Rail Accident Report
Serious injury to a passenger alighting from a
train at Loughborough Central station
14 January 2023
Report 13/2023
October 2023
This investigation was carried out in accordance with:
• the Railway Safety Directive 2004/49/EC
• the Railways and Transport Safety Act 2003
• the Railways (Accident Investigation and Reporting) Regulations 2005.
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This report is published by the Rail Accident Investigation Branch, Department for Transport.
Preface
Preface
The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to
improve railway safety by preventing future railway accidents or by mitigating their
consequences. It is not the purpose of such an investigation to establish blame or
liability. Accordingly, it is inappropriate that RAIB reports should be used to assign
fault or blame, or determine liability, since neither the investigation nor the reporting
process has been undertaken for that purpose.
RAIB’s findings are based on its own evaluation of the evidence that was available at
the time of the investigation and are intended to explain what happened, and why, in a
fair and unbiased manner.
Where RAIB has described a factor as being linked to cause and the term is
unqualified, this means that RAIB has satisfied itself that the evidence supports both
the presence of the factor and its direct relevance to the causation of the accident or
incident that is being investigated. However, where RAIB is less confident about the
existence of a factor, or its role in the causation of the accident or incident, RAIB will
qualify its findings by use of words such as ‘probable’ or ‘possible’, as appropriate.
Where there is more than one potential explanation RAIB may describe one factor as
being ‘more’ or ‘less’ likely than the other.
In some cases factors are described as ‘underlying’. Such factors are also relevant
to the causation of the accident or incident but are associated with the underlying
management arrangements or organisational issues (such as working culture).
Where necessary, words such as ‘probable’ or ‘possible’ can also be used to qualify
‘underlying factor’.
Use of the word ‘probable’ means that, although it is considered highly likely that the
factor applied, some small element of uncertainty remains. Use of the word ‘possible’
means that, although there is some evidence that supports this factor, there remains a
more significant degree of uncertainty.
An ‘observation’ is a safety issue discovered as part of the investigation that is not
considered to be causal or underlying to the accident or incident being investigated,
but does deserve scrutiny because of a perceived potential for safety learning.
The above terms are intended to assist readers’ interpretation of the report, and to
provide suitable explanations where uncertainty remains. The report should therefore
be interpreted as the view of RAIB, expressed with the sole purpose of improving
railway safety.
Any information about casualties is based on figures provided to RAIB from various
sources. Considerations of personal privacy may mean that not all of the actual effects
of the event are recorded in the report. RAIB recognises that sudden unexpected
events can have both short- and long-term consequences for the physical and/ or
mental health of people who were involved, both directly and indirectly, in what
happened.
RAIB’s investigation (including its scope, methods, conclusions and recommendations)
is independent of any inquest or fatal accident inquiry, and all other investigations,
including those carried out by the safety authority, police or railway industry.
Report 13/2023 October 2023
Loughborough
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Report 13/2023 4 October 2023
Loughborough
Serious injury to a passenger alighting from
a train at Loughborough Central station,
14 January 2023
Contents
Preface3
Summary7
Introduction8
Definitions 8
The accident9
Summary of the accident 9
Context9
The sequence of events15
Events preceding the accident 15
Events during the accident 16
Events following the accident 17
Analysis18
Identification of the immediate cause 18
Identification of causal factors 18
Identification of underlying factors 28
Observations 30
The role of the regulator 30
Summary of conclusions 32
Immediate cause 32
Causal factors 32
Underlying factors 32
Actions reported as already taken or in progress relevant to this report 33
Actions reported that address factors which otherwise would have resulted
in an RAIB recommendation 33
Other reported actions 33
Background to RAIB’s recommendations 34
Recommendations and learning points35
Recommendations35
Learning points 36
Report 13/2023 5 October 2023
Loughborough
Appendices37
Appendix A - Glossary of abbreviations and acronyms 37
Appendix B - Investigation details 38
Appendix C – Urgent safety advice 39
Report 13/2023 6 October 2023
Loughborough
Summary
Summary
At 11:50 hrs on Saturday 14 January 2023, a passenger alighting from a train at
Great Central Railway’s 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 train’s doors, and the train’s 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.
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.
Report 13/2023 7 October 2023
Loughborough
Introduction
Introduction
Definitions
1 Metric units are used in this report, except when it is normal railway practice to
give speeds and locations in imperial units. Where appropriate the equivalent
metric value is also given.
2 The report contains abbreviations and acronyms, which are explained in appendix
A. Sources of evidence used in the investigation are listed in appendix B. Urgent
Safety Advice issued by RAIB during the investigation is contained in appendix C.
Report 13/2023 8 October 2023
Loughborough
The accident
The accident
Summary of the accident
3 At 11:50 hrs on Saturday 14 January 2023, a passenger alighting from a train
onto platform 1 at Loughborough Central station sustained a serious injury,
requiring admission to hospital.
4 The train involved had just arrived at Loughborough Central station on a return
journey from Leicester North station, where the passenger involved had boarded.
5 The door from which the passenger alighted was the leading door on the train and
was adjacent to the platform end ramp rather than the level part of the platform.
Location of accident
© Crown Copyright. All rights reserved. Department for Transport 100039241. RAIB 2023
Figure 1: Extract from Ordnance Survey map showing location of the accident at Loughborough.
Context
Location
6 The railway through Loughborough Central station can be traced back to the
1890s when the then Manchester, Sheffield & Lincolnshire Railway was extended
southwards from Sheffield to London. Loughborough Central station was opened
in 1899 and closed as a mainline station in 1969. Efforts to preserve it began
shortly afterwards. The operation of heritage trains by Great Central Railway
(GCR) started in 1974. The general layout of the station, platforms and tracks has
remained largely unchanged since Loughborough Central was closed in 1969
(figures 2 and 3).
7 GCR now operates public passenger trains on the railway which runs from
Loughborough Central southwards to a station at Leicester North, a journey of
8 miles (12.87 km). Intermediate stations are located at Quorn & Woodhouse and
Rothley (figure 4).
Report 13/2023 9 October 2023
Loughborough
The accident
N
Location of accident
Platform 1
Platform 2
Figure 2: Google Earth image showing Loughborough Central station.
Loco shed To Leicester North
Up loop
Route
of train
Platform 1 Up Main line
Platform 2
N
Down Main line
Loughborough North
Carriage sidings
signal box
Figure 3: Layout of the track around Loughborough Central station.
8 The north end of platform 1 at Loughborough Central was in generally good
condition with the coping stones at the platform edge made from a coarse
dressed stone. The area intended for use by passengers was level with no
identified trip hazards. The condition of the platform surface and the level of grip it
offered are not considered to be factors in this accident.
Organisations involved
9 GCR is a heritage railway. GCR owns Loughborough Central station, the
associated railway infrastructure and passenger coaches involved in the accident.
The locomotive involved and its tender are owned by the Loughborough Standard
Locomotives Group but are maintained by GCR.
10 GCR staff working on the train and at Loughborough Central station at the time of
the accident were all volunteers, although the railway also has paid employees.
11 GCR freely co-operated with the investigation.
Report 13/2023 10 October 2023
Loughborough
The accident
Loughborough Central
Quorn &
Woodhouse
Rothley
Leicester North
Figure 4: Route of the Great Central Railway.
Train involved
12 The train involved was the 11:05 hrs service from Leicester North station to
Loughborough Central station. It comprised a steam locomotive, number 78019,
built by British Railways in 1954 and 6 Mk11 coaches of different types (figure 7).
The rear three coaches (on departure from Leicester North) were unavailable
for general passenger use as they were being prepared for a dining service
later in the day. A Brake Second Open (BSO (D)) coach was the third coach
from the locomotive. This coach houses a parking brake which is operated by
the guard when the train is stationary. The locomotive was being driven with the
tender leading and was on the return leg of a journey which had started out from
Loughborough at 10:20 hrs.
13 GCR recorded 63 passengers on the train during the journey from Leicester North
to Loughborough Central.
1
Mk1 coaches were constructed in the 1960s and 70s. They share certain construction characteristics and have
slam type doors.
Report 13/2023 11 October 2023
Loughborough
14 The passenger coach involved was a Mk1 Tourist Second Open (TSO), number
The accident
4857. It has a central aisle with eight groups of four seats around tables on either
side of the aisle. A pair of toilets are located at one end of the coach. Access and
egress is available by three pairs of external doors, with one pair of doors at each
end of the coach and one pair in the middle (figure 5). The doors are hinged so
they open outwards and incorporate a ‘droplight’ window. Droplight windows have
a simple vertical sliding windowpane which is opened by pulling down a horizontal
lip attached to the top edge of the pane. To open a door, passengers inside the
train have to open the droplight and reach outside to operate the external door
handle. There is no internal door handle. The doors are not locked centrally using
a central door locking system and individual doors are not locked by train crew in
normal service unless there is an out-of‑course incident (such as a fault) or the
coach is not in service. Passengers and staff can move between coaches using
interconnecting gangways. In common with all other coaches on the train, coach
4857 was not fitted with a public address system.
Centre doors ‘Toilet end’ doors
Direction of travel
Accident door
Figure 5: Layout of a Mk1 Tourist Second Open (TSO) coach.
15 The locomotive and tender are fitted with steam brakes while the rest of the train
uses vacuum operated brakes with the coaches and locomotive being connected
via the automatic vacuum train pipe. The brakes on the whole train are operated
by the driver using a single valve in the locomotive cab (see paragraph 60).
16 Following an overhaul, the locomotive had recently (November 2022) returned
to service. It was subject to GCR’s maintenance and inspection regime, with its
last examination, including the braking system, completed in December 2022. No
defects relevant to the accident were found at that time.
17 The passenger coaches involved were subject to GCR’s maintenance and
inspection regime which required inspections every three months. A dedicated
coach door examination was completed on coach 4857 in December 2022. This
included checks on the general condition of the doors as well as specific checks
on the operation of the handles and locks. No issues requiring attention were
recorded and, when the door involved was inspected by RAIB after the accident,
no defects were identified. The coach floor and stepping board at the door
involved were in good condition.
Report 13/2023 12 October 2023
Loughborough
The passenger involved
The accident
18 The passenger, Mr Alan Smith, was 76-years old and was visiting GCR with his
partner. The passenger was around 6 feet tall and witness evidence described
him as being an agile and independent person, although he was visually impaired
as a result of congenital cataracts.2
19 The passenger’s left leg was reported to be around half an inch (13 mm) shorter
than the right as a result of a previous operation to replace his left hip joint. This
length difference was managed with an insert in his left shoe and had no known
effect on his mobility. Witness evidence describes the passenger as having good
balance and being able to walk quickly with long strides. The passenger was
wearing lace‑up shoes with a non-slip sole at the time of the accident.
20 The passenger was described as an active man who would confidently travel on
public transport in all its forms. This included regularly using mainline trains alone
and without assistance. He used a ‘symbol’ cane if travelling alone, to indicate to
others that he was visually impaired and may require additional time and space
when moving around. Like many visually impaired people, he did occasionally
also use a cane to find and avoid obstacles (known as a ‘guide cane’ or ‘long
cane’) when navigating complex transport hubs. He was not carrying a cane on
the day of the accident.
21 RAIB has seen no evidence that the passenger was influenced by the presence
or actions of other passengers, and he had not consumed alcohol that day. RAIB
found no evidence of factors that might have influenced the passenger’s cognitive
function or decision‑making.
Staff involved
22 A driver, a fireman and a cleaner3 were on the footplate of the locomotive.
The driver had been a volunteer at GCR since 1989 and began working on
the footplate in 1993, qualifying as a fireman in 1995 and as a driver in 2007.
They had driven locomotive 78019 many times as well as many other types of
locomotive. Outside volunteering at GCR, the driver of the locomotive had a
professional background as a railway rolling stock engineer.
23 GCR assesses driver competency annually, alternating between a practical
assessment and Rule Book knowledge test. The driver was in date for both
assessments. While drivers are responsible for identifying a suitable stopping
point for the train and controlling the locomotive to achieve that, they have no
specific responsibilities for monitoring passengers getting on or off trains.
24 The fireman had been a volunteer at GCR since 2012, initially as a cleaner before
training as a fireman after 18 months. Firemen are also required to undertake a
practical and Rule Book assessment on alternating years, and the fireman was in
date for both. The role of a fireman is primarily related to the safe management of
the locomotive’s boiler. Staff working in the role of fireman have no responsibility
for identifying the correct stopping position of the train or the management of
passengers.
2
Cataracts occur when the lens inside an eye develops cloudy patches. These patches can expand causing blurry,
misty vision and eventually blindness.
3
Cleaners are responsible for assisting in general duties around trains and in depots. Cleaner is usually the first
role undertaken by someone working on locomotives, often as the first step in the progression to the roles of
fireman and then driver.
Report 13/2023 13 October 2023
Loughborough
25 The cleaner was an inexperienced volunteer who had been volunteering at
The accident
GCR for about nine months at the time of the accident. The role of cleaner is not
considered a safety-critical role, so GCR do not require formal assessment of
competence.
26 A guard and a trainee guard were in the BSO (D) coach. The guard was
experienced in the role, having volunteered at GCR for 20 years. They were
accredited to work at GCR in the role of guard, guards’ inspector and duty
traffic manager. As a guards’ inspector, they were responsible for assessing the
competence of other guards. Their annual rules assessment was out of date (see
paragraph 110). Despite being beyond the 12-month period in which they should
have been assessed, there is no evidence to indicate the guard was not aware
of, nor complying with, the requirements of their role. The conduct of the guard is
not causal to this accident because they were not in a position to intervene in the
accident, nor were they required to be. The trainee guard was working under the
direction of the guard.
27 Also working on the train was a travelling ticket inspector (TTI) who had no
specific safety-related responsibilities on this train. Six catering staff were
also on the train, either working in the buffet coach (number 1962, figure 7) or
preparing the train for the later dining service. These catering staff had no safety
responsibilities and played no part in the accident.
28 On platform 1 at Loughborough Central station when the train arrived were three
other staff, a platform inspector, the station master and the duty traffic manager.
These staff were all located on the southern half of the platform, with the platform
inspector walking north alongside the train as it slowed to a halt. The GCR Rule
Book requires staff on the platform to provide a warning to any passengers that
they identify as trying to leave trains via doors that are not in the platform. It also
requires platform staff to be in a position to help passengers who seek assistance.
External circumstances
29 At the time of the accident, it was daylight with good visibility in the area around
the platform. The weather at Loughborough was dull and wet with continuous rain
before and during the accident. There was no significant wind, and a minimum
temperature of 6°C was recorded during the day at East Midlands Airport (7 miles
(11.3 km) away), meaning there was no ice or frost present. There was no
significant ambient noise at the station although there would have been some
background noise from the locomotive as the train was in the platform. RAIB has
concluded that external influences did not affect the accident.
Report 13/2023 14 October 2023
Loughborough
The sequence of events
The sequence of events
Events preceding the accident
30 The train was prepared for service by GCR volunteers, including the driver,
fireman, cleaner and a fitter from around 06:00 hrs on the day of the accident.
Train preparation included ‘fitness to run’ inspections.
31 The fitness to run inspections included a check of the integrity of the locomotive
steam brake system, which was successfully undertaken. The driver then
conducted a vacuum brake system leak test. While creating the vacuum in the
system, the driver observed that the needle on the vacuum gauge did not move
as smoothly as they expected when increasing the level of vacuum. Despite this,
the locomotive passed the checks and was deemed fit to enter service. As the
locomotive was being moved from the engine shed to platform 1 at Loughborough
Central station, the driver performed a running brake test during which the
locomotive’s brakes performed in line with expectations.
32 The locomotive was then coupled to the coaches at Loughborough Central station
and final checks on the integrity of the train’s brake systems were conducted. At
10:21 hrs, the train left the station, one minute later than its planned departure. It
arrived at Leicester North station at 10:53 hrs, three minutes later than planned.
The delay was attributed to temporary speed restrictions (TSRs) along the route
connected to engineering works at two bridges.
33 As the train arrived at Leicester North, the driver observed that the brake was
slow to release, and they had to apply power to overcome it. On arrival, the
driver satisfied themselves that the braking system was making and maintaining
sufficient vacuum and then ran the locomotive around the train for the return
journey.
34 During the stop at Leicester North, the passenger involved in the accident
boarded the train with his partner. They entered coach 4857. This coach was
at the northern end of the train. It was therefore directly behind the locomotive
during the return journey to Loughborough. They entered the trailing end of the
coach and walked the length of the coach taking seats at the leading end (nearest
to the locomotive, figure 7).
35 Once the locomotive had been coupled up for the return journey, the driver
examined the locomotive for any signs of overheated brake blocks which would
indicate a dragging brake.4 The brake blocks showed no signs of overheating. At
11:15 hrs the train set off on the return journey, 10 minutes later than timetabled.
36 Another individual, who also boarded the train at Leicester, joined the passenger
and his partner at their table and travelled to Loughborough. This individual is
referred to in the remainder of the report as the ‘second passenger’.
4
A dragging brake is the term used to describe a brake that remains applied (perhaps partially) after the command
for braking is removed.
Report 13/2023 15 October 2023
Loughborough
37 On two occasions during the return journey, the driver experienced the brakes
The sequence of events
being slow to release. On the first of these, while slowing for a TSR between
Quorn and Loughborough (figure 4), they had to apply power to overcome the
additional unwanted braking effort. The second occasion was on the approach
to Loughborough Central station. This time no additional power was needed to
overcome unwanted braking.
Events during the accident
38 Closed-circuit television (CCTV) at Loughborough Central station shows that the
train entered platform 1 at 11:48 hrs, 14 minutes later than timetabled.5 The driver
of the locomotive was anticipating that the train’s brakes would be slow to release
as they had been earlier, so adjusted their driving accordingly. However, on this
occasion the issue with the brakes did not manifest itself, so the train travelled
further along the platform than the driver had intended. When the train came to a
stop, the leading edge of the leading door of the first coach (4857) was adjacent
to the platform end ramp and beyond the end of the platform by approximately
1.6 metres (figure 10). The driver was aware that the train had gone beyond the
intended stopping position and that the leading door of coach 4857 was likely
to be beyond the platform. However, they could not safely reposition the train
because passengers would have started to alight from the passenger coaches.
39 The guard and trainee guard were in the BSO (D) coach in accordance with
paragraph 4.4 of section H of the Rule Book, as their duties required them to
apply the hand brake once the train had stopped. The TTI, who was not required
to be in any specific location at stations, was in another coach. Although the
platform inspector, station master and duty traffic manager were on platform 1
when the train arrived (paragraph 28) there was no GCR Rule Book requirement
or briefing tasking them with being at the platform ends to manage the risk of a
train unintentionally stopping with a passenger door situated off the platform.
40 The platform inspector recognised that the train had stopped further along the
platform than it would have normally. Their assessment was that the leading door
of coach 4857 was just beyond the level part of the platform. However, they saw
passengers at the middle door of coach 4857, which was much closer to the
platform inspector’s position, and went to that door to assist them. At that time,
the platform inspector had not seen any passengers waiting to board or alight at
the leading door of coach 4857.
41 The passenger and his partner planned to get off the train at Loughborough
Central. Witness evidence indicates that on arrival, the passenger went to the
leading end of coach 4857 and opened the door. The passenger then stepped
down onto the platform ramp, placing one foot after the other.
5
Although there is CCTV at Loughborough Central station, the camera covering the accident location had droplets
of rain on the lens which obscured the view of the platform end ramp where the accident occurred.
Report 13/2023 16 October 2023
Loughborough
42 On stepping down from the coach, the passenger lost his footing and crumpled
The sequence of events
to the ground. This left him lying on the platform ramp adjacent to the door
(figure 6). His partner stepped down from the coach around him and went to help
him. Shortly after this, the second passenger also lost their footing exiting from
this door. Witness evidence about where the second passenger landed differs,
with one account suggesting that they landed on the first passenger. The second
passenger was not injured and was able to get up unaided.
Events following the accident
43 GCR staff and visitors, including an off-duty doctor, went to the passenger’s
assistance and an ambulance was called, which took him to hospital. In hospital it
was identified that the passenger had sustained a spiral fracture to the left femur
and he underwent surgery which included replacement of a prosthetic hip joint.
44 The locomotive remained in service. The issue with the brakes was formally
reported by the driver and shared with a second driver who was rostered to take
over the train later that day. This second driver also reported the braking issue
and a subsequent examination of the locomotive identified the likely defect that
had caused the variation in brake performance (see paragraph 59).
45 Three days later, having been made aware of the severity of the injury to the
passenger, GCR appointed two staff to undertake an internal investigation.
On 22 January, GCR undertook a reconstruction of the position of the train to
allow some measurements of the platform-train interface (PTI) to be taken.
Subsequently, GCR reported the accident to the safety authority for railways in
Great Britain, the Office of Rail and Road (ORR). Although this accident should
have been notified to RAIB,6 GCR did not notify RAIB that it had occurred. RAIB
was subsequently informed of the accident by ORR as part of the normal liaison
arrangements between the two organisations.7
46 A further reconstruction was undertaken on 30 January at which both ORR and
RAIB were present.
6
Regulation 4 and Schedule 2(2) of The Railways (Accident Investigation and Reporting) Regulations 2005 (as
amended) require accidents connected to the operation of trains which result in serious injuries to one person to be
notified to RAIB within three working days.
7
https://www.gov.uk/government/publications/mou-between-raib-btp-and-orr.
Report 13/2023 17 October 2023
Loughborough
Analysis
Analysis
Identification of the immediate cause
47 The passenger 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.
48 Witness evidence indicates that the passenger, having opened the leading
end door of coach 4857, commented to his partner that there was a
larger- than- normal vertical distance between the stepping board and the platform.
For this reason, he decided to alight first to help his partner from the train. The
passenger then stepped down deliberately, one foot after the other, but lost his
footing and crumpled to the ground. Shortly after this, the second passenger
also stepped down from leading door of coach 4857 and lost their footing
(paragraph 41).
Identification of causal factors
49 The accident occurred due to a combination of the following causal factors:
a. The train stopped with the leading door of coach 4857 adjacent to the platform
end ramp (paragraph 50).
b. The passenger was unable to safely alight from the train due to the
nature of the stepping distance between the door and platform end ramp
(paragraph 67).
c. Control measures put in place by GCR had not effectively controlled the risk
of a person alighting from a door which was not adjacent to a usable platform
(paragraph 86).
Each of these factors is now considered in turn.
The stopping position of the train
50 The train stopped with the leading door of coach 4857 adjacent to the
platform end ramp.
51 Witness accounts, corroborated by photographs taken after the accident, show
that the train stopped with the front edge of the leading door on coach 4857
approximately 1.6 metres beyond the end of the level part of the platform.
52 To help drivers stop the train in the correct place, GCR had placed a marker
between the platform line and a siding adjacent to the north end of the platform
which runs parallel to it. This marker was intended to help drivers judge the
position of the leading coach so they could stop with all passenger doors correctly
platformed. The marker was positioned to align with the leading end of the
coaches rather than the locomotive cab because a variety of different locomotives
are used on the railway, each with different cab positions relative to the coaches.
The driver of the train at the time of the accident reported that they found no
difficulty with identifying the marker and judging the train’s position relative to it.
Report 13/2023 18 October 2023
Loughborough
53 This causal factor arose due to a combination of the following:
Analysis
a. The usable length of the platform was only around 2 metres longer than
the distance between the end doors of the train formation, leaving a small
tolerance for the stopping position of trains (paragraph 54).
b. An intermittent variation of brake performance made accurately stopping the
train difficult (paragraph 59).
Each of these sub-factors is now considered in turn.
Useable platform length
54 The usable length of the platform was only around 2 metres longer than
the distance between the end doors of the train formation, leaving a small
tolerance for the stopping position of trains.
55 Loughborough Central station has two platforms, numbers 1 and 2, located
between the Up and Down Main lines (a configuration referred to as an ‘island
platform’ (figure 3)). Platform 1 runs along the east side of the station. The
horizontal length of each platform, between the ramps at each end, is 122 metres.
56 At the north end of the island, a ramp is provided which slopes from platform
height to ground level. This ramp runs across the whole width of the platform
island. Visitors can use a path down the middle of the ramp to access a walkway
that leads to the Locomotive Shed and a picnic area. The level part of the platform
is marked out by white lines painted on the platform edge. At each end, where the
platform end ramp starts, there is a short white line perpendicular to the platform
edge (figures 6 and 11).
Accident
door
Figure 6: The north end platform ramp.
Report 13/2023 19 October 2023
Loughborough
57 The train involved was formed of a locomotive, tender and six coaches
Analysis
(paragraph 12 and figure 7). The distance between the rear edge of the trailing
end door of the trailing coach and the front edge of the leading door of the leading
coach was 119.9 metres. This means that platform 1 was just over 2 metres
longer than the distance between the extreme end doors of the train involved.
If the train had stopped centrally along the available level platform length, then
there would have been just over 1 metre of level platform beyond each door at
both ends (figure 8).
Direction of travel
Locomotive TSO 4857 RBR 1962 BSO (D) 9316 FO 3072 RK 1525 FO 3079
Coaches locked out of use
Figure 7: Formation of the train involved in the accident. Refer to Appendix A for vehicle type definitions.
58 Coach 4857 had a pair of toilets at one end with the vestibule inboard of them
(paragraph 14, figure 5). Consequently, the passenger doors at that end are
around 1.36 metres further inboard than the leading end doors. When the train
travelled north from Leicester North station, the toilets were at the trailing end
of coach 4857. If the coach had been orientated with the ‘toilet end’ leading, the
external door at that end would have been adjacent to the start of the platform
end ramp.
Actual stopping position of train in platform 1
Locomotive TSO 4857 RBR 1962 BSO (D) 9316
Ramp
Accident door stopped over ramp
Position of doors in coach TSO 4857 if orientation reversed
‘Toilet end’ door partially accomodated on platform
Figure 8: Stopping positions of the train involved in the accident.
Report 13/2023 20 October 2023
Loughborough
Locomotive brake defect
Analysis
59 An intermittent variation of brake performance made accurately stopping
the train difficult.
60 The locomotive and tender use pressurised steam generated by the steam boiler
to provide the braking force. Braking effort is transmitted to the wheels via a
steam brake cylinder connected to brake blocks through a series of linkages.
A manual parking brake is also provided, used only when the locomotive is
stationary.
61 A partial vacuum created by the locomotive is used in a vacuum brake system
fitted to the passenger coaches. The difference in pressure between the vacuum
brake pipe and atmospheric pressure determines the level of braking force
demanded along the train. The brake force on each coach is generated by the
pressure differential between the vacuum brake pipe and the stored vacuum
within each brake cylinder, which acts on a piston. A further manual parking brake
is provided on the BSO (D) coach, used by the guard when the train is stationary
(paragraph 12).
62 When coupled to passenger coaches, drivers use the vacuum brake control to
apply the brakes. A ‘combining valve’ provides simultaneous operation of the
steam brake (on the locomotive and tender) and the vacuum brakes (on the
coaches). This arrangement simplifies the controls used by the driver.
63 The locomotive was declared fit to run in passenger service after checks and a
functional brake test (paragraphs 30 and 31). During the journey to Leicester,
the driver noticed that the brakes were ‘dragging’ and despite inspecting the
train at Leicester, was unable to determine the cause (paragraph 35). The
GCR Rule Book does not require that the train be taken out of service in such
circumstances, and the driver was free to use their professional judgement as
to whether to continue using the train. The driver viewed the issue as one of
irregular performance rather than as a safety risk.
64 On the return journey to Loughborough the braking issue became apparent twice
more (paragraph 37). On arriving at Loughborough, the driver anticipated that
the fault would again affect the train, so adapted their driving to suit. However,
witness evidence is that at this point the brakes performed normally meaning
that the train came to a halt a little beyond the point that the driver intended
(paragraph 38).
65 The driver reported the braking issue to a second driver, who was taking over the
train for the remainder of the day, and a locomotive defect card was submitted,
detailing the brake issue along with three minor unrelated issues. Subsequently,
the train was examined and a spindle in the locomotive brake combining valve
was found to be sticking. This caused the locomotive steam brakes to remain
applied after the driver had stopped demanding braking. RAIB considers this to
be the likely cause of the variation in brake performance experienced on the day
of the accident.
66 The spindle was later machined to reduce its diameter and GCR reported that this
resolved the sticking issue.
Report 13/2023 21 October 2023
Loughborough
The platform-train interface
Analysis
67 The passenger was unable to safely alight from the train due to the nature
of the stepping distance between the door and platform end ramp.
68 Witness evidence indicates that the passenger stepped out of the leading door
of coach 4857 in a deliberate and considered way but that he lost his footing
and fell while doing so (paragraph 48). The available evidence indicates that,
although the passenger appreciated that there was a significant vertical stepping
height present, he had probably not realised that the door was adjacent to the
platform end ramp instead of the platform itself. The increased stepping height
and the slope presented by the ramp would have created a challenging surface
on which to step and RAIB considers that it is almost certainly the reason why the
passenger lost his footing. This is supported by the second passenger also losing
their footing on exiting the leading door and falling onto the ramp.
69 This causal factor arose due to a combination of the following:
a. There was a larger-than-normal vertical stepping height present when
stepping from the coach’s foot step to the platform, which increased the
likelihood of a loss of footing by the passenger (paragraph 70).
b. The passenger was stepping onto a sloping surface that he was probably
unaware of, further increasing the likelihood of him losing his footing
(paragraph 78).
Each of these sub-factors is now considered in turn.
Vertical stepping height
70 There was a larger-than-normal vertical stepping height present when
stepping from the coach’s foot step to the platform, which increased the
likelihood of a loss of footing by the passenger.
71 The platform at Loughborough Central was built in the 1890s (paragraph 6).
An engineering drawing from 1895 shows a designed platform height of 3 feet
(914.4 mm) above rail level (ARL). RAIB has not been able to determine if it was
originally constructed to that design, but records held by GCR show that in 1956
(while still a part of the national network) the track bed at the north end of platform
1 was found to be 6 inches (152 mm) ‘too high’. In July 2015 GCR measured the
track bed as 7.75 inches (197 mm) ‘too high’ at the north end.
72 RAIB has not been able to determine how or when the track bed became higher
than the design, but it may have been a result of periodic re-laying of the track
and the addition of ballast over many years.
73 A consequence of the elevated track bed was an increased vertical stepping
height for passengers. For example, on the coach involved in the accident,
correctly platformed doors at the north end of platform 1 were approximately
430 mm (17 inches) vertically above the platform. GCR was managing this
stepping height by providing wooden stepping boxes (figure 9). Such stepping
boxes are carried on passenger coaches and provided at platforms for use by
on- train or platform staff if required.
Report 13/2023 22 October 2023
Loughborough
Analysis
430 mm
Figure 9: A stepping box and standard stepping height.
74 Stepping distances (which consist of a vertical stepping height, a horizontal
stepping gap and a resultant diagonal stepping dimension) have been managed
on railways by various standards over time. Providing a consistent stepping
distance for passengers across a network requires a standardised platform
height. At modern mainline stations, this is 915 mm ARL8 which is consistent
with the original design height at Loughborough of 3 feet (914.4 mm). Current
guidance within Railway Group Standards9 for mainline trains is that, when at a
compliant platform, operators should aim to have a vertical stepping height that is
no more than 230 mm. It should be noted that not all historic mainline platforms
and rolling stock comply with this standard nor are they required to.
75 Heritage operators may use guidance which is published and distributed by the
Heritage Railway Association (HRA). HRA is a trade body and produces guidance
on various topics to its members. The guidance (HGR-A0000-RSP5)10 describes
how ‘the floor or footboards of passenger rolling stock should be as close as
practicable to the platform. The vertical and horizontal distances between the
platform edge and the floor or footboards of the passenger rolling stock should
not exceed 250 mm and 275 mm respectively, or 350 mm on the diagonal’. While
the horizontal gap at Loughborough Central was within the range advised in
HGR-A0000-RSP5, the vertical stepping heights and diagonal stepping distances
were not.
8
Railway Group Standard GIRT7020, issue 2: June 2022, ‘GB Requirements for Platform Height, Platform Offset
and Platform Width’.
9
Railway Group Standard GMRT2173, issue 4, June 2022, ‘Size of Vehicles and Position of Equipment’.
10
HRA document HGR-A0000-RSP5, issue 1, February 2020, which is derived from a previous document written
by ORR.
Report 13/2023 23 October 2023
Loughborough
76 The stopping position of the train with the leading door of coach 4857 adjacent
Analysis
to the ramp meant that this normal stepping height of around 430 mm was
further increased across the width of the door to between 560 mm and 590 mm
(figure 10). While witness evidence indicates that the passenger had identified
the larger-than-normal vertical drop at Loughborough Central, and that he had
attempted to descend carefully, the increased distance nevertheless would
increase the chance of an accident exiting the train.
560 mm
590 mm
430 mm
Figure 10: Reconstruction photos showing standard platform stepping height (left) and the increased
stepping heights from the train at its stopped position (right).
77 Both the passenger and the second passenger boarded the train at Leicester
(paragraph 34) where the vertical stepping distance is much smaller (between
170 mm and 220 mm). GCR told RAIB that the platform at Leicester North was
constructed around 1990 and was compliant to mainline railway standards at
the time. RAIB has considered whether both passengers may have developed
an expectation of the platform height at Loughborough Central, based on their
experience at Leicester North. While this cannot be entirely discounted, witness
evidence is that the passenger had identified the presence of an increased
vertical stepping height (paragraph 41). Witness evidence also shows that the
second passenger knew about the platform height at Loughborough Central
having travelled widely on GCR for many years.
The passenger’s perception of the platform end ramp
78 The passenger was stepping onto a sloping surface, that he was probably
unaware of, further increasing the likelihood of him losing his footing.
79 In addition to the larger-than-normal vertical stepping height, the sloped surface
would make stepping out from the coach more challenging for passengers. In
particular, a passenger who steps out and who is unaware of the slope is more
likely to lose their footing. Although the details of witness accounts vary, it is clear
that the passenger in this case lost his footing as his feet made contact with the
sloped surface of the platform end ramp.
80 On 30 January 2023, GCR reconstructed the position of the train to assist the
understanding of the nature of the stepping distance between the train and
the platform. Photographs of the train taken post-accident showed that the
reconstructed position of the train was consistent with that on the day of the
accident.
Report 13/2023 24 October 2023
Loughborough
81 RAIB inspectors took a series of photographs to document the reconstruction.
Analysis
It was observed during the reconstruction that the slope along the platform end
ramp was not easy to distinguish. As such, it is likely that a visually impaired
person would not be able to distinguish the slope. Figure 11 shows the view of the
platform end ramp taken from the position of a person preparing to alight from the
leading door of coach 4857.
Level
Ramp
Figure 11: Photo of ramp viewed from coach doorway.
82 The passenger was registered as severely sight impaired or ‘blind’,11 as a result
of developing cataracts as an infant. He is described as having some central
vision in his left eye and some peripheral vision in his right eye. Every year he
had an annual check at a specialist eye hospital. Witness evidence, corroborated
by medical records, confirmed that his sight had not deteriorated significantly
throughout his adult life and there was no recent change in his vision before the
accident. Despite the challenges presented by his eyesight, the passenger would
use mainline railways alone and did not feel the need to seek assistance when
doing so. Although GCR has arrangements in place for passengers requiring
assistance, the passenger did not feel the need to arrange such assistance on the
day of the accident and was helped by his partner.
83 Witness evidence regarding the loss of footing by the second passenger
suggests that visually impaired passengers may also not perceive the potential
hazard created by the slope along the platform end ramp and consequently not
successfully negotiate it.
11
RNIB (the Royal National Institute of Blind People) is the UK’s leading sight loss charity. It advocates using the
term ‘blind’ for persons who are severely sight impaired.
Report 13/2023 25 October 2023
Loughborough
84 The white painted lines around the platform at Loughborough Central were in
Analysis
good condition (figures 6, 9, 10 and 11). Before the train left Leicester North
station, the passenger enquired of his partner whether the platform end ramp had
white painted markings on it. His partner was not able to see the ramp from their
seat but was able to see white lines marking the extent of the level platform which
they reported back to the passenger.
85 This suggests that the passenger may have understood the significance of
the white painted lines around platforms. However, it cannot be determined
conclusively if the passenger saw these white lines further along the platform
before leaving the train at Loughborough Central and, if so, if he appreciated that
their absence signified the end of the platform and the start of the ramp.
The management of passenger / train interface risk at Loughborough Central station
86 Control measures put in place by GCR had not effectively controlled the
risk of a person alighting from a door which was not adjacent to a usable
platform.
87 GCR had documented risk assessments for all of its station platforms. The risk
assessment for platform 1 at Loughborough Central station was completed in
August 2019. It considered issues associated with train dispatch, the nature of
the platform surface and risks arising from overcrowding and poor weather. It
recognised the larger-than-normal vertical stepping distance and how stepping
boxes would be available to mitigate the associated risks (paragraph 73).
88 GCR had recognised that when it ran seven or eight-coach trains they could not
be safely accommodated in platform 1 at Loughborough Central station (that is
to say with all the doors adjacent to the platform). GCR explained that on these
occasions staff would be briefed to ensure that passengers in affected coaches
were told not to use certain doors which might not be adjacent to the platform.
Guards would either speak12 to passengers themselves to convey this message
or would ask the TTI to assist in this task. Platform staff would also be positioned
to prevent passengers from trying to alight from these doors. This practice was
supported by a requirement in GCR’s Rule Book13 which required guards to warn
passengers on trains where not all the doors would be safely accommodated.
Although the risk assessment identified some additional control measures, there
was no defined means of ensuring they were followed up (see paragraph 103).
However, the train involved in the accident was formed of six coaches, so none of
these additional control measures were applied.
12
As the vehicles are not fitted with a public address system (paragraph 14) this would need to be conveyed
face- to-face.
13
Paragraph 5.5.1 of section H of GCR’s Rule Book GCR87109 December 2012.
Report 13/2023 26 October 2023
Loughborough
89 Steam locomotive drivers at GCR are judged against various criteria when being
Analysis
assessed. One of these criteria is the ability to accurately stop trains. GCR uses
a standard of stopping ‘within ten feet (3 metres) of an ideal position’. Drivers who
can achieve this consistently are considered to meet the required competence.
In terms of this criterion alone, the fact that the train involved had passed
approximately 1.6 metres (5 feet, 3 inches) beyond a safe position (with all doors
platformed) was within this standard. Even if the driver had intended to stop so
that the passenger coaches were positioned centrally along the platform (with
approximately 1 metre of level platform at each end) the final position was still
within 10 feet (3 metres) of that point. GCR reported that the ‘ten feet’ requirement
was a historic British Railways standard for vacuum braked trains. GCR and
other operators of vacuum braked trains hauled by steam locomotives consider it
reasonable and achievable by a competent driver.
90 Although the risk assessment for platform 1 at Loughborough Central
recognised that trains with more than six passenger coaches could not be
safely accommodated, it did not recognise that the allowable margin for error
when stopping a six-coach train was small (paragraph 57). This meant that the
risk assessment did not specifically recognise there was also a risk of a door
on a six- coach train not being safely accommodated or arrange for any control
measures to be put in place for such occurrences.
91 The risk assessment did refer to a control measure of ‘additional staff where
available provided to warn passengers at the north end of the platform’. This
control measure was described in the context of trains that are longer than six
coaches. Implementing this control measure required staff to be present to
recognise that the train had stopped in a position where doors were not adjacent
to the platform, and that people were about to use them. This control measure
was not intended to apply to the train involved in this accident. The nearest
member of staff to the leading door (the platform inspector) nevertheless realised
that the train had stopped further along the platform than it would normally do.
They were, however, engaged in attending to passengers at another door and
were also unaware that the leading door was about to be used (paragraph 39).
92 Although GCR had a policy of offering assistance to passengers who either
requested or appeared to need help, the risk assessment for platform 1 at
Loughborough Central also did not consider passengers (such as mobility or
visually impaired people) whose use of the railway exposed them to greater
levels of individual risk. As GCR has acknowledged, the nature of the railway (as
a heritage attraction) means that they have a greater proportion of families with
young children, and older people. GCR has also recognised that an increasing
number of visitors and passengers may have no prior experience of using slam
door stock (such as Mk1 coaches) and/or trains without centrally controlled doors
and/or stations without modern platforms.
93 The door concerned had a notice above it warning passengers of the danger of
leaning out of an open droplight window. This notice also required passengers
to ensure that the train was ‘in the platform and has come to a complete stand
before opening the door’. This notice was fitted in response to a passenger fatality
on the mainline in 2018 which involved a passenger who was fatally injured as a
result of having their head out of a window on a moving train.14
14
https://www.gov.uk/raib-reports/report-14-2019-fatal-accident-at-twerton.
Report 13/2023 27 October 2023
Loughborough
Identification of underlying factors
Analysis
Reaction to previous incidents
94 GCR did not have effective processes for learning lessons from operational
experience.
95 Schedule 1 of The Railways and Other Guided Transport Systems (Safety)
Regulations 2006 (ROGS) requires duty holders to have ‘procedures to ensure
that accidents, incidents, near misses and other dangerous occurrences are
reported, investigated and analysed and that necessary measures are taken’. At
the time of the accident, GCR had a policy on reporting accidents and incidents15
which had been approved (by the managing director) in February 2022. Its
stated intent was to ‘provide guidance to senior members of staff (“Investigating
Managers”) involved with the investigation of accidents and incidents and any
required regulatory reporting’.
96 The policy described the importance of reporting and investigating safety issues
to meet legal obligations and as part of the risk management process. RAIB
was supplied with recent examples of GCR reports where incidents had been
investigated and recommendations made to improve safety as a result. Although
the policy acknowledged the value of investigating ‘near misses’, it contained no
direction or guidance on how operational staff could, through their day-to-day
experience of working on the railway, contribute to the railway’s understanding of
risk by reporting minor incidents or ‘near misses’.
97 RAIB identified that the accident on 14 January 2023 was not an isolated
occasion where a coach door had not been safely accommodated at
Loughborough Central station. A very similar accident happened in 2014 when
an elderly, visually impaired passenger fell when they tried to alight from a coach
at a door that was adjacent to the platform end ramp at Loughborough Central.
This passenger was taken to hospital but was discharged after being examined.
This accident was notified to GCR staff at the time and an accident report was
completed, although RAIB found no evidence that it triggered a review of the
associated risk assessment or that any changes were made as a result of it.
98 Witness evidence indicates that, two weeks after the January 2023 accident, a
train again stopped so that the leading door of the leading coach was beyond
the level part of the platform and that passengers had alighted on to the platform
ramp. RAIB has seen social media reports suggesting that other visitors had
experienced similar incidents at Loughborough Central.
99 Evidence suggests there had been a considerable number of incidents of
passengers alighting from doors not adjacent to platforms on GCR. Had GCR
provided an effective means of ensuring that staff understood the importance
of vigilance towards identifying and reporting such ‘near misses’, then the
opportunity would have existed for GCR to identify these previous incidents,
revise risk assessments, and implement effective mitigation measures.
15
Policy document 62 – Accident / Incident Reporting and Investigation Procedures, issue 3 February 2022.
Report 13/2023 28 October 2023
Loughborough
Risk assessment and safety leadership
Analysis
100 GCR had no effective process to support the identification, management
and monitoring of risk.
101 Regulation 19 of ROGS requires that transport operators ‘make a suitable
and sufficient assessment of the risks to the safety of any persons for the
purpose of identifying the measures he needs to take to ensure safe operation
of the transport system’. Although an overarching policy within GCR’s safety
management system (SMS) described how risks should be assessed, GCR did
not have a documented process that described how this would be done. The
SMS referred to two policies, a risk assessment ‘Philosophy’ policy and a risk
management and risk assessment ‘Process’ policy. Although both documents
had reference numbers and were directly cited, RAIB found that the ‘Philosophy’
document did not actually exist and that the ‘Process’ document, although almost
complete, had not been approved or issued since it was written in 2014.
102 This meant that when risk assessments were prepared by GCR staff, the staff
doing this did not have access to any internal guidance that would support them.
There was no process or guidance on where to seek advice, or guidance on
areas such as what skills an assessor should have or how the assessment should
be approached. Some staff at GCR understood that HRA offered such guidance,
but GCR did not have formal arrangements for accessing this.
103 The risk assessment for platform 1 at Loughborough Central contained some
proposed mitigation actions for issues that had been identified. However, there
was no formal process to revise this risk assessment or to track the effectiveness
of control measures (paragraph 88). GCR explained that it relied on the individual
making the assessment to follow up, so was vulnerable to actions being
overlooked or forgotten.
104 GCR explained that at the time of the accident overall safety leadership was
undertaken at board level and there was no ‘Head of Safety’ post overseeing
safety. This meant that no one with an operational management role was
overseeing and co-ordinating the activities undertaken by the various departments
and ensuring that there was a co-ordinated approach to safety management.
105 The unissued policy on risk management and risk assessment contained
requirements for GCR to develop and maintain a risk register. GCR explained it
did have a record of organisational risks but there was no formal register of safety
risks for railway operations.
106 RAIB found that there was also no defined means of sharing or co-ordinating risk
assessment information between different departments within GCR. For example,
although the process for producing the risk assessment for the platforms at
Loughborough Central station had involved someone with driving competence,
there was no requirement for such assessments to involve staff from different
departments or for control measures to be briefed out more widely.
Report 13/2023 29 October 2023
Loughborough
107 Although a high-level requirement existed in the GCR SMS for the railway to audit
Analysis
and review its safety policies every two years, it had no effective policy or process
for doing so. This is likely to have been a consequence of the risk management
and assessment ‘Process’ policy not being adopted. This absence of a defined
risk assessment periodic review process meant the possible opportunities for
incorporating lessons from operational incidents (paragraph 94) may have been
lost.
108 The platform risk assessments at GCR did not consider the risk posed to
passengers with disabilities, such as mobility or sensory impairment
(paragraph 92). If it had done so, it may have recognised that the transition
between the level platform and the platform end ramp, while perhaps apparent to
most passengers would not be so for all.
Observations
Competence management
109 There was an error in correctly recording the competence of the train’s
guard.
110 GCR has a policy of requiring staff who undertake safety‑critical roles to undergo
periodic assessments. Guards are required to undertake an annual assessment,
alternating between their knowledge of the Rule Book and a practical
assessment. The guard on the train involved had not completed their annual Rule
Book assessment within the preceding year. However, the records held by GCR
incorrectly recorded the status of the individual’s assessment and showed that
they were in date. Consequently, GCR was unaware that the guard’s assessment
was overdue.
Notification of the accident to RAIB
111 RAIB was not directly notified of the accident by GCR.
112 Accidents involving serious injury to persons in circumstances such as this
accident are notifiable to RAIB within three days (paragraph 45). Although notified
to ORR, this accident was not reported directly to RAIB.
The role of the regulator
113 ROGS came into force in 2006, providing the current regulatory regime for rail
safety, including heritage railways. Under ROGS, mainline operators are not
permitted to operate vehicles unless they have obtained safety certification
from the national safety authority, which is ORR for most railways in the United
Kingdom. Applicants need to show how their safety management system allows
them to run their transport system safely.
Report 13/2023 30 October 2023
Loughborough
114 Lower risk sectors such as heritage railways that do not run at speeds above
Analysis
25 mph (40 km/h) do not need a safety certificate but must still have a written
safety management system in place, which sets out the method by which they
manage risks. During August 2023, ORR published guidance16 for heritage
railways to help them interpret and apply the specific requirements of ROGS in a
proportionate way.
115 There is no requirement for ORR to review a heritage railway’s SMS. ORR
undertakes a programme of proactive inspections of heritage railway duty holders
and will also undertake inspections in response to accidents or serious complaints
against the railway. ORR also held a series of workshops between 2021 and 2023
for heritage railways on assessing the maturity of dutyholder’s SMS.
16
https://www.orr.gov.uk/sites/default/files/2023-08/sms-guidance-guidance-for-minor-and-heritage-railways-v1.pdf.
Report 13/2023 31 October 2023
Loughborough
Summary of conclusions
Summary of conclusions
Immediate cause
116 The passenger 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
(paragraph 47).
Causal factors
117 The causal factors were:
a. The train stopped with the leading door of coach 4857 adjacent to the platform
end ramp (paragraph 50, Recommendations 1 and 2). This causal factor
arose due to a combination of the following:
i. The usable length of the platform was only around two metres longer
than the distance between the end doors of the train formation, leaving
a small tolerance on the stopping position of trains (paragraph 54,
Recommendation 1).
ii. An intermittent variation of brake performance made accurately stopping
the train difficult (paragraph 59, Recommendation 1).
b. The passenger was unable to safely alight from the train due to the nature of
the stepping distance between the door and platform end ramp (paragraph 67,
Recommendations 1 and 3). This causal factor arose due to a combination
of the following:
i. There was a larger-than-normal vertical stepping height present when
stepping from the coach’s footstep to the platform, which increased
the likelihood of a loss of footing by the passenger (paragraph 70,
Recommendations 1 and 3).
ii. The passenger was stepping onto a sloping surface, that he was probably
unaware of, further increasing the likelihood of him losing his footing
(paragraph 78, Recommendations 1 and 3).
c. Control measures put in place by GCR had not effectively controlled the risk
of a person alighting from a door which was not adjacent to a useable platform
(paragraph 86, Recommendations 1, 2 and 3).
Underlying factors
118 The underlying factors were:
a. GCR did not have effective processes for learning lessons from operational
experience (paragraph 94, Recommendation 1).
b. GCR had no effective process to support the identification, management and
monitoring of risk (paragraph 100, Recommendation 2).
Report 13/2023 32 October 2023
Loughborough
Actions reported as already taken or in progress relevant to
Actions reported as already taken or in progress relevant to this report
this report
Actions reported that address factors which otherwise would have
resulted in an RAIB recommendation
119 Widespread sharing of safety learning helps duty holders to understand and
mitigate risks that are within their control. This is especially important in the
heritage sector with railways that are geographically separate and use a variety
of rolling stock in different operating environments. HRA has a dedicated section,
titled ‘Urgent Safety Information’, within its website which can be accessed by
members. This has subsequently been developed by HRA through its Operating
and Safety Committee with the intent of ensuring that its members are brought
up to date with the latest safety learning, including learning outcomes from near
misses across the sector. HRA explained that ‘Urgent Safety Information’ is
proactively shared with members and so is not reliant on members checking the
website.17
120 This resource improves the coverage and speed at which safety learning is
shared within the heritage sector.
Other reported actions
121 A week after the accident, GCR committed to arrange an independent review
of its SMS, which is in progress, and transferred safety responsibility to a new
general manager. A new GCR Board Health, Safety and Environment Committee
was established to scrutinise safety performance and to hold the meneral
manager and the company’s executive to account for the discharge of their safety
responsibilities.
122 GCR has created a new role, head of safety & compliance, and an individual has
been appointed to that role. A Board Health and Safety sub-committee has been
established, chaired by a senior manager from the mainline railway industry.
123 GCR reviewed all its PTI risk assessments and now routinely operates five‑coach
trains, unless there is a specific need for six and seven coaches when they will
staff trains and platforms accordingly. The effect of the new mitigations was
observed and reviewed in February 2023 and all footplate crew had attended a
mandatory training and briefing session on the new arrangements by the end of
March 2023.
124 GCR undertook a full review of train dispatch and stopping point risk
assessments for all platforms, and revised stop markers were implemented after
consultation with footplate crews. A new incident reporting policy and supporting
documentation has been published and a review of all staff competency records
took place to ensure all competencies are up to date. GCR intends to buy a
proprietary software package to manage competence records.
17
HRA included the RAIB urgent safety advice that related to the accident at Loughborough Central station in the
‘Urgent Safety Information’ section of its website.
Report 13/2023 33 October 2023
Loughborough
Background to RAIB’s recommendations
Background to RAIB’s recommendations
125 On the UK’s mainline railway, the Railway Safety and Standards Board (RSSB)18
safety risk model (SRM) v9.00.00, dated March 2022, expresses safety risk
in terms of predicted fatalities and weighted injuries19 (FWI). SRM risk data is
used by the railway industry to support safety-related decision making. The
SRM estimates the fatality risk to passengers and other members of the public
(excluding trespass, suicide and level crossings) on the mainline railway network
to be 12.8 FWI per year. The fatality risk to passengers at the PTI represents
around half of that risk. The mainline railway manages this risk through
implementing a number of standards and best practice guidance aimed at closely
monitoring and controlling the hazards at the PTI.
126 While heritage railways are much less intensively used than the mainline railway,
the nature of heritage railway stations, the rolling stock and their operation means
that some risks (for example, manually operated doors) which are not normally
present at mainline stations may be found at heritage railway stations. Heritage
railways may also see a different demographic of visitors and passengers than is
found on the mainline. RAIB, therefore, considers that risks at the PTI at heritage
railways, while different to the mainline railway, remain significant. Despite this,
RAIB has not found any dedicated guidance on assessing and mitigating the risks
associated with the PTI at heritage railways.
127 On 29 March 2023, RAIB issued urgent safety advice (USA) to heritage railways
and other operators of trains who use passenger coaching stock without doors
which are centrally controlled and/or locked by train crew (principally slam door
rolling stock). This USA advised a review of the risks associated with the use of
train formations which may not be fully platformed or which are of a length close
to that of the platforms being called at. The content of the USA is at appendix C.
18
A not-for-profit company owned and funded by major stakeholders in the railway industry, and which provides
support and facilitation for a wide range of cross-industry activities.
19
Defined by RSSB as the aggregate amount of safety harm. One FWI is equivalent to one fatality, 10 major
injuries or 200 minor injuries or shock/trauma events requiring hospital admission, or 1000 minor injuries or
shock/ trauma events not requiring hospital admission.
Report 13/2023 34 October 2023
Loughborough
Recommendations and learning points
Recommendations and learning points
Recommendations
128 The following recommendations are made:20
1 The intent of this recommendation is to ensure that the safety
management system at Great Central Railway adequately controls
the risks arising from its activities, so that it incorporates industry best
practice, complies with legal requirements and is updated at appropriate
intervals.
Great Central Railway should continue with the review of its safety
management system with a focus on:
• developing a robust process for assessing and controlling the risks
arising from its activities, and ensuring this process is well understood
by the staff responsible for creating and reviewing risk assessments
• ensuring that it has a well-defined process for investigating and
reporting accidents and near misses that enhances its understanding
of the risks arising from its activities
• ensuring that the needs of disabled21 passengers and staff are
reflected in their assessment of risk (paragraphs 117a, 117a.i, 117a.ii,
117b.i, 117b.ii, 117c and 118a).
Once complete, Great Central Railway should develop a timebound plan
to implement any changes identified in a sustainable and consistent
manner.
20
Those identified in the recommendations have a general and ongoing obligation to comply with health and safety
legislation, and need to take these recommendations into account in ensuring the safety of their employees and
others.
Additionally, for the purposes of regulation 12(1) of the Railways (Accident Investigation and Reporting) Regulations
2005, these recommendations are addressed to the Office of Rail and Road to enable it to carry out its duties under
regulation 12(2) to:
(a) ensure that recommendations are duly considered and where appropriate acted upon; and
(b) report back to RAIB details of any implementation measures, or the reasons why no implementation measures
are being taken.
Copies of both the regulations and the accompanying guidance notes (paragraphs 200 to 203) can be found on
RAIB’s website www.gov.uk/raib.
21
As defined in section 6 of the Equality Act 2010.
Report 13/2023 35 October 2023
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Recommendations and learning points
2 The intent of this recommendation is to ensure that Great Central
Railway has an organisational structure and process that provides
effective oversight of how the various departments manage risk and
ensures they operate in a co‑ordinated, mutually beneficial manner.
Great Central Railway should continue to review its organisational
structure and processes to give senior managers and the board a
comprehensive understanding of what activities are being undertaken
to manage risks, and that learning from accidents, incidents and near
misses is shared. It should implement a programme of thorough regular
audits, which are capable of identifying corrective actions needed to
improve the management of risk (paragraphs 117a, 117c, 118b).
This recommendation may apply to other heritage railways.
3 The intent of this recommendation is to ensure that Heritage Railway
Association members have access to guidance on managing the risks
around the platform-train interface, in particular how those risks can be
influenced by the demographic of heritage railway visitors.
The Heritage Railway Association, in consultation with its members,
should produce guidance on identifying and assessing the risks
associated with the platform-train interface. This guidance should
reflect where relevant any applicable law, guidance and good practice,
including from other railways (including mainline). It should also consider
how heritage railways should control the risks which arise from the
use of heritage rolling stock and infrastructure, the use of heritage
railways by persons with disabilities and the demographic of visitors and
passengers to such railways (paragraphs 117b, 117b.i, 117b.ii. 117c and
118b).
Learning points
129 RAIB has identified the following learning points:22
1 It is important to have a robust system to manage records of staff
training and competence so that the status of staff competence can be
readily ascertained ensuring appropriate deployment of staff and timely
planning of refresher training (paragraph 109).
2 It is important to report promptly notifiable accidents to RAIB in
accordance with Railways (Accident Investigation and Reporting)
Regulations 2005 (paragraph 111).
22
‘Learning points’ are intended to disseminate safety learning that is not covered by a recommendation. They are
included in a report when RAIB wishes to reinforce the importance of compliance with existing safety arrangements
(where RAIB has not identified management issues that justify a recommendation) and the consequences of failing
to do so. They also record good practice and actions already taken by industry bodies that may have a wider
application.
Report 13/2023 36 October 2023
Loughborough
Appendices
Appendices
Appendix A - Glossary of abbreviations and acronyms
ARL Above rail level
BSO (D) Brake Second Open with spaces for disabled passengers.
CCTV Closed-circuit television
FO First Open
FWI Fatalities and weighted injuries
GCR Great Central Railway
HRA Heritage Railway Association
ORR Office of Rail and Road
PTI Platform-train interface
RBR Restaurant Buffet Refurbished
RK Restaurant, Corridor
RNIB Royal National Institute of Blind People
ROGS Railways and Other Guided Transport Systems (Safety)
Regulations 2006
RSSB Rail Safety and Standards Board
SMS Safety management system
SRM Safety risk model
TSO Tourist Second Open
TSR Temporary speed restriction
TTI Travelling ticket inspector
USA Urgent safety advice
Report 13/2023 37 October 2023
Loughborough
Appendix B - Investigation details
Appendices
RAIB used the following sources of evidence in this investigation:
• information provided by witnesses
• CCTV recordings taken from Loughborough Central station
• site photographs and measurements
• weather reports and observations at the site
• a review of previous reported accidents
• a review of medical records supplied to RAIB
• a review of risk assessments and safety management system documentation
provided by GCR
• a review of previous RAIB investigations that had relevance to this accident.
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Appendix C – Urgent safety advice
Appendices
Urgent Safety Advice 01/2023:
Passenger doors not centrally
controlled and/or locked by
train crew
Published 29 March 2023
1. Safety issue
Suitable arrangements may not be in place to mitigate the risks arising from the
operation of passenger trains formed of rolling stock with doors that are not
centrally controlled and/or locked by train crew (principally slam door rolling stock)
where these trains are close to, or longer than, the length of station platforms.
2. Safety advice
Heritage railways and other operators of trains who use passenger coaching stock
without doors which are centrally controlled and/or locked by train crew (principally
slam door rolling stock) should review the risks associated with the use of train
formations which may not be fully platformed or which are of a length close to that
of the platforms being called at.
Duty holders should ensure that a suitable and sufficient assessment of the risks is
carried out and that any appropriate control measures identified are implemented.
These assessments should consider:
• the type and location of passenger doors on the relevant rolling stock
• the length of passenger trains compared to the platforms at which they may call
• the capabilities of the braking systems of the trains involved and the level of
precision which is reasonably achievable by them when stopping
• the level of accuracy in stopping position required of train crew and if this is
supported by relevant competency and assessment processes
• if the level of stopping position accuracy required of train crew aligns with the
capability of the trains involved and the accuracy required at the relevant
platforms
• the effectiveness of existing measures intended to manage the risk of
passengers exiting a train that is not fully platformed or which may stop in line
with areas not intended for public use, such as platform ramps
Report 13/2023 39 October 2023
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Rail Accident Investigation Branch Urgent Safety Advice 01/2023: Loughborough
supported by relevant competency and assessment processes
• if the level of stopping position accuracy required of train crew aligns with the
capability of the trains involved and the accuracy required at the relevant
platforms
• the effectiveness of existing measures intended to manage the risk of
Appendices
passengers exiting a train that is not fully platformed or which may stop in line
with areas not intended for public use, such as platform ramps
• the visibility from the cab of different traction units and the effectiveness of any
stopping markers in place.
Rail Accident Investigation Branch Urgent Safety Advice 01/2023: Loughborough
3. Issued to:
Heritage railways and other operators of trains who use passenger coaching stock
which has passenger doors which are not centrally controlled and/or locked by train
crew (principally slam door rolling stock).
4. Background
At around 11:49 hrs on 14 January 2023, a passenger lost their footing and
sustained a serious injury while alighting from a train at Loughborough Central
station on the Great Central Railway.
The Great Central Railway is a heritage railway and the passenger train involved
was formed of historic slam door rolling stock. The accident occurred just after the
train had stopped and as the passenger was alighting from the leading door of the
train’s leading coach. The train stopped in a position which meant that this door was
adjacent to the ramped part of the platform, which is not intended for public use.
The passenger lost their footing and sustained their injuries while they were
stepping down from the coach and onto the platform ramp.
Report 13/2023 40 October 2023
Loughborough
This report is published by the Rail Accident Investigation Branch,
Department for Transport.
© Crown copyright 2023
Any enquiries about this publication should be sent to:
RAIB Email: enquiries@raib.gov.uk
The Wharf Telephone: 01332 253300
Stores Road Website: www.raib.gov.uk
Derby UK
DE21 4BA