RAIB investigation - West Wickham Incident

Discussion in 'UK Railway Discussion' started by Saint66, 24 Apr 2015.

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  1. Saint66

    Saint66 Member

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    https://www.gov.uk/government/news/serious-accident-at-west-wickham-station

    Hopefully this is just a one off incident! But it's always a concern when anything like this happens.
     
    Last edited: 24 Apr 2015
  2. asharpe

    asharpe Member

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    That sounds like a major design/programming fault. I hope the passenger is recovering well.
     
  3. ComUtoR

    ComUtoR Established Member

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    She isn't

    I shall be watching this investigation with interest. My guess is that nothing will change. DOO will still run, Networker doors will remain as is, and Monitors will still be awful.

    Speaking of "design flaws" You used to be able to circumvent the hustle alarm and when the automated PIS came in it cut of the hustle alarm :/
     
  4. Sleepy

    Sleepy Member

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    <( and DOO is safe because ............. luck ??
     
  5. SpacePhoenix

    SpacePhoenix Established Member

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    How would the guard spot an incident like the above on some of the modern stock which doesn't have any windows that the guard? If the incident is close enough to the door they're dispatching from they'll spot it but what if is down the other end of the train or there are people blocking the guard's line of sight to the incident?
     
  6. Monty

    Monty Established Member

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    The guard is required to remain on the platform and ensure that the train doors have closed properly and are free of obstructions before closing his local door and instructing the driver to depart. Even on long trains the guard should be able to see the someone is still near set of doors and is struggling to depart. If the station is very busy you wait until the platform has cleared sufficiently or you move to another location to get a better vantage point.
     
    Last edited: 24 Apr 2015
  7. Bletchleyite

    Bletchleyite Veteran Member

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    Incidents have occurred where guards have dispatched trains with people leaning on them/trapped in doors, and they have also been injured/killed.

    This situation, it seems to me, resulted from someone not doing their job properly and ensuring the train was clear before departing. Not because of the method of dispatch. If a driver in a DOO train can't see that it's clear (e.g. because of a faulty monitor) surely they need to get up and look out of the window before departing, not make assumptions?
    --- old post above --- --- new post below ---
    It sounds like slightly poor design in that a passenger may receive minor injuries from being trapped in a door. I've not come across trains with this flaw - I've only seen those where the hustle alarm sounds at all doors and the button remains lit, or the button goes out as soon as close is pressed and the hustle alarm doesn't sound. It was not, however, the primary cause, which was a member of staff dispatching a train (whether it was DOO or not is IMO irrelevant) without having certainly seen that it was clear to do so. In guard operation, that's the guard's job. In DOO, it's the driver's. But whoever's it was, it was not done.

    (It is interesting that SBB (Switzerland)'s guard dispatch procedure does not have this check, instead having the driver do a cursory check in a mirror, which I've seen to result in trains departing with open doors. I wonder how often people are dragged along over there?)
     
    Last edited: 24 Apr 2015
  8. A-driver

    A-driver Established Member

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    This is a well known fault in networkers. You can get interlock with a door obstructed. Happened at Huntingdon and kings cross as well. If you try to open the doors after the driver presses 'close doors' nothing happens. If you try a second time within a couple of seconds the door will open but no hustle alarm sounds and it immediately closes again which it appears is what happened here. Then when you become trapped the rubber seal strips on the doors closes around various obstructions (such as hands and coats and now apparently bags) and seals them firmly into the doors. The driver gets interlock and the train is able to take power.
     
    Last edited: 24 Apr 2015
  9. Bletchleyite

    Bletchleyite Veteran Member

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    That does sound like rather a design flaw which needs fixing - but as noted not the primary cause.
     
  10. A-driver

    A-driver Established Member

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    Well you clearly haven't read the raib prelim report which states the driver didn't see anyone trapped so no, certainly doesn't appear as someone not doing their job properly but feel free to do your normal thing of blindly blaming the staff without having a clue what actually happend! Seems more likely that it may be a blind spot on the screens or interference from sunlight casting shadows etc which is all very common on DOO monitors combined with the poor door design of networkers allowing interlock when someone is trapped, I don't know any other trains where this is possible.

    Pleas don't post your idiotic counts blaming staff for things you clearly know absolutely nothing about.,.
    --- old post above --- --- new post below ---

    No-you are very wrong. It is the primary cause. Staff error seems not to be and I know a lot more about this incident than has been posted here as it was briefed regarding networker operation (we also sign networkers at my TOC).
     
  11. gtr driver

    gtr driver Member

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    "This situation, it seems to me, resulted from someone not doing their job properly and ensuring the train was clear before departing. Not because of the method of dispatch. If a driver in a DOO train can't see that it's clear (e.g. because of a faulty monitor) surely they need to get up and look out of the window before departing, not make assumptions?"

    Firstly, maybe you should wait for the results before blaming someone quite so blatantly as you have here.

    Secondly:

    "Neither the trainee driver nor the instructor saw that a person was trapped by the train doors before the train was driven away from the platform."

    Do you think they would have moved off if they had seen her? If they had no doubt about the quality of their view, why get up? If a monitor is faulty, or a mirror is broken, of course a driver doesn't make assumptions. There are actions that are undertaken under such situations. The indication here is that their view was sound to the best of their knowledge.

    And thirdly, what choice do drivers have? Stop, open doors, count twenty seconds for dwell time, check if clear by whatever means you have, if not clear, wait until it is, if view not acceptable by normal means then take remedial action, if view acceptable and doors clear, close doors and keep looking until closed. If someone does something that has dangerous consequences (which they often CHOOSE to do with full knowledge of the dangers by the way) and the driver cannot see the initial event or the consequences of it, what course of action CAN he take?

    The rail industry has choices. It can have a guard on every train and/or staff on the platforms to make dispatch as safe as possible. But it doesn't appear to be willing to swallow the cost of that any more, with the government's blessing.

    So it has DOO. Then it has to have other means to give the driver a decent view during darkness, along crowded platform edges, curved platforms, etc etc, such as monitors or mirrors, saving money but introducing greater risks. If those means don't work, the driver can get out and walk back if he's unhappy with the view. I've done it and caused several minutes delay closing each door individually because I don't wish to be judged by ignorant armchair pundits or become the subject of an RAIB enquiry. But in many places these methods could not be seen as 100% safe, as we have seen here.

    Unfortunately the earlier post is probably quite correct. The dispatch methods will remain, even if they are unsatisfactory, because they save money and the implications of such an event taken to the logical conclusion could see an end to DOO and a rise in costs which apparently we aren't prepared to accommodate even though life and limb is at stake here.
     
  12. Bletchleyite

    Bletchleyite Veteran Member

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    No, but I suppose the question is why they did not see that someone was standing by the door, and no doubt trying to pull their bag out and getting a little panicky. I'm sure the RAIB will be able to establish this in due course.

    Surely keep looking not until closed, but until you are certain there is nobody trapped?

    In this case it seems there is a problem with the door system such that the passenger may not have been aware that the door close button had been pressed. They therefore did not choose to take a dangerous action.

    It can also improve DOO technology with train-side cameras, improved quality displays, perhaps infrared cameras as used in CCTV these days etc. It might viably get to the point that a DOO driver can see better than a guard potentially 11x20m away from a problem on a curved platform.

    Good on you for that. But might a trainee have failed in that, and the instructor become distracted? That's for the RAIB to find, I guess.

    Or an improvement to DOO, which might include improved sensors on doors, for on-train cameras the view remaining visible until the whole train is out of the platform (I know this has been hotly debated, but in some countries this approach is used), or even computerised hazard detection of some kind. There are many, many options. I don't like to see any of them (be that reinstating guards or be that technology improvements, or be that more platform dispatch staff) missed from consideration purely on ideological grounds.
     
  13. bramling

    bramling Established Member

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    Certainly on the trains I work with it's possible to get interlock with small items present in the door rubbers. This normally means coat strings or the like, but has also included plastic suitcase handles. Our trains have the facility that the doors can be pushed back slightly to free any such obstruction. I think I'm right that on Networkers the doors would be firmly locked shut?

    I agree with the point about monitors. There's always the possibility of monitors being out of alignment or the view being obstructed in some way. Even if everything is perfect, there's always the risk of the driver missing something, or misinterpreting the view he is presented with. This is why doors safety (the platform/train interface) is regarded by the rail industry as a major risk. Unfortunately, passengers seem much less aware of the level of risk - I don't believe the industry will ever be able to fully 100% mitigate against this risk.

    I would also tend to agree that guard operation is safer - the guard is able to concentrate on the platform throughout the process, whereas the driver will always at some point have to start focussing on the line ahead. The design of modern units does not help the guard though, as on most power-door stock once his local door is closed, his view of the platform is very limited. Many DOO drivers can be observed sticking their heads out of their window when moving off to mitigate against this very risk, but obviously this is only fully effective when the platform is not crowded, and can only be done if the platform is on the driver's side.

    As A-driver says, unless in possession of insider information, best to wait for the report before speculating about anyone's actions. Dragging someone rates very highly in the list of what would form most drivers worst nightmares, speculation about whether they have performed their job correctly is not helpful.
     
    Last edited: 24 Apr 2015
  14. A-driver

    A-driver Established Member

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    Your knowledge on rail operations is very limited obviously and Yet you still feel comfortable blaming individual staff members for things you know absolutely nothing about!

    The entire DOO system is unsuitable for the modern railway. Platforms are too busy to rely on poor quality screens and mirrors easily affected by sunlight and darkness.

    On the GN route we have been mistrusted since before Xmas not to use any mirrors to dispatch trains over 4cars long in darkness as too many shadows at the back with poor platform lighting means a very high risk of not seeing someone trapped in the doors. But what is being done to rectify the issue? Nothing.

    It's all too common to find monitors completely invisible in bright sunlight or visibility poor in them meaning whilst the train looks clear it actually isn't. Or cameras misaligned or blank.

    Recently I took an 8 car317 into a platform and when it was clear closed the doors. No interlock. Opened and closed again, still no interlock. I looked out the window and someone was holding doors open but I couldn't see that on the screens. I counted 17 doors visible on the screens of my 8 car train. But 2 sets of doors appeaed twice on much, much closer Inspection and one set didn't appear at all! No way any driver would notice that unless what happened to me happened. Absolutely no way at all. If it had been a 365 and I had dragged someone because of it it certainly wouldn't be my fault in any way at all. I'd be completely blameless. But the scary thing is that despite me reporting this daily nothing was done to fix it for almost 3 weeks!

    So certainly not obviously someone not doing their job but you carry on blaming staff for things you don't have the faintest clue about. It's people like you posting things like this which create such a strong divide on this forum.
     
  15. GodAtum

    GodAtum Established Member

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    I wonder how old she is that what life changing injuries she sustained?
     
  16. Zoidberg

    Zoidberg Established Member

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    20s and head and leg injuries as per

    http://m.newsshopper.co.uk/news/128...eatening_injuries__on_tracks_at_West_Wickham/

     
  17. SPADTrap

    SPADTrap Established Member

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    I've wondered the same thing but thought I was going crazy seeing duplicated images. I really dislike using monitors, especially as some only show what they 'need to' and you are expected to look back to see the rest, was a shock to me when I first started driving, I'd have at least expected the full train to be visible on the monitors if they are to be used but we are to look in two places at once it seems with certain formations.
     
    Last edited: 24 Apr 2015
  18. Bletchleyite

    Bletchleyite Veteran Member

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    That is very, very concerning - a non-visible but safety-critical fault. I wonder how it could be ensured that this does not occur? Perhaps bold, large print numbers or letters by the doors, so you could, if suspicious of a problem, ensure they were all correctly shown?
    --- old post above --- --- new post below ---
    Yes, I would have expected a driver to be able to see *all* doors using the same mechanism. If not it seems to me that that system of DOO is unsafe.

    It doesn't say to me that *all* DOO is unsafe, but it is very concerning.
     
  19. martynbristow

    martynbristow Member

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    Isn't the problem described here solved by (over)sensitive-edge?
    But there should be redundant viewing with potentially an extra camera doing a 2d compressed image of the train.
    Basically literally looking back and forward :/
     
  20. LowLevel

    LowLevel Established Member

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    For the folk saying 'the guard might not have seen them either' - the whole point is that if they were doing the job properly they most definitely would have seen them because a human being that close to the train is obviously an issue. Once the doors are closed you check them and if you can't see clear you walk until you can. It would take a lot to get stuck in the doors post closure.

    However, never mind, I'll just sit and watch another RED reconstruction at my next safety brief telling me the same things as when this last happened on another DOO train and nothing will change.
     
  21. A-driver

    A-driver Established Member

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    Well yes, obviously. But no one will spend the money on such things. DOO equipment was installed when the railway was much quieter.

    As I said earlier-we have been instructed not to rely on mirrors after dark. Mirrors are no longer installed on new stations or DOO systems as they are deemed unfit for purpose. But why are the mirrors which we have been told not to use not being replaced with screens? Simple, cost.
     
  22. theking

    theking Member

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    So what's people's opinions of doo on Crossrail then.

    9 car 200 metre long trains sounds like it will be tough for the driver.
     
  23. bramling

    bramling Established Member

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    Still 3 sets of doors less than a Central or Victoria Line train. I presume the Crossrail trains will have bodyside/in-cab CCTV, which is definitely an improvement on mirrors and monitors, although it could represent an increased "start up" SPAD hazard.
     
  24. FordFocus

    FordFocus Member

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    Interesting idea Neil but I don't think it would be workable. If you take a look at some DOO monitors when a train is the in the station the angle would be impossible to get a clear view. Plus you would have overlap in door numbers when units are running in multiple coupled together.
     
  25. LeeLivery

    LeeLivery Member

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    Firstly that is such a horrible story to hear and I hope she gets well.

    Apparently they wont because of platform edge doors and many London Underground stations have dispatch.
    --- old post above --- --- new post below ---
    I have no doubt that any competent guard would have seen it. Especially as West Wickham isn't a busy station and has straight platforms.
     
    Last edited: 25 Apr 2015
  26. sbt

    sbt Member

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    There might be ways to make it work.

    To deal with the overlap issue the door numbers could include the 'last two' of the unit number. The probability of a number clash would be quite low and eliminated by a rule forbidding units with the same 'last two' in the the same formation on DOO lines.

    To deal with the visability from an angle issue I can see two approaches. The first is to repeat the numbers and use isometric drawing to allow them to be read at an angle. This has been done with road markings. You would require at least two versions, one to be read from each end of the unit, and possibly three, with one to be read directly side on. Testing would have to establish which angle of projection to use in the alphanumerics.

    The second, and probably better, approach is not to use alphanumerics at all, or to supplement them. There is no particular reason to use them as all that is needed is something that allows each door to be clearly distinguished and has an identifiable sequence. My first thought would be a system of horizontal lines, one above the other, some thin, some thick, some dashed, some dotted. Possibly other simple geometric shapes could be worked in to the system, provided they could be distinguished from an angle.

    Example system, which is not a definitive proposal, but has had a bit of thought put in to it:

    Door -
    A B C D E F G H I J K L M N O P Q R S T U V X Y Z
    - - - : : : : = = = = + + + + / / / / O O O O V V
    . - - . - - - . - - - . - - - . - - - . - - - . -
    # . - # . - - # . - - # . - - # . - - # . - - # .
    # # . # # . - # # . - # # . - # # . - # # . -
    # # # # # # . # # # . # # # . # # # . # # # .

    Unit Nos -
    0 1 2 3 4 5 6 7 8 9
    / X X X X X X X X X
    . . / / X X X X X X
    # . / # . / / X X X
    # # . # # . / . / /
    # # # # # # . # . /
    # # # # # # # # # .

    Unit 37, Door G

    : : :
    -----
    -----
    -----
    . . .

    X X
    / X
    / X
    . .


    Or


    : : : # X X
    ----- # / X
    ----- # / X
    ----- # . .
    . . .


    (Grey # would not appear in symbol - its there just to get the formatting right)

    You will note I have included a dot at the bottom of a symbol to aid the driver in determining if he has read the whole symbol.
     
    Last edited: 25 Apr 2015
  27. W230

    W230 Established Member

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    Goingon from A-driver says, we have been instructed the same on the TL route regarding stations with mirrors. We've had an entry in the WON for months about Network Rail working with TOCs to solve the problem. No change as of yet...

    And another thing abotut DOO monitors - even at St Pancras LL, a recently built station, the DOO monitors are not good. You can check all is clear on the monitors shut the doors and then find you have people running for your train and getting trapped in the doors. The reason? The monitors dont show enough depth of the platform so people out of view of the monitors are still on the platform wanting to board the train. This is why i always look back but even then there are people at the bottom of the stairs who are out of my view trying to still board the train when the doors close. I know this isnt what happpened at West Wickham but it gives you a flavour of the problems of DOO monitors. No despatchers at St Pancras really is ridiculous in my opinion. How can a astation of this size enot warrant despatcher?!

    And furthermore, 387s/377s have a in cab monitors wich we must use, ignoring the on platform monitors. And these are even worse, offering an even shallower platform depth. While the 387 monitors are an improvement on the truly awful 377 monitors, theyre still not very good.
     
  28. badassunicorn

    badassunicorn Member

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    What I find disturbing is how on the West Anglia route, at certain stations which either have dispatchers permanently (T-Hale) or sometimes (Harlow Town/ Broxbourne) if you are in 379 stock you must self dispatch. I find this so bizarre that a distinction between stock is made when dispatching. If the staff are standing there blowing whistles why not have them also give CD/Bat and RA. It seems like NXEA at the time had their shiny new 379's with cameras and wanted to use them for the sake of it!
     
  29. bramling

    bramling Established Member

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    I wonder if it will be possible at the PED stations to have platform cameras broadcast inside the cab. This is what happens on the JLE.

    It's worth adding that LU doesn't have dispatch as such, except if the monitors are defective. Even where platform staff are provided and raise the baton, this is just a guide for the driver - the Rule Book is very clear that the onus of safety is still 100% with the driver.
     
  30. A-driver

    A-driver Established Member

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    Quite simply they are doing that in the hope that once all stock has cameras fitted they can say goodbye to their platform staff and save some money...that's the only reason really. Certainly safer, easier and more customer friendly to have someone on the platform with excellent views of the entire platform and train dispatching than a driver looking into fairly poor quality screens giving a very narrow view of what is happening.
     
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