Rail Accident Investigation Branch
Summary
At 11:50 hrs on Saturday 14 January 2023, a passenger alighting from a train at Great Central Railways Loughborough Central station lost his footing and sustained a serious injury. The train had made a planned stop at platform 1. The door used by the passenger opened onto the platform end ramp, approximately 1.6 metres beyond the end of the level part of the platform.
The passenger, who was visually impaired, lost his footing and fell while alighting from the train because he was unable to safely negotiate the step down onto the platform end ramp.
This was because the level platform was only around two metres longer than the distance needed to safely accommodate all of the trains doors, and the trains brakes were not performing in a consistent, predictable manner. Measures implemented by the railway had not effectively controlled the risk of passengers using doors which were not adjacent to usable platforms.
RAIB identified two underlying factors, that Great Central Railway did not have effective processes for learning lessons from operational experience, and had no effective process to support the identification, management and monitoring of risk.
Recommendations
The report makes three recommendations. The first is addressed to Great Central Railway and relates to the assessment and control of risk, learning from previous events, and ensuring that the needs of disabled passengers are considered. The second recommendation, also addressed to Great Central Railway, relates to auditing and assurance of its risk management activities. The third recommendation is made to the Heritage Railway Association and relates to the provision of guidance on managing the risks around the passenger / train interface at heritage railway stations.
RAIB has identified two learning points. The first is a reminder of the importance of having a robust system to manage staff training and competence records. The second reminds duty holders of the importance of prompt accident reporting.
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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