Discussion:
RAIB: ... and all for the want of a horseshoe nail
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Peter Able
2017-09-22 13:53:15 UTC
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Fascinating report on what could have been a deadly incident at Bank DLR.

An alignment fault on a CCTV camera was noted but, by the split of
responsibilities, the maintainer sent wasn't allowed to re-align the camera.

An intending passenger wedged himself into the door of a train. This caused
the doors to re-open.

None of this was seen by the driver as for unproven reasons he decided not
to follow normal departure procedure but relied on CCTV images alone to
judge departure.

A late-arriving passenger saw the doors opening to release the wedging and
thought that she had plenty of time to board - but quickly found that she
couldn't and backed off (and this is all at the CCTV-invisible door,
remember)

A draw-string on her coat happened to get caught in the door and she was
dragged forward with the departing train.

Fortunately she got one arm out of the coat and the train dragged the coat
off her.

Oh, and the door obstacle detection specification was that the system must
be able to detect a "test block" 30mm thick. Now how many coats,
draw-strings - or human hands - are at least 30mm thick under compression?

https://www.gov.uk/government/news/report-122017-dangerous-train-door-incident-at-bank-station



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Recliner
2017-09-22 13:59:13 UTC
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Post by Peter Able
Fascinating report on what could have been a deadly incident at Bank DLR.
An alignment fault on a CCTV camera was noted but, by the split of
responsibilities, the maintainer sent wasn't allowed to re-align the camera.
An intending passenger wedged himself into the door of a train. This caused
the doors to re-open.
None of this was seen by the driver as for unproven reasons he decided not
to follow normal departure procedure but relied on CCTV images alone to
judge departure.
A late-arriving passenger saw the doors opening to release the wedging and
thought that she had plenty of time to board - but quickly found that she
couldn't and backed off (and this is all at the CCTV-invisible door,
remember)
A draw-string on her coat happened to get caught in the door and she was
dragged forward with the departing train.
Fortunately she got one arm out of the coat and the train dragged the coat
off her.
Oh, and the door obstacle detection specification was that the system must
be able to detect a "test block" 30mm thick. Now how many coats,
draw-strings - or human hands - are at least 30mm thick under compression?
https://www.gov.uk/government/news/report-122017-dangerous-train-door-incident-at-bank-station
'Driver'?
Peter Able
2017-09-22 14:23:52 UTC
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Post by Recliner
Post by Peter Able
Fascinating report on what could have been a deadly incident at Bank DLR.
An alignment fault on a CCTV camera was noted but, by the split of
responsibilities, the maintainer sent wasn't allowed to re-align the camera.
An intending passenger wedged himself into the door of a train. This caused
the doors to re-open.
None of this was seen by the driver as for unproven reasons he decided not
to follow normal departure procedure but relied on CCTV images alone to
judge departure.
A late-arriving passenger saw the doors opening to release the wedging and
thought that she had plenty of time to board - but quickly found that she
couldn't and backed off (and this is all at the CCTV-invisible door,
remember)
A draw-string on her coat happened to get caught in the door and she was
dragged forward with the departing train.
Fortunately she got one arm out of the coat and the train dragged the coat
off her.
Oh, and the door obstacle detection specification was that the system must
be able to detect a "test block" 30mm thick. Now how many coats,
draw-strings - or human hands - are at least 30mm thick under
compression?
https://www.gov.uk/government/news/report-122017-dangerous-train-door-incident-at-bank-station
'Driver'?
No, she went by DLR.



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Recliner
2017-09-22 14:49:11 UTC
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Post by Peter Able
Post by Recliner
Post by Peter Able
Fascinating report on what could have been a deadly incident at Bank DLR.
An alignment fault on a CCTV camera was noted but, by the split of
responsibilities, the maintainer sent wasn't allowed to re-align the camera.
An intending passenger wedged himself into the door of a train. This caused
the doors to re-open.
None of this was seen by the driver as for unproven reasons he decided not
to follow normal departure procedure but relied on CCTV images alone to
judge departure.
A late-arriving passenger saw the doors opening to release the wedging and
thought that she had plenty of time to board - but quickly found that she
couldn't and backed off (and this is all at the CCTV-invisible door,
remember)
A draw-string on her coat happened to get caught in the door and she was
dragged forward with the departing train.
Fortunately she got one arm out of the coat and the train dragged the coat
off her.
Oh, and the door obstacle detection specification was that the system must
be able to detect a "test block" 30mm thick. Now how many coats,
draw-strings - or human hands - are at least 30mm thick under compression?
https://www.gov.uk/government/news/report-122017-dangerous-train-door-incident-at-bank-station
'Driver'?
No, she went by DLR.
So why the references to the 'driver'? In fact, the train was being driven
automatically, as it usually is.
Peter Able
2017-09-22 14:55:26 UTC
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Post by Recliner
Post by Peter Able
Post by Recliner
Post by Peter Able
Fascinating report on what could have been a deadly incident at Bank DLR.
An alignment fault on a CCTV camera was noted but, by the split of
responsibilities, the maintainer sent wasn't allowed to re-align the camera.
An intending passenger wedged himself into the door of a train. This caused
the doors to re-open.
None of this was seen by the driver as for unproven reasons he decided not
to follow normal departure procedure but relied on CCTV images alone to
judge departure.
A late-arriving passenger saw the doors opening to release the wedging and
thought that she had plenty of time to board - but quickly found that she
couldn't and backed off (and this is all at the CCTV-invisible door,
remember)
A draw-string on her coat happened to get caught in the door and she was
dragged forward with the departing train.
Fortunately she got one arm out of the coat and the train dragged the coat
off her.
Oh, and the door obstacle detection specification was that the system must
be able to detect a "test block" 30mm thick. Now how many coats,
draw-strings - or human hands - are at least 30mm thick under compression?
https://www.gov.uk/government/news/report-122017-dangerous-train-door-incident-at-bank-station
'Driver'?
No, she went by DLR.
So why the references to the 'driver'? In fact, the train was being driven
automatically, as it usually is.
WHOOSH!

PA
Recliner
2017-09-22 14:53:49 UTC
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Post by Recliner
Post by Peter Able
Fascinating report on what could have been a deadly incident at Bank DLR.
An alignment fault on a CCTV camera was noted but, by the split of
responsibilities, the maintainer sent wasn't allowed to re-align the camera.
An intending passenger wedged himself into the door of a train. This caused
the doors to re-open.
None of this was seen by the driver as for unproven reasons he decided not
to follow normal departure procedure but relied on CCTV images alone to
judge departure.
A late-arriving passenger saw the doors opening to release the wedging and
thought that she had plenty of time to board - but quickly found that she
couldn't and backed off (and this is all at the CCTV-invisible door,
remember)
A draw-string on her coat happened to get caught in the door and she was
dragged forward with the departing train.
Fortunately she got one arm out of the coat and the train dragged the coat
off her.
Oh, and the door obstacle detection specification was that the system must
be able to detect a "test block" 30mm thick. Now how many coats,
draw-strings - or human hands - are at least 30mm thick under compression?
https://www.gov.uk/government/news/report-122017-dangerous-train-door-incident-at-bank-station
'Driver'?
Indeed.
One solution could be for the doors to close to the point at which object
detection ceases, then pause, then close finally. The closure to a small gap
would provide a very, very strong warning, and no-one is going to try
to jump through that gap. The pause need only be a second or to: time to
withdrawn an object that is caught.
The force required to remove objects from power doors is considerable.
Actually, she didn't try to jump through the gap, but stopped just before
the doors. I guess her forward momentum meant that her coat's loose
drawstring swung forward, and got caught in the doors just as they closed.
It was soft enough to be squashed, and wasn't detected.
Recliner
2017-09-22 14:49:29 UTC
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Post by Peter Able
Fascinating report on what could have been a deadly incident at Bank DLR.
An alignment fault on a CCTV camera was noted but, by the split of
responsibilities, the maintainer sent wasn't allowed to re-align the camera.
An intending passenger wedged himself into the door of a train. This caused
the doors to re-open.
None of this was seen by the driver as for unproven reasons he decided not
to follow normal departure procedure but relied on CCTV images alone to
judge departure.
A late-arriving passenger saw the doors opening to release the wedging and
thought that she had plenty of time to board - but quickly found that she
couldn't and backed off (and this is all at the CCTV-invisible door,
remember)
A draw-string on her coat happened to get caught in the door and she was
dragged forward with the departing train.
Fortunately she got one arm out of the coat and the train dragged the coat
off her.
Oh, and the door obstacle detection specification was that the system must
be able to detect a "test block" 30mm thick. Now how many coats,
draw-strings - or human hands - are at least 30mm thick under compression?
From the report:

46. Testing carried out by the RAIB demonstrated that the door system was
able to detect a rigid object signifcantly smaller than the 30 mm x 60 mm
standard test block. Provided that the object was rigid, the door system
was able to detect objects as small as 1 mm wide (such as a steel ruler).
47. However, the RAIB found that objects which were thin and flexible,
such as a coat drawstring or fabric, were deflected around the door nosing
rubbers (paragraph 64) and were not detected by the door system.

48. The PSA was unaware that an object had become trapped in the leading
door because he was operating the doors from the EDP and the CCTV monitor
he was relying on did not show the leading door.
Peter Able
2017-09-22 14:54:31 UTC
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Post by Recliner
Post by Peter Able
Fascinating report on what could have been a deadly incident at Bank DLR.
An alignment fault on a CCTV camera was noted but, by the split of
responsibilities, the maintainer sent wasn't allowed to re-align the camera.
An intending passenger wedged himself into the door of a train. This caused
the doors to re-open.
None of this was seen by the driver as for unproven reasons he decided not
to follow normal departure procedure but relied on CCTV images alone to
judge departure.
A late-arriving passenger saw the doors opening to release the wedging and
thought that she had plenty of time to board - but quickly found that she
couldn't and backed off (and this is all at the CCTV-invisible door,
remember)
A draw-string on her coat happened to get caught in the door and she was
dragged forward with the departing train.
Fortunately she got one arm out of the coat and the train dragged the coat
off her.
Oh, and the door obstacle detection specification was that the system must
be able to detect a "test block" 30mm thick. Now how many coats,
draw-strings - or human hands - are at least 30mm thick under
compression?
46. Testing carried out by the RAIB demonstrated that the door system was
able to detect a rigid object signifcantly smaller than the 30 mm x 60 mm
standard test block. Provided that the object was rigid, the door system
was able to detect objects as small as 1 mm wide (such as a steel ruler).
47. However, the RAIB found that objects which were thin and flexible,
such as a coat drawstring or fabric, were deflected around the door nosing
rubbers (paragraph 64) and were not detected by the door system.
48. The PSA was unaware that an object had become trapped in the leading
door because he was operating the doors from the EDP and the CCTV monitor
he was relying on did not show the leading door.
And?

PA
r***@cix.compulink.co.uk
2017-09-22 15:27:32 UTC
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In article
Post by Recliner
Post by Peter Able
Post by Recliner
'Driver'?
No, she went by DLR.
So why the references to the 'driver'? In fact, the train was being
driven automatically, as it usually is.
The report says "PSA", the official reference to the previously titled
"Train Captain".
--
Colin Rosenstiel
Recliner
2017-09-22 17:47:27 UTC
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Post by r***@cix.compulink.co.uk
In article
Post by Recliner
Post by Peter Able
Post by Recliner
'Driver'?
No, she went by DLR.
So why the references to the 'driver'? In fact, the train was being
driven automatically, as it usually is.
The report says "PSA", the official reference to the previously titled
"Train Captain".
They've been called PSAs for a long time now.
r***@cix.compulink.co.uk
2017-09-22 20:20:36 UTC
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Post by Recliner
Post by r***@cix.compulink.co.uk
In article
Post by Recliner
Post by Peter Able
Post by Recliner
'Driver'?
No, she went by DLR.
So why the references to the 'driver'? In fact, the train was being
driven automatically, as it usually is.
The report says "PSA", the official reference to the previously titled
"Train Captain".
They've been called PSAs for a long time now.
I think they always have but the term Train Captain was more for public
consumption.
--
Colin Rosenstiel
Offramp
2017-09-22 17:26:23 UTC
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It would have been SUPERB if she had been obliterated unto death. A lesson for all door jumpers.
Recliner
2017-09-22 17:47:08 UTC
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On Fri, 22 Sep 2017 10:26:23 -0700 (PDT), Offramp
Post by Offramp
It would have been SUPERB if she had been obliterated unto death. A lesson for all door jumpers.
Except that she didn't.
r***@cix.compulink.co.uk
2017-09-22 19:41:14 UTC
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Post by Offramp
It would have been SUPERB if she had been obliterated unto death. A
lesson for all door jumpers.
A bit tough on those who chose not to jump, though.
--
Colin Rosenstiel
Recliner
2017-09-22 19:50:09 UTC
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Post by r***@cix.compulink.co.uk
Post by Offramp
It would have been SUPERB if she had been obliterated unto death. A
lesson for all door jumpers.
A bit tough on those who chose not to jump, though.
In fact, she was entirely in the right: she didn't try and jump the closing
doors, and when her coat got caught and she couldn't free it, she had the
presence of mind to quickly pull it off rather than being pulled into the
tunnel by the departing train, just ahead (she was at the front door of the
train). She then told the PSA on the following train, and staff went and
retrieved her coat from the tunnel.
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