Rail Accident Investigation Branch
Summary
At around 15:26 hrs on Wednesday 3 May 2023, a passenger train operated by Northern Trains Ltd departed from Styal station, Manchester, with five bodyside doors open.
The train involved was a three-car class 323 electric multiple unit. Immediately before the incident, the train had experienced technical difficulties which meant that the driver was unable to release the brakes and take power. As a result of this, Northern Trains Ltd control instructed the driver to isolate safety systems relating to the doors to allow the train to move. The safety isolations did not resolve the issue; however, after further checks, the train became able to move.
The train travelled for approximately 10 seconds with five doors open. Once the train reached 3.1 mph (5 km/h), a safety system caused the open doors to close automatically. No one was hurt in the incident, although people were moving towards the train and a passenger was standing in an open doorway when the train started to move.
The incident occurred because the engineering safeguards on the train to prevent the train from departing with the doors open had been bypassed to try and rectify a fault. The train departed without the driver receiving an indication that the dispatch process was complete and without confirmation that the doors were closed.
The investigation identified that the process used by Northern Trains Ltd for assessing trains before being released into service had permitted the train to be in service with an unidentified intermittent defect. Northern Trains Ltds processes for authorising the isolation of engineered safeguards on trains in service did not effectively control the risks created by such isolations. Also, Northern Train Ltds training did not provide the driver with the necessary skills for managing stressful situations.
Recommendations
RAIB has made three recommendations addressed to Northern Trains Ltd. The first seeks to improve the management of the risk of trains being in operational service with known intermittent faults. The second recommendation considers how the operational risk of trains being in service with safety systems isolated is managed. The third recommendation looks to provide operational staff with the skills and strategies to manage out-of-course incidents and stressful situations.
RAIB has also identified a learning point to remind train operators of the importance of complying with operating rules when isolating safety systems.
Notes to editors
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The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
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RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
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