RAIB Safety Digest triggered by incident at Bushey station

The Safety Digest into this incident has now been published. It involved a southbound West Midlands Trains Class 350 train.

A passenger attempted to board the train while the doors were closing, placing their forearm between them assuming that they would reopen if they encountered an obstruction as would a lift door.
The design of the sensitive edge system was such that the obstruction was not detected.
The conductor assumed that the bodyside lights extinguishing meant that there was nothing/nobody trapped in the doors. They say they shouted to the passenger to stand clear, but the passenger did not hear anything.

www.gov.uk/government/publications/safety-digest-072018-bushey/passenger-trapped-in-train-doors-and-dragged-at-bushey-station-26-march-2018

~9.30pm in March, probably.

The digest published by RAIB refer to it as a sensitive edge system.

Errr this was a failure of the Conductor...  Ding, ding and away. Perhaps a driver having access to CCTV would have seen the passenger?

As for suggested action, perhaps have automatic gates onto the platform, to prevent passengers accessing the platform during train dispatch.  It was common for porters / ticket collectors at stations to close the barrier just before the train was due to depart.

Yes the conductor caused the trap-and-drag but they were also the one who stopped it. Other trap and drag incidents on DOO routes show that even with CCTV it can be very difficult to determine whether someone is merely close to the train or interacting with it. The only way you can guarantee no trap and drag incidents is to ensure that there is no person between the train and the yellow line at any time the train is moving. I can't think of any way of achieving this without one or more members of staff who can (individually or collectively) monitor the entire platform-train interface from the moment the door closing alarm starts until the moment the entire train has left the platform. Certainly for trains longer than about two carriages the driver is going to need to be looking at the line ahead before the rear of the train is clear of the platform.

It's thankful such incidents are rare.
In the bigger picture, if the number of pedestrians coming into contact with moving road vehicles could be reduced to this level, it would be a major step forward for road safety.

The issue is surely with the design of the sensitive edge, and the adjustment of it, as pointed out by the report. Distraction or inattention by the guard/conductor at what was surely a quiet time of day would have been another factor.
On statistics, the passenger boardings/alightings on DOO routes surely would have to be compared with these on the others to get a fair picture..

So half of the incidents, occur on just a third of the trains, but those trains are carrying over half or is it 2/3rds of the passengers... I have worked with some awful Guards, that have made appalling errors, but I had always found most Guards were good... Those stats don't paint a good picture for Conductors.

To be fair watching the conductors working on Southern, I would not want their job having to work on crowded trains, working from a set of doors being used by passengers.


I have worked as a Station foreman seeing out trains on curved platforms and even double sided platforms (Slam door stock).  Hmm leading porter 1 signals to leading porter 2 who signals to the guard... No thanks, can we have a set of cameras on each door, and perhaps even a computer flagging up objects near the doors.  Or even better a system that detects if objects are stuck in the door.

A redesign would indeed do the job, and as the report mentions has been done for new installations. What hasn't been done is a retrofit, presumably because such would be very expensive and/or difficult thus not being seen as proportionate.

Having spent the last 30 odd years involved in fire and safety systems in general, the one thing you can never 'engineer' for is the human being

Touch wood, but if this were to ever happen again and someone ended up being killed, would the findings be the same...

What is fitted is not sensitive edge equipment, it relies purely on something blocking the doors from closing. there is nothing in it to detect something being dragged by a train, unless a door is pulled open by the dragged item the train will not know if there is a problem.

The underground system is far more effective, if a coat string gets caught and the train drags a child the train braes will automatically apply. It really is good enough to do that.

No, because the chain of events would have to be slightly different to get a different outcome, thus the recommendations would be different.



This what the RAIB say:

A 1st-generation Walkman and a latest-generation iPod are very different to each other. They use very different technologies, and the iPod offers many more features and a better user experiecnce, but they are still ultimately both personal music players doing the same job.
The Class 350 sensitive edge system and the S stock sensitive edge system use different technologies, and the latter offers more features and a better better user experience, but they are still ultimately both sensitive edge systems doing the same job.