Posted By Bill Fisher Raymond I have to suggest that a description paragraph will give you a better return and indeed a more focussed return. A couple of of-the-cuff comments, without knowing detail. 1. You hint that the situation was not "forseeable" in which case Risk Assessment wouldn't have helped. 2. However you have, I am sure a system in place - we call it "STAR" - Stop, Think, Act, Review - which effectively works on arising changes and looks for just that to happen. So in essence that should have picked it up. Regards Bill

Posted By Stuart Nagle Ray. Firstly: I would have thought that designer risks, in the refurbishment of the station should have highlighted the need to ensure that new fixed equipment was in place, tested and operational prior to re-commisioning of the station. This could have been in the form of a checklist to ensure all safety critical componenets were fully operational before accepting handover.... Secondly: Design layout of controls probably have not changed for some time - to avoid operator error in situations like this (but I stand to be corrected), but if automated, as you seem to imply by the control unit, if the control unit was fitted and working would the doors have been openable on the 'wrong' side? Perhaps not.... This would/should/was perhaps a further indication of an un-safe system in respect of the design/commisioning, and should perhaps have been tested prior to commisioning.... I appreciate that the problems may well stem for other areas, such as completion dates/times etc necessary to ensure the transport systems were operational within a contract period, but it appears to be an inherent fault in the commisioning process rather than an oversight in health and safety per se, which led to a possible major problem. It would appear to me, being a sceptic of human nature, that perhaps someone knew all about this, but perhaps it was overlooked in order to facilitate meeting a dealine!! and that the system could be controlled by other means (the button) until such time as the ERROR could be corrected.... Stuart

Posted By Ken Taylor I'm not familiar with any of this but wonder whether you have highlighted a failure to adequately consider the ergonomic aspects of design for the manual controls. Controls need to be designed to accord with people rather than relying on people to adapt to controls.

Posted By Philip Roberts Raymond, Risk assessments should be reviewed periodically and when significant changes have been made. I would think that major refurbishment would count as a significant change so a risk assesssment should have been done on re-commissioning the platform. This should have picked up any safety related features not in operation and the added risk of train movement on the second platform. I would think that some breaches of RGS have taken place as well as breaches of Management of H&S regulations, but stand to be corrected, regards Phil

Posted By Raymond Rapp Jonathan Unfortunately I was not aware of this practice until Wed afternoon (day 3) and following a discussion with colleagues I issued an email to the project manager stating that if the CSDE equipment was not fixed I would issue a safety notice. I do not think there is any value in reporting this matter to CIRAS as I am dealing with it. Yes, as you have rightly pointed out the pressures of maintaining a service often leads to safety taking a back seat. This incident is one of many, but I will do my utmost to stamp out poor practice before it becomes endemic. Ray