The inevitable outcome of OPO at unstaffed

My goodness, what a frightening set of circumstances, I suspect that the passenger, her rescuer and the driver all have sleepless nights as a result. This could have happened with any train anywhere and it is just reassuring that there was enough space between the lower parts of the train and the platform edge to allow her to survive. It is also noticeable that, apart from repositioning the OPO mirror, the report's recommendations are more waffly statements rather than definitive corrections. Hopefully it will be tackled in a positive manner rather than become a witch hunt.

The inevitable outcome of a passenger acting in a dangerous manner

We all have a responsibility to act in a safe manner which the lady in this case did not! Accidents like this have occured on manned stations as well.

The lady concerned did not sustain serious injuries according to the report which is a good to see.

XF

From the summary given, I would suggest that many and repeated failures at management level to follow quite specific inspection and supervision requirements was at the heart of this unfortunate sequence of events, starting with whoever it was who signed off for the OPO monitor replacement works in 2003 right up to 2010's failure to perform cab rides.

@rt
1. Supposing it is standard practice to run boxes of frozen burgers through a metal detector before shipping them out, because it's been found that on rare occasions a chunk of metal chips off a gear-tooth in the meat grinding machine and it can get into the product.
2. Suppose as well that a procedure is in place that requires that a metal detector be tested before each shift begins by passing a standard 'phantom' through.
3. I don't know or care if you are veggie or wouldn't eat a frozen burger to save your life, but just suppose that you bite down on a bit of sharp metal in a burger and cut your mouth.

Common sense would dictate that there might be bone or something hard in your burger, but you trust your food manufacturer to do everything reasonably within their power to prevent this kind of contamination. Wouldn't you want the system investigated to find out why that had happened? The manufacturer would like to know if their managers / supervisors aren't following procedures, I bet.

I used this example because that's exactly what happened to me when I was temping in a meat packing plant as a student in the 80s. I had a case knife in my coat pocket and when I switched lines to the other metal detector, it went off and shut the line down. The detector on line A was faulty and had been for up to five days, which was the last recorded time a phantom had been run through it. When I rechecked a sample of boxes that had been passed by A, I found 7 boxes with pea-sized lumps of metal in them. Rather than recheck the 20,000 cases, the supervisor just let it go. I went above their head, even as an agency worker, and it turned out that only six out of the twenty supervisors had ever signed the machine off as tested. I wasn't ever asked to work there again, BTW.

And that's why preventable accidents happen. Accidents DO happen, yes, but in this case the severity of the incident was increased by a series of management and procedural failures. The fact that the woman fell down the gap was her fault. The fact that the train started and endangered her life was a combination of the driver, management and planning.

Colin.
The driver didn't overrun. If anything he stopped short! The OPO monitor was three and a half meters before the 8 car stop, and (from 2003, following replacement works) wasn't angled so that it was 100% visible from the cab. It's true he failed to make a proper train check before departing, but there was a culture of improper train checks that was not addressed by management! If the RAIB can find the data to support their conclusion that there was a problem with the monitor and lax train checks by simply examining the driving records, the TOPC should be doing the same thing as routine.

Only hurt a little maybe by the doors. The driver should have moved towards the DOO monitor or something... hopefully this will never, ever happen again, but unlikely...

That's what puzzles me - why did this relatively minor incident merit an RAIB report? There was a similar incident a few years ago at my local station, but there was no inquiry at all.
(There are differences: it was broad daylight: the passenger was trying to board the train, but fell right underneath: the train had a guard, and there was a despatcher on the platform: consequently the train didn't move; the passenger was hospitalised).

Two points:
1- "Obstructing the doors can be dangerous"
2- OPO drivers should check the entire PTI after getting a pilot light.

+ 1

Well said, trt, - although occasionally, lugging enormous bags at rush hour is sometimes unavoidable

[Rincew1nd's underlining]

I suspect the RAIB investigated this case because there was a failure in the system which led to the accident and also because the potential outcome could have been much worse. In the incident you have described the system worked to prevent a similar thing happening.

There has to be a gap, there is no getting away from having a gap, and the gap can vary in size, the RAIB recognise this is a natural hazard of rail travel. If there is a gap, big enough to fit a person down, then the chance exists of someone falling down it; what is special about this case is that the train moved off with someone in the gap - that is what really should not have happened.

I was in Liverpool when this happened. Essentially the facts seem to be:

Late Saturday night.
Last train.
Possibly too much to drink
Underage girl tried to get on a train that had already had its doors closed and possibly started moving.

A tragedy but not really something you could blame Merseyrail for. Of course the RAIB report will almost certainly not mention that passengers have a responsibility for their own safety too.

www.liverpoolecho.co.uk/liverpool-news/local-news/2011/11/08/merseyrail-worker-arrested-over-death-of-train-tragedy-victim-georgia-varley-100252-29737657/

Georgia mistakenly stepped off the train a stop too soon and bent down to put on the shoes she had taken off. By the time she stood up and realised her mistake the doors had closed behind her. A friend called through the window to tell her to stand back and they would go back for her but her inquest heard how CCTV footage captured her leaning against the train.

Georgia fell down the gap and was killed. Friends on board described the emergency brakes going on as the train pulled away from the station.



Read More www.liverpoolecho.co.uk/liverpool-news/local-news/2011/11/21/georgia-varley-s-family-want-merseyrail-to-install-platform-safety-gates-to-stop-anyone-else-falling-under-train-100252-29810322/2/#ixzz1fyosdKCH

Absolutely nothing that you could blame Murkyrail for at all. A very unfortunate collision of events, I don't think even with continuous monitoring OPO would have made much difference: passengers *do* have a responsibility for their own safety.

www.bbc.co.uk/news/uk-england-manchester-16212963

And this time on the Manchester trams.