RAIB urges im­proved view­ing sys­tems af­ter ‘trap and drag’

Rail (UK) - - Network News -

The Rail Ac­ci­dent In­ves­ti­ga­tion Branch (RAIB) says Lon­don Un­der­ground must im­prove plat­form cam­era views, train door sys­tems, train­ing for train op­er­a­tors and the views of in-cab CCTV sys­tems, af­ter a woman suf­fered se­ri­ous in­juries when her bag was caught in the doors of a train at Not­ting Hill Gate sta­tion on Jan­uary 31.

In the in­ci­dent, the train’s op­er­a­tor (the Cen­tral Line train was op­er­at­ing un­der Au­to­matic Train Op­er­a­tion at the time) failed to no­tice that the pas­sen­ger’s bag was caught in a door and started the train. The pas­sen­ger was dragged for ap­prox­i­mately 75 me­tres along the sta­tion plat­form and 15 me­tres into the tun­nel.

An emer­gency alarm on the train was ac­ti­vated about ten sec­onds af­ter the train started mov­ing, and the driver ap­plied the emer­gency brake at about this time. The woman was treated in hospi­tal for about a month.

The in­ves­ti­ga­tion con­cluded that it was likely that the train op­er­a­tor did not per­ceive the pas­sen­ger be­cause of a se­ries of fac­tors as­so­ci­ated with his task, which caused him not to con­sciously process the avail­able in­for­ma­tion.

The view on the in-cab CCTV mon­i­tor also did not ad­e­quately as­sist him to de­tect that a pas­sen­ger was trapped in the doors, and he re­lied on other cues to de­part from the sta­tion rather than thor­oughly check­ing the mon­i­tor.

Al­though the train’s doors are de­signed to pre­vent the train’s trac­tion power when they de­tect an ob­struc­tion, the bag’s ma­te­rial was too thin to be de­tected on the train in­volved.

Mod­el­ling by RAIB showed that the view of the pas­sen­ger in­volved on the train’s CCTV mon­i­tor did not ad­e­quately as­sist the train op­er­a­tor to de­tect that her bag was trapped be­fore de­par­ture, but that the in­ci­dent could have been seen on the train’s mon­i­tor about four sec­onds af­ter de­par­ture.

At busy times, Not­ting Hill Gate Plat­form 4 is manned with staff as­sist­ing with train despatch, as it has a re­verse curve which pre­vents train op­er­a­tors see­ing the en­tire plat­form-train in­ter­face with­out mir­rors or mon­i­tors. How­ever, at the time of the ac­ci­dent, there were no staff on the plat­form.

As well as en­cour­ag­ing Lon­don Un­der­ground to im­ple­ment a rec­om­men­da­tion to re­view mea­sures that re­duce the risks of pas­sen­gers be­com­ing trapped in train doors (fol­low­ing a sim­i­lar in­ci­dent at Clapham South on March 12 2015), RAIB wants the com­pany to en­sure door sys­tems on fu­ture rolling stock can bet­ter de­tect small ob­jects.

And fol­low­ing con­cerns about inat­ten­tion by train op­er­a­tors on ATO trains, due to the na­ture of their task, RAIB wants LU to im­ple­ment task-re­lated strate­gies such as in­ter­spers­ing more reg­u­lar pe­ri­ods of man­ual driv­ing, ex­tra task-fo­cused vig­i­lance ac­tiv­i­ties, or pro­vid­ing alerts if an ATO start is at­tempted be­fore the sys­tem is ready.

The third rec­om­men­da­tion is to re­view the pre­sen­ta­tion of im­ages on plat­form mon­i­tors, in­clud­ing the num­ber and con­fig­u­ra­tion of im­ages dis­played to train op­er­a­tors.

And the fourth is to re­view its com­pe­tence man­age­ment pro­grammes for all train op­er­a­tors, to en­sure con­sis­tency of train­ing tech­niques for vis­ual scan­ning of plat­form mon­i­tors and aware­ness of the lim­i­ta­tions of door in­ter­lock sys­tems.

A fi­nal rec­om­men­da­tion is that LU should re­view in­for­ma­tion pro­vided to staff about Plat­form Emer­gency Stop Plungers (which were not used in this ac­ci­dent), and im­ple­ment mea­sures to pro­mote the de­vices’ ef­fec­tive use.

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