Rail Accident Report Train dispatch accident at Elstree & Borehamwood station 7 September 2018 Report 03/2019 May 2019 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 2019 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.gov.uk/raib. Any enquiries about this publication should be sent to: RAIB Email: [email protected] The Wharf Telephone: 01332 253300 Stores Road Website: www.gov.uk/raib Derby UK 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 words such as ‘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, words such as ‘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. Information about casualties is based on figures provided to the RAIB from various sources. Considerations of personal privacy may mean that not all of the actual effects of the event are recorded in the report. The RAIB recognises that sudden unexpected events can have both short and long term consequences for the physical and/or mental health of people who were involved, both directly and indirectly, in what happened. 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 03/2019 May 2019 Elstree & Borehamwood This page is intentionally left blank Report 03/2019 4 May 2019 Elstree & Borehamwood Train dispatch accident at Elstree & Borehamwood station, 7 September 2018 Contents Preface 3 Summary 7 Introduction 8 Key definitions 8 The accident 9 Summary of the accident 9 Context 11 The sequence of events 14 Key facts and analysis 17 Background information 17 Identification of the immediate cause 20 Identification of causal factors 20 Identification of underlying factors 27 Observation 28 Previous occurrences of a similar character 28 Summary of conclusions 30 Immediate cause 30 Causal factors 30 Underlying factor 30 Additional observation 30 Previous RAIB recommendations relevant to this investigation 31 Actions reported as already taken or in progress relevant to this report 32 Recommendations and learning point 33 Recommendations 33 Learning point 34 Appendices 35 Appendix A - Glossary of abbreviations and acronyms 35 Appendix B - Investigation details 36 Report 03/2019 5 May 2019 Elstree & Borehamwood This page is intentionally left blank Report 03/2019 6 May 2019 Elstree & Borehamwood Summary Summary At around 14:03 hrs on 7 September 2018, a passenger and her dog were involved in a train dispatch accident at Elstree and Borehamwood station. The dog’s lead became trapped in the closed doors of a departing train, dragging the dog off the platform and leading to its death. The passenger was not injured but was very distressed. The accident happened because the train driver did not observe the passenger in close proximity to the train, both before he decided to close the train doors and before he decided it was safe to depart from the station. An on-train CCTV system is provided to allow the driver to monitor the side of the train and the adjacent platform edge during the dispatch process. The design of the door obstacle-detection system was such that a thin object, such as the dog’s lead, could not be detected. As a result, the train was able to depart with the dog’s lead trapped in the closed door. As a result of this investigation, the RAIB has made two recommendations. The first is made to Govia Thameslink Railway. It relates to the development of suitable guidance to drivers on the time needed to safely observe the platform-train interface before and after closing the train doors, and enhancing its driver management processes by routinely monitoring the safety of train dispatch. The second recommendation is made to the Rail Delivery Group, in consultation with RSSB and train operators. It relates to investigating technologies to better assist train dispatch staff to detect people or items which may become trapped in train doors. Report 03/2019 7 May 2019 Elstree & Borehamwood Introduction Introduction Key definitions 1 Metric units are used in this report, except when it is normal railway practice to give speeds and locations in imperial units. Where appropriate the equivalent metric value is also given. 2 The report contains abbreviations, explained in Appendix A. Sources of evidence used in the investigation are listed in Appendix B. Report 03/2019 8 May 2019 Elstree & Borehamwood The accident Summary of the accident The accident 3 At around 14:03 hrs on Friday 7 September 2018, a passenger and her dog were involved in a train dispatch accident at Elstree and Borehamwood station (figures 1 and 2). As the passenger was boarding the train, the doors closed trapping her dog’s lead, while the passenger and the dog were left standing on the platform. 4 The train then departed, dragging the dog off the platform and into the gap between the platform and train. The dog suffered fatal injuries. The passenger was not physically injured but was very distressed by the accident. In slightly different circumstances, the passenger herself could have become trapped by the long scarf she was wearing. Location of accident © Crown Copyright. All rights reserved. Department for Transport 100039241. RAIB 2019 Figure 1: Extract from Ordnance Survey map showing location of accident Report 03/2019 9 May 2019 Elstree & Borehamwood The accident Bedford St Albans City Elstree & Borehamwood Mill Hill Broadway West Hampstead Thameslink St Pancras Farringdon City Thameslink Blackfriars London Bridge Elephant & Castle River Thames Tulse Hill Wimbledon Sutton Figure 2: Location of Elstree and Borehamwood station in relation to London St Pancras and other railway locations referenced in this report. The Thameslink route is shown in purple, certain other railway routes are shown in green. Report 03/2019 10 May 2019 Elstree & Borehamwood Context Location 5 Elstree and Borehamwood station is located on the Midland Main Line that runs between London, Bedford, the East Midlands and Sheffield. The station is located The accident 12 miles and 770 yards (20 km) north of a datum located at London St Pancras station. The station has four platforms. Platforms 1 and 2 are used by all trains which are timetabled to stop at Elstree and Borehamwood. Platform 1 (figure 3) serves the up1 slow line, and platform 2 serves the down slow line. Platforms 3 and 4 serve the fast lines which are normally closed to the public by means of barriers; no trains are timetabled to stop at these platforms. The station building adjoining platform 1 provides access to the platforms and houses the ticket office. Figure 3: View looking north along platform 1 showing the location of the accident (red arrow) 6 All trains which call at Elstree and Borehamwood station are dispatched (paragraph 37) using Driver Only Operation (DOO)2. On class 700 trains (the type involved in this accident), the driver views the side of the train and the adjacent platform edge by means of an in-cab Closed Circuit Television (CCTV) system.