Report 13/2023: Serious injury to a passenger alighting from a train at Loughborough Central station
Serious injury to a passenger alighting from a train at Loughborough Central station, 14 January 2023.
Summary
At 11:50 hrs on Saturday 14 January 2023, a passenger alighting from a train at Great Central Railway鈥檚 Loughborough Central station lost his footing and sustained a serious injury. 皇冠体育app train had made a planned stop at platform 1. 皇冠体育app 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.
皇冠体育app 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 train鈥檚 doors, and the train鈥檚 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
皇冠体育app report makes three recommendations. 皇冠体育app 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. 皇冠体育app second recommendation, also addressed to Great Central Railway, relates to auditing and assurance of its risk management activities. 皇冠体育app 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. 皇冠体育app first is a reminder of the importance of having a robust system to manage staff training and competence records. 皇冠体育app second reminds duty holders of the importance of prompt accident reporting.
Response to recommendations:
- RAIB will periodically update the status of recommendations as reported to us by the relevant safety authority or public body
- RAIB may add comment, particularly if we have concerns regarding these responses.