RAIB: ... and all for the want of a horseshoe nail
"Recliner" wrote in message
...
Peter Able wrote:
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.
And?
PA
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