Rail Accident Report
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Rail Accident Report Dangerous train door incident at Bank station on the Docklands Light Railway 6 February 2017 Report 12/2017 September 2017 This investigation was carried out in accordance with: l the Railway Safety Directive 2004/49/EC; l the Railways and Transport Safety Act 2003; and l the Railways (Accident Investigation and Reporting) Regulations 2005. © Crown copyright 2017 You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned. This document/publication is also available at www.raib.gov.uk. Any enquiries about this publication should be sent to: RAIB Email: [email protected] The Wharf Telephone: 01332 253300 Stores Road Fax: 01332 253301 Derby UK Website: www.gov.uk/raib DE21 4BA This report is published by the Rail Accident Investigation Branch, Department for Transport. Preface Preface The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to improve railway safety by preventing future railway accidents or by mitigating their consequences. It is not the purpose of such an investigation to establish blame or liability. Accordingly, it is inappropriate that RAIB reports should be used to assign fault or blame, or determine liability, since neither the investigation nor the reporting process has been undertaken for that purpose. The RAIB’s findings are based on its own evaluation of the evidence that was available at the time of the investigation and are intended to explain what happened, and why, in a fair and unbiased manner. Where the RAIB has described a factor as being linked to cause and the term is unqualified, this means that the RAIB has satisfied itself that the evidence supports both the presence of the factor and its direct relevance to the causation of the accident. However, where the RAIB is less confident about the existence of a factor, or its role in the causation of the accident, the RAIB will qualify its findings by use of the words ‘probable’ or ‘possible’, as appropriate. Where there is more than one potential explanation the RAIB may describe one factor as being ‘more’ or ‘less’ likely than the other. In some cases factors are described as ‘underlying’. Such factors are also relevant to the causation of the accident but are associated with the underlying management arrangements or organisational issues (such as working culture). Where necessary, the words ‘probable’ or ‘possible’ can also be used to qualify ‘underlying factor’. Use of the word ‘probable’ means that, although it is considered highly likely that the factor applied, some small element of uncertainty remains. Use of the word ‘possible’ means that, although there is some evidence that supports this factor, there remains a more significant degree of uncertainty. An ‘observation’ is a safety issue discovered as part of the investigation that is not considered to be causal or underlying to the event being investigated, but does deserve scrutiny because of a perceived potential for safety learning. The above terms are intended to assist readers’ interpretation of the report, and to provide suitable explanations where uncertainty remains. The report should therefore be interpreted as the view of the RAIB, expressed with the sole purpose of improving railway safety. The RAIB’s investigation (including its scope, methods, conclusions and recommendations) is independent of any inquest or fatal accident inquiry, and all other investigations, including those carried out by the safety authority, police or railway industry. Report 12/2017 September 2017 Bank This page is intentionally left blank Report 12/2017 4 September 2017 Bank Dangerous train door incident at Bank station on the Docklands Light Railway, 6 February 2017 Contents Preface 3 Summary 7 Introduction 8 Key definitions 8 The incident 9 Summary of the incident 9 Context 9 The sequence of events 12 Events preceding the incident 12 Events during the incident 12 Events following the incident 12 Key facts and analysis 14 Background information 14 Identification of the immediate cause 16 Identification of causal factors 16 Identification of the underlying factor 21 Previous occurrences of a similar character 22 Summary of conclusions 24 Immediate cause 24 Causal factors 24 Underlying factor 24 Previous RAIB recommendations relevant to this investigation 25 Actions reported that address factors which otherwise would have resulted in a RAIB recommendation 26 Recommendations and learning points 27 Recommendations 27 Learning points 28 Report 12/2017 5 September 2017 Bank Appendices 29 Appendix A - Glossary of abbreviations and acronyms 29 Appendix B - Glossary of terms 30 Appendix C - Investigation details 31 Report 12/2017 6 September 2017 Bank Summary Summary At around 21:30 hrs on 6 February 2017, at Bank Station on the Docklands Light Railway, part of a coat worn by a passenger on the platform became trapped in the closing door of a train. The passenger was unable to release the coat from the closed door, but managed to partially take off the coat before it was dragged from her as the train departed. The passenger was not injured, but was distressed by the incident. The incident occurred because the part of the coat which was trapped was too small to be detected by the obstacle detection system fitted to the train door. Additionally, the design of the door nosing rubbers meant that a relatively high pull force was required by the passenger to extract her coat. The member of Docklands Light Railway (DLR) staff on the train was unaware that the coat was trapped. His position when dispatching the train meant that he was dependent on a CCTV system to observe the doors during the dispatch, but defects in this CCTV system meant that the staff member was unable to observe the door of the train at which the incident occurred. As a result of this investigation, the RAIB has made three recommendations. One recommendation is made to Keolis Amey Docklands, in conjunction with Docklands Light Railway Limited, to review the design of door nosing rubbers with a view to reducing the forces needed to remove trapped objects. The second recommendation, made to Docklands Light Railway Limited, seeks that their specification for new trains to be procured gives adequate consideration to the safety learning from this investigation in relation to pull-out forces. The third recommendation is also made to Keolis Amey Docklands; this is to improve its processes for the management of platform observation equipment. The RAIB has also repeated a learning point for staff responsible for the dispatching of trains; that door obstacle detection systems are not always able to detect small objects and therefore it is vital that a final, visual, safety check is made to ensure that no object is trapped in a closed door prior to a train being allowed to depart from a station. Report 12/2017 7 September 2017 Bank Introduction Introduction Key definitions 1 Metric units are used in this report. 2 The report contains abbreviations and technical terms (shown in italics the first time they appear in the report). These are explained in appendices A and B. Sources of evidence used in the investigation are listed in appendix C. Report 12/2017 8 September 2017 Bank The incident Summary of the incident The incident 3 At around 21:30 hrs on Monday 6 February 2017, a passenger approached a Docklands Light Railway (DLR) train service standing at platform 9 at Bank station (figure 1). As she neared the leading train door (identified as door leaves B1 and B2), the door closed. Part of the passenger’s coat, the drawstring used to tighten the coat around her waist, became trapped between the leaves of the closed door. The passenger managed to partially take off her coat before the train moved away from the platform. The departing train dragged the coat from the passenger and into the tunnel beyond Bank station. 4 The passenger remained on the platform at Bank station. She was uninjured, but distressed by the incident. Her coat was subsequently recovered by railway staff from the tunnel, between Bank station and the next station at Shadwell. Docklands Light Railway © Copyright TfL Reg. User No. 16/E/3079/P Figure 1: TfL network map and extract showing location of the incident Context Location 5 Bank station is located in the City of London. The station is a large underground complex serving three London Underground lines in addition to the DLR (figure 1). Bank station is linked by underground passages to Monument station, which serves two further London Underground lines. Platforms 9 and 10 are used exclusively by DLR trains. 6 Bank station is the westernmost extremity of the DLR network. All DLR trains arriving at Bank terminate at platform 10. Passengers alight from an arriving train and the empty train then moves into a headshunt beyond the station. The train then reverses direction and is routed into platform 9 where passengers embark prior to the train departing towards the east. Report 12/2017 9 September 2017 Bank The incident Organisations involved 7 Keolis Amey Docklands (KAD) is responsible for the operation of the DLR. KAD employed the Passenger Service Agent (PSA) on the train involved. KAD is also responsible for most of the system maintenance, including all maintenance of the trains. 8 KAD operates the system under a franchise agreement with Docklands Light Railway Limited (DLRL). This franchise agreement commenced in December 2014.