in the unlocked position when the door was fully closed. Incidentally during the 8 year period (84-91) covered by the report the average number of fatalities per year from falling from trains was 21.

That's the distinction to draw though, HSTs don't have door interlock so they can't obtain interlock with a door open, simply because they don't have interlock. The CDL is only a secondary locking system, the doors if properly closed should keep themselves closed. I don't think the system is in any way unsafe, it just relies on staff performing their duties diligently in checking all doors are closed properly, which I have every faith in them doing.

Indeed the report says the very same

230 The most important finding of the investigation has been that a train door lock that is properly engaged before departure will not come open during the course of a journey in normal service.

 

[lastladporter]

P.G some good findings there. but as usual it raises many questions
1/Having waded through this it appears that the vast majority of instances involved deliberate opening/misuse by passengers. Q/ were these witnessed or assumed? especially the ones that were related to the tamworth area, where the focus of skulduggery was concentrated, and other hotspots.
Originally Posted by HSE

2/ 233 The most important failure mode identified, and that posing the clearest risk, is where a lock handle is misaligned so that the lock bolt can jam in the fully retracted position, combined with a door that can stick in its frame. This combination has been found on trains in service, reproduced in laboratory conditions, and the lock jamming effect carefully measured. In this situation the door appears from inside the carriage to be properly closed. A very slight pressure applied to a door in that condition could cause it to open; a passenger leaning on it would be likely to fall out.
Q, I have seen this misalignment many times on d.m.u`s but never on an h.s.t , were all class of door tested or just hst`s? also the train would have to have been judged by staff on the platform as secure, guards and porters alike.

3/They did find that latches could jam and result in doors being closed but not locked but that this was not due to not being properly lubricated, more to do with the tolerances required during fitting and/or maintainence of the locks combined with doors that when closed were a tight fight into the frame (and this isn't a criticism of fitters). Incidentally the report came up with a figure of under 1.5% of locks jamming.
Q/ again ive seen it plenty on dmu`s but not hst`s - those big hst handles shot up and near broke your wrist if you had your hand in the wrong place- if a door was shut and the handle was defective i.e hanging down or limp , the door would have been locked out of use and defective door card applied - i dont see how it could fail once shut and dont really see how it could fail to be noticed if it had failed, because ive never seen a handle shoot up when the catch hasnt engaged correctly. also i think 1.5% is quite a high number really - was that whilst in use or in the lab? all doors or,i assume, hst`s only? because in use that would be a lot of door fails - even if only on hst`s and would surely have resulted in many more accidents.

4/This seems to have been down to the way BR investigated incidents prior to the HSE report - the lock would be removed from the door in question and sent to Derby for testing, whereas in some cases testing in-situ would reveal a fault, albeit one in which the handle was visibly in the unlocked position when the door was fully closed. Incidentally during the 8 year period (84-91) covered by the report the average number of fatalities per year from falling from trains was 21.
Q/ this is assuming /i suppose/ they knew which door passengers fell from? again witnesses would be needed? or was this just on doors with a defect label that had been identified and reported or was it every door on a train that a passenger was supposed to have fallen from?

5/That's the distinction to draw though, HSTs don't have door interlock so they can't obtain interlock with a door open, simply because they don't have interlock. The CDL is only a secondary locking system, the doors if properly closed should keep themselves closed. I don't think the system is in any way unsafe, it just relies on staff performing their duties diligently in checking all doors are closed properly, which I have every faith in them doing.
Q/ Again i go back to the visual checks , especially of that big door handle . usually there would be 3 members of staff at point of disembarkation (perhaps not now but then, always)- a guard (who ,if 1st on the unit and performing duties properly) would have unlocked and opened and shut every door at start of shift when preparing the train. then visually ,with at least 2 platform staff (as a rule) ,looked down the door before giving the right away.

6/Originally Posted by HSE
230 The most important finding of the investigation has been that a train door lock that is properly engaged before departure will not come open during the course of a journey in normal service.
and again i quote
Having waded through this it appears that the vast majority of instances involved deliberate opening/misuse by passengers.
Q, theres the rub, after all the in depth analysis, if the door is secured properly , and anyone who has slammed a hst door shut will know if the door "sounds right" when slammed ,and ive never seen a faulty door shut with the handle in the correct position , it all boils down to deliberate opening /misuse by passengers.

it still all seems to come back to this , was it a coincidence that so many people (not all of the 21 a year, but a small percentage latched onto by the press) seemed to just fall out of trains around certain geographical areas, and was the pinpointed reason - too much booze- really to blame for individuals mistaking a toilet door for one which had to be accessed by dropping a window and leaning out of a train moving at high speed to obtain a handle located on the outside of the door? and i would assume all the doors opened would have had to be the ones going with the airflow direction, as ones opened against the airflow would have surely been pinned open by wind force? and when rolling in to a station surely platform staff would have noticed a door on the catch , hsts couldnt be opened from the inside unlike dmu`s.

or was there anything more sinister behind it?

oh well, i suppose we will never know for sure.

 

[Phil6219]

Can I just throw this idea out here regarding mistaking the external door for the lavatory door...

While I too find it extremely hard to believe that someone (who despite being rat-arsed) would mistake the external door for the lavatory door after dropping open a window and reaching into the cold night air to open said door perhaps it is just a touch simpler, in that the door was not latched properly and just the force of someone either leaning on it (to window hang) or pushing it having mistaken it for the WC would cause it to open and thus the person falls out...

After I typed "cold night air" that got me thinking again, how many of these incidents occurred during daylight hours vs night time?

I would also believe that there is a certain number of cases where it was the intention of the person to open the external door knowing full well what it was, having been on a MK2 (no CDL) but secondary door locking (the good old bolt across the top) and very late at night a rather drunk woman made repeated attempts to open the door to "go outside" despite us hurtling down Shap at some considerable speed. It was just fortunate that she was foiled by the few of us in the vestibule area, the SDL and also the fact she didn't realise where the actual handle was and was just trying to force the door with the internal grab handle...

Before I started working in preservation I spotted a door adjar once, I just slammed it shut since we were doing about 3mph at the time. Now I'm trained and all that I know the proper procedure is to stop the train, explain to the guard and then work from there and that should be the same on the "big" railway too.

Incidentally during my time as air crew I have had so many instances of passengers making their way into the forward galley to visit the lav and either try the cockpit door, the forward closet door or even the very boarding door they came on through - despite having a window and an odd shaped handle complete with direction arrow stating "move handle this way in emergency"...

Phil

 

[PG]

lastladporter, we have to bear in mind that at the time of the report the Southern region in particular still had vast numbers of slam door EMUs in service and since the report was BR wide this may have skewed the findings somewhat - particularly the statistics quoted.

1) I think they were mostly from incidents where people had survived after exiting from a moving train who subsequently admitted that they had deliberately opened the door or had been tampering with the door.

2) All types of slam doors were tested from Mk1 to Mk3 and the failure mode mentioned could occur on all of them.

3) Agreed, once shut properly the door lock would not fail. This all boils down to despatch and the vital necessity to observe the position of the door handle (on HST/Mk3) to be horizontal. An 8 coach HST has 28 public slam doors so a 1.5% failure rate (remember this is the maximum so the actual rate could have been less) would roughly mean 1 potentially faulty door (probably intermittently) on every 3rd HST set.

4) Not sure without re-reading the report but I think it refers to any door that it was suspected that a passenger had fallen from.

5) Yes I'd concur, and add that the only benefit of CDL is in preventing people opening doors while the train is in motion or not at a station.

6) Just to pick up on your point of the sound - although personally I'd be inclined to agree, the report concluded that the sound alone could not be relied upon and that the visual check of the handle position was the important factor in determining that the door was properly closed.

I think the report mentioned a figure of 85% of the doors that were the subject of falls being hinge at the rear of the direction of travel.

Phil6219, re your point on time of day, the report identified a distinct peak occurring between 5pm and 9pm.
--- old post above --- --- new post below ---
Have just had a thought re a possible scenario that could have occurred:

• Train pulls into station - passenger mistakenly opens door on non-platform side.
• Realising the platform is not adjacent they close the door (and exit correctly on the platform side) but possibly through the specific fault conditions occurring as mentioned in the report ie misalignment of lock and tight fitting door in frame, the door is not properly locked and so the handle is visibly in the unlocked position ie near vertical on HST/Mk3.
• Train is despatched correctly with all platform side doors being observed to be properly closed.

Sometime later, before the train arrives at a platform on the opposite side of the train where the incorrectly closed door would be noticed, a passenger leans on the same door eg whilst standing in vestibule or getting some air - and thus the door opens and they fall out?

​

 

[321Clss93]

Or maybe they were all just doing this:

 

[Taunton]

It seems surprising that in so many cases the passengers who were involved managed to fall unseen, because commonly passengers in the vestibule are two or more together, the other ones there would pull the cord or report it immediately, yet there seems no evidence of this.

Not noted here, but when the first air-con stock appeared, the Mk 2d in 1971, they did not have a sliding droplight on the doors any more, but did have a large door operating handle on the inside. They were quite stiff to operate/throw over, but there was nothing other than common sense that stopped you opening the door while the train was running. After some months there had been several falls, including a child who had fiddled with the handle, and the design was changed back to droplights, and the inefficiency for the air con accepted.

Of course, trains like high density suburban dmus and similar stock all had door latches on the inside as well as outside, you needed two strong thumbs to operate them, and it was actually easier to lower the droplight and use the outside handle, but I don't remember any history of passenger falls from these, nor any latch faults.

 

[lastladporter]

321class93 , Or maybe they were all just doing this:
there you go , as i posted earlier someone taking in the air and a psychotic serial killer comes from behind you grabs your legs and tips you out!!!!!!!!!!! no sign of a struggle , no evidence after a few bounces along the ballast-
ok ,that was a bit tongue in cheek , but not impossible, i still go back to the senior conductor who "fell" or "jumped " or whatever .
PG the hinge at rear of direction to travel is vital , because that door shouldnt have self closed again, and when passing a platform-tunnel etc surely some would have been torn from their hinges? or at least spotted by staff, signalmen etc etc , especially at night ,it would have been like a beacon . so in theory anyone falling from the door with hinge at rear to travel could have exited via the window? pie in the sky? or a mistake from a serial killer?.
--- old post above --- --- new post below ---
taunton , i made a similar point about dmu`s, i too dont remember many (if any) falls from these ,yet i remember many occasions when the handle was at shut (horizontal) position but the lock hadnt engaged meaning the door was shut to but not secured.
i also recall a 6 coach hauled by a class 37 (i think) flying through a station i was working on expecting it to stop ,as scheduled, the early morning workmen with at least 6-8 doors ajar, legs half out in anticipation of the -disembark whilst still moving -technique, so they got away quick , only to fly through at @ 60 mph (the guard hadnt brake tested , went too far to set back to station, we were 1st station it was scheduled to stop at , it had gone over several busy road crossings ,thankfully with the signals with them) but anyway , no one fell out , no one had any injuries .
as you say passengers falling out seemingly unseen is also a little strange.

 

[D7666]

Still, if anyone could shed some light on the original story of this topic, I'd be keen to hear it.

I do not recall the specific tv story not hst incidents but I do seem to recall a series of open door incidents mid 1980s maybe into early 1990s with WCML Mk.3. Off the top of my head - and this is a vague memory and possibly based on contemporary gossip - something about a wrong lubricant used, or perhaps the right lubricant per the manual but therein wrongly specified, for door the handle mechanism. I think it referred to the handle bit, or the catch engagement, or both, and the mechanism becoming more sticky not closing properly, but the stickiness on the catch bit was enough to make it feel the door was closed from the inside of the train. I also think there was a type of lithium grease involved, I can't recall if that was the perceived fault, or the fix, or some variation in between. Whatever it was once the cause was established it was very quickly sorted out, and all way way before CDL.

--
Nick

 

[PG]

PG the hinge at rear of direction to travel is vital , because that door shouldnt have self closed again, and when passing a platform-tunnel etc surely some would have been torn from their hinges? or at least spotted by staff, signalmen etc etc , especially at night ,it would have been like a beacon . so in theory anyone falling from the door with hinge at rear to travel could have exited via the window? pie in the sky? or a mistake from a serial killer?

Aye that bit about the door hinges prevalently being rear to direction of travel is unexpected as you'd think an open door would either be ripped right off never mind closing without a trace!

I have to say its all a bit strange... maybe in years to come they'll be a documentary exposing a serial killer with the tip em' oot t' windae modus operandi

 

[headshot119]

For people wondering about the CDL system on HSTs having never been "tightened up", the more recent fitment of CDL to 121032 has similar flaws. The system fitted doesn't actually check if the doors are closed, it just confirms there is power to the electromagnets on each door, it's perfectly possible to drive with one or more of the doors open.

 

[LowLevel]

That said if the guard on a 121 isn't capable of making sure all their doors are shut before taking off they are probably in the wrong job Having dispatched 12 or 13 coach charter trains in my platform days that's a bit more challenging!

 

[Nym]

For people wondering about the CDL system on HSTs having never been "tightened up", the more recent fitment of CDL to 121032 has similar flaws. The system fitted doesn't actually check if the doors are closed, it just confirms there is power to the electromagnets on each door, it's perfectly possible to drive with one or more of the doors open.

That does sound very much like the design has someone trying to down prove what is happening, rather than being failsafe...

Should the doors not be 'locked unless told to be unlocked'?

 

[185]

Central door locking isn't always perfect.

In 2006, I had a door open in traffic on a First Transpennine Express 158. At first the company suspended me, stating I had wilfully and intentionally opened a door at 85mph. (lol)

Then it was realised:
1) It was an intermediate door with no internal 'butterfly' door release.
2) I was sat 40 feet away at the rear of the train with 2 passengers and the trolley dolly.
3) I would have needed (quote-the report) 40-foot long arms like Mister Tickle to open the door latch.

Later they accepted it was a combination of poor maintenance and a loose cable flicking ballast up which caused the external butterfly to open.

In 2008, was also suspended after the doors came open on the wrong side at a station on a 170.
1) 5 witnesses were with me at Hull on the platform side, 10 feet away from the offside door release.
2) In the subsequent report, it was again mentioned I clearly must have exceptionally long arms. Clearly.
3) They later acknowledged there were eight previous faults with 170303 due to a wiring fault.

Twice suspended, and did they apologise? Course not. The safety section officer who was involved in producing the reports has left TPE, and what goes on behind the scenes is now becoming more and more clear.

 

[Nym]

Well, in the case of the latter that no-one in Derby knows how to do wiring and the lack of engineering support or casualty managment at TPE maintenance results in incidents like wrong side releases and harnessing faults not being investigated?