Merseyrail Guard on Trial (Report now out)

[GB]

Report is now out for this accident.

http://www.raib.gov.uk/publications/investigation_reports/reports_2012/report222012.cfm

Fatal accident at James Street station, Liverpool

Summary

At 23:29 hrs on Saturday 22 October 2011, sixteen year-old Georgia Varley was struck and killed by the train she had left 30 seconds earlier. She was leaning against the train as it began to move out of the station and when she fell, the platform edge gap was wide enough for her to fall through and onto the track. Her post-mortem toxicology report recorded a blood alcohol concentration nearly three times the UK legal drink drive limit and she was wearing high heeled shoes at the time of the accident.

The guard dispatched the train while the young person was leaning against it. It is possible that he did this because he had seen her but expected her to move away before the train moved. It is also possible that he looked briefly in her direction but did not see her (‘looked but failed to see’ is a known phenomenon in routine, repetitive tasks). It is also possible that he did not see her because his attention was on his control panel and a large group of people on the platform.

By the time the guard warned the young person to stand back she had been leaning against the train for approximately eleven seconds. It is not known when the guard saw her during this time or, if he saw her, whether he delayed taking action in the expectation that she would move away.

Platform video camera footage shows him warning her to stand back in the moments before the train departs and it is likely he did this because he thought that it would be immediately effective and because he had no direct and immediate way to stop the train. While the rail industry’s overall safety record has improved in recent years, accidents at the platform/train interface have increased, even when accounting for an increased number of passenger journeys over a period of time which saw a known industry hazard (trains with slam doors but no central locking) withdrawn from service. This indicates that the industry’s focus on operational matters has not delivered improved safety at the platform/train interface, which suggests that there is a need to consider
technical solutions to reduce the risk.

This report makes three recommendations. The objective of recommendation one is for Merseyrail to reduce train dispatch accident risk by improving the way in which it operates its trains. The objective of recommendation two is for Merseyrail to reduce the likelihood of falls through the platform edge gap. The objective of recommendation three is for the Office of Rail Regulation to ensure that the findings of this report are taken into account in published guidance.

 

[northwichcat]

So the girl had already alighted at the wrong station before she wrongly alighted at James Street and had previously caused a delay and she was given an opportunity to re-board at James Street but didn't.

 

[khib70]

So the girl had already alighted at the wrong station before she wrongly alighted at James Street and had previously caused a delay and she was given an opportunity to re-board at James Street but didn't.

The girl's state of intoxication is indisputable and well covered in both the trial evidence and the RAIB report. It is not listed in the report as a causal factor of the accident.

I think we'd all do well to remember who was/is on trial here, and who wasn't/isn't

 

[Mutant Lemming]

A court of law has reached it's decision whether one agrees with it or not. Demonising one side or the other will do no one any good. The main issue I can see is the disparity in the sentencing whereby one would escape with a lesser sentence if a death was caused by dangerous driving or even by a deliberate act of vandalism.

 

[GB]

Mersey Rail were aware of unauthorized dispatch procedures but did nothing about it? Why are they not brought up on charges?

However, had the guard followed Mersey Rail published dispatch procedure the likely result would have been the same!

The guard could have followed Merseyrail’s published procedure to dispatch the train when the passenger doors first closed, as they were unobstructed and the platform adjacent to the train was clear. Under the Merseyrail procedure the guard would board and then wait until his door closed before sending the ‘ready to start’ code. He would not have been able to see the young person approach and come into contact with the train because of his narrow field of view through the door’s fixed window (see figure 12) and, if all other events remain unchanged, the outcome would have been unchanged.

 

[Kilted_Scot]

Mersey Rail were aware of unauthorized dispatch procedures but did nothing about it? Why are they not brought up on charges?

However, had the guard followed Mersey Rail published dispatch procedure the likely result would have been the same!

I read that and was astounded! All i know is that now, I dont care how delayed my train is, if some idiot is going to be anywhere near it on the platform I am going nowhere, I dont need to go jail for doing my job! hock:

 

[northwichcat]

Mersey Rail were aware of unauthorized dispatch procedures but did nothing about it? Why are they not brought up on charges?

That probably relates to Northern (also owned by Abellio and Serco) immediately went to a guard dispatches from the back of the train rule soon after the incident.

Wouldn't following an incorrect dispatch procedure mean an internal discipline opposed to charges?

 

[transmanche]

Mersey Rail were aware of unauthorized dispatch procedures but did nothing about it? Why are they not brought up on charges?

However, had the guard followed Mersey Rail published dispatch procedure the likely result would have been the same!

I read that and was astounded! All i know is that now, I dont care how delayed my train is, if some idiot is going to be anywhere near it on the platform I am going nowhere, I dont need to go jail for doing my job! hock:

Although since the accident, Merseyrail have 'formalised' the previously unauthorised method - see para 27 of the report.

However, if the guard had followed the official procedure, I wonder if the charge could have resulted in a conviction. The result would have been the same, but guard would not have even seen the girl approach the train.

 

[Ferret]

I read that and was astounded! All i know is that now, I dont care how delayed my train is, if some idiot is going to be anywhere near it on the platform I am going nowhere, I dont need to go jail for doing my job! hock:

What I wasn't previously aware of was that the Guard warned the deceased to stand back which was a warning she failed to take notice of. Yet he was still convicted of the offence of manslaughter. This would appear to clarify for us Guards what our level of responsibility actually is so far as the law is concerned.

 

[GarethW]

What I wasn't previously aware of was that the Guard warned the deceased to stand back which was a warning she failed to take notice of. Yet he was still convicted of the offence of manslaughter. This would appear to clarify for us Guards what our level of responsibility actually is so far as the law is concerned.

That is probably why he WAS convicted.

He warned her, she took no notice, he dispatched the train.

 

[Ferret]

That is probably why he WAS convicted.

He warned her, she took no notice, he dispatched the train.

Or continued to dispatch the train, without giving the driver 1 on the buzzer. But yes GarethW, that's my understanding of it. The point I'm making is that it highlights to us Guards exactly what we are responsible for, and what we must do.

 

[maniacmartin]

Its very interesting that the RAIB report places a lot of emphasis on problems with the procedures of how the trains should be dispatched, technical problems with the stock and with the platform edge.

Then again, RAIB reports are not to establish blame, but to recommend changes that reduce the chances of similar accidents happening again.

 

[snail]

The main issue I can see is the disparity in the sentencing whereby one would escape with a lesser sentence if a death was caused by dangerous driving or even by a deliberate act of vandalism.

Neither of which are covered by the Health and Safety at Work Acts, which apply here, giving a statutory duty of care to other employees and the general public.

 

[AndyLandy]

Its very interesting that the RAIB report places a lot of emphasis on problems with the procedures of how the trains should be dispatched, technical problems with the stock and with the platform edge.

Then again, RAIB reports are not to establish blame, but to recommend changes that reduce the chances of similar accidents happening again.

I would suspect that's precisely why. The courts have already established "blame". The RAIB report is now investigating the wider issues. If recommendations can be made regarding the stock or the platforms, or the dispatching process such that incidents like this are prevented from occurring, all the better. For example, if the gap between the train and platform edge had been smaller, even if everything else occurred the same way, Georgia Varley might have lived to tell the tale.
--- old post above --- --- new post below ---
On a totally separate note, I was surprised to see this quote (emphasis mine)

While the rail industry’s overall safety record has improved in recent years, RSSB research shows that accidents at the platform/train interface have increased since 2005/2006, even when accounting for an increased number of passenger journeys. The increase in this type of accident has taken place over a period of time which saw a known industry hazard (trains with slam doors but no central locking) withdrawn from service

I wonder why that might be...

 

[FGW_DID]

The list of similar accidents was of interest, the majority of which seemed to result from the unsafe actions of the passenger!

Perhaps the RAIB could have included a recommendation to carry out a publicity campaign (similar to Network Rail's Level Crossing one) to educate the public that a railway station can be a dangerous place.

 

[swj99]

Perhaps the RAIB could have included a recommendation to carry out a publicity campaign (similar to Network Rail's Level Crossing one) to educate the public that a railway station can be a dangerous place.

That would be a good idea. Maybe one that emphasizes that most, if not all of the people involved in platform edge gap accidents probably didn't expect it to happen to them.

 

[snail]

The list of similar accidents was of interest, the majority of which seemed to result from the unsafe actions of the passenger!

Yes, two in particular caught my attention:
Gunnersbury, where the Court of Appeal "upheld the ruling that both the injured man and the train operator were liable for the accident. The injured man because of his behaviour while under the influence of alcohol; the train operator because their guard did not act on the passenger’s behaviour".

and Angmering, where a 16-year old three times over the legal limit and wearing high heels fell - shudderingly familiar, though in this case it looks like the guard was not prosecuted.

 

[transmanche]

Yes, two in particular caught my attention:
Gunnersbury, where the Court of Appeal "upheld the ruling that both the injured man and the train operator were liable for the accident. The injured man because of his behaviour while under the influence of alcohol; the train operator because their guard did not act on the passenger’s behaviour".

and Angmering, where a 16-year old three times over the legal limit and wearing high heels fell - shudderingly familiar, though in this case it looks like the guard was not prosecuted.

I noticed those as well. The Anmering incident doesn't appear to have been the subject of an RAIB (or similar) report. I'm curious as to the differences in the cases which led to one leading to a manslaughter case and the other not.

I suspect that the guard's lawyers will be looking at these cases closely - as they suggest grounds for appealing the sentence, if not the verdict.

 

[Matt Taylor]

Or continued to dispatch the train, without giving the driver 1 on the buzzer. But yes GarethW, that's my understanding of it. The point I'm making is that it highlights to us Guards exactly what we are responsible for, and what we must do.

Which is what exactly? Paragraph 63c suggests that even if the train is clear and someone moves toward the train after you've closed your local door it can still be our fault if they get run over.

My interpretation is that as the train started moving she moved away from the train and at that point she was safe. Out of McGee's sight she has then moved back to the train and fallen down the gap and that is why she died.

 

[Ferret]

Which is what exactly? Paragraph 63c suggests that even if the train is clear and someone moves toward the train after you've closed your local door it can still be our fault if they get run over.

My interpretation is that as the train started moving she moved away from the train and at that point she was safe. Out of McGee's sight she has then moved back to the train and fallen down the gap and that is why she died.

My reading of it is that the guard had given 2 on the buzzer, shouted a warning which wasn't heeded, but still didn't give 1 on the buzzer to stop the train. That to me makes it clear that shouting a warning isn't sufficient to stay within the law.

 

[Matt Taylor]

In which case there'll soon be a rethink once the delay minutes start piling up.

 

[Ferret]

In which case there'll soon be a rethink once the delay minutes start piling up.

I disagree - the only way there will be a rethink is if the conviction is appealed. Us guards causing a few delay minutes will make sod all difference to that!

 

[jnjkerbin]

What would be the reason behind withholding the report until after the Crown Prosecution service had made its decision? I would imagine that it would be good for at least the judge and the jury to have seen this report if they didn't anyway.

Joe

 

[Kali]

Back when LT tube trains had guards, they used to hold their local door open ( and keep their head out ) until the train had cleared the platform - is that actually legal, these days? I did notice the report mentioned "provisions necessary to prevent the dispatcher from falling out" or something near.

 

[GB]

What would be the reason behind withholding the report until after the Crown Prosecution service had made its decision? I would imagine that it would be good for at least the judge and the jury to have seen this report if they didn't anyway.

Joe

So it does not sway the judges or juries decision.

 

[Ferret]

What would be the reason behind withholding the report until after the Crown Prosecution service had made its decision? I would imagine that it would be good for at least the judge and the jury to have seen this report if they didn't anyway.

Joe

I wonder if they were concerned about prejudicing the case by releasing the report to the public domain.

Tbh, I'm a little frustrated that the Court case took precedence, because there are lessons to be learned within the RAIB report, and to me there has been an unnecessary delay. I guess I'm thinking of myself here first and foremost, in terms of wanting to know whether I need to change the way I perform my duties, and taking the view that what's done is done. But that's my perogative of course!
--- old post above --- --- new post below ---

So it does not sway the judges or juries decision.

Although you will have noticed my agreement with you regarding prejudicing the case, this report *should* have formed part of the evidence during the trial. I'm not sure whether it happened or not, but the report's author appearing as an expert witness would have assisted the jury in reaching a verdict no end.

Without wishing to dredge up old ground too much, a jury can be made up of people who really don't understand the issues at hand. The recent thread at the time of Mcgee's conviction (which I still believe was correct) proved that some people are way out of their depth when it comes to understanding all the issues in this very complex case.

It's my opinion that the delay in releasing the report was ultimately unhelpful, even if that decision to delay was taken with the best of intentions, and maybe even under direction from the Judge. Other opinions on this of course are equally valid.

 

[Nick W]

I'm curious now: the unauthorised practice for dispatching trains is safer for the public, as the guard has a clearer view, but involves the guards placing themselves in a greater amount of danger.

Even though the guard was increasing his risk on a daily basis to benefit the passenger, he was still convicted, in spite of the fact that the outcome would have been the same had he used the authorised method.

 

[bailey65]

I don't think the guard should have been jailed he hadn't done anything malicious and was doing his job.
It is a very sad case all round and the guard will be emotionally scarred for life,it just shows what a difficult job the guard has when large crowds of drunken revellers,football crowds etc are packed onto the platforms.
Unfortunately the british disease of alcohol abuse played a major part which is why i'm glad the government are now looking at minimum unit prices but that is a different topic.

 

[Phil6219]

It was an interesting read, thought I'd leave it a while to re-review it before making any comments.

Quote:
Originally Posted by Matt Taylor
Which is what exactly? Paragraph 63c suggests that even if the train is clear and someone moves toward the train after you've closed your local door it can still be our fault if they get run over.

My interpretation is that as the train started moving she moved away from the train and at that point she was safe. Out of McGee's sight she has then moved back to the train and fallen down the gap and that is why she died.

My reading of it is that the guard had given 2 on the buzzer, shouted a warning which wasn't heeded, but still didn't give 1 on the buzzer to stop the train. That to me makes it clear that shouting a warning isn't sufficient to stay within the law.

From what I have read I am in agreement with Ferret, as had it been the case of Matt's interpretation of it the guard would not have been prosecuted.

Perhaps there is a small twist of irony that had he simply followed the official procedure and closed the local door then gave a 2-bell he wouldn't have been sent down as he wouldn't have been able to see her. Of course that would only be possible had she not been touching the train when he closed the local door.

A bigger irony is highlighted in the report where it states that in the days immediately following the accident there were significant delays caused by crews following the procedure to the letter. With the final piece being of course that Merseyrail then changed the procedure to the "unofficial" one which had been almost considered the norm.

One thing highlighted in the report is the quick judgement calls required in similar situations, should the guard issue a 1 bell when someone is running alongside the train waving their friends off? or when the drunkard is trying desperately to force a door open? It also mentions quite rightly that if it became standard procedure to stop the train when someone is running alongside or standing too close to the train then the public would eventually figure out that it is possible to stop a departing train by putting themselves in such a position.

Several months ago I was at my usual haunt waiting for a special when a 156 pulled in on Five with a Liverpool-Blackpool service, there was a chavy bloke who was hiding round "the bikeshed" on P6 was smoking and drinking. The doors are closed and just after the guard closes the local door and gives the 2 the guy runs over and presses the button by the guards door. The guard is shaking his head and the guy starts making obscene gestures and shouting at the guard whilst running alongside the sprinter kicking it. The train had been gone all of 30 seconds and the BTP arrived from their office on P4 and nicked him. My question is though, should the guard have stopped the train and had he not would he have been prosecuted had the end of a bell fallen (granted he would probably have fallen behind the rear bogie).

In which case there'll soon be a rethink once the delay minutes start piling up.

I've got to agree here, while at first delay minutes won't mean much eventually the companies will take notice. If everyone adheres to the rulebook and enforces no standing behind the yellow line then things will change.

Other companies in other industries have suffered by various forms of "work to rule", from things such as pay to fairly petty things. While a TOC will be unable to punish staff from refusing to despatch in certain situations the company will eventually have to find a way to resolve the situation.

Phil

 

[Ferret]

I'm curious now: the unauthorised practice for dispatching trains is safer for the public, as the guard has a clearer view, but involves the guards placing themselves in a greater amount of danger.

Even though the guard was increasing his risk on a daily basis to benefit the passenger, he was still convicted, in spite of the fact that the outcome would have been the same had he used the authorised method.

He was convicted (IMO) because he wasn't quick enough to halt the dispatch process. And if I'd have been on the jury, based on the RAIB I'd have had to go for a guilty verdict myself. I do have issues with the sentence handed down, and the comments of the mother of the dead girl, but the conviction (IMO) must stand.

But, as you say, if he'd followed the official dispatch procedure in force at the time, he'd not have seen the deceased move back to the train, and (IMO) could not have been found guilty. Perverse it may be, but in not following procedure, he was in a position to have prevented the tragedy. And unfortunately he didn't.