Formal Inquiries

Purley report and recommendations

Railway Safety has issued its formal inquiry report into the circumstances leading to the death of a station assistant at Purley on 5 July 2002.

The formal inquiry was convened under independent chairmanship and included representatives on the panel from the involved parties. As with all such inquiries the panel's task was to establish the immediate and underlying causes of the accident and make recommendations to prevent or reduce the risk of recurrence.

Sequence of events

At 2315hrs on 5 July 2002 a passenger train travelling from Caterham to Norwood, pulled into Purley Station, where people on the platform alerted the driver to a fire onboard his train. The driver instructed passengers to evacuate the train and alerted the platform staff to the danger.

The fire had been deliberately started, using removed seat covers and paper, adjacent to doors on the platform side of the second coach of the 4-coach train. The fire generated thick acrid smoke and had apparently taken hold of the internal partition and the door pocket. The driver tackled the fire from inside the vehicle, and a station assistant, who had given him the fire extinguisher, stood beside him.

The fire was extinguished at 2335hrs. At this time the Station Assistant became breathless and went to the station office to use his asthma pump. A second station assistant called for an ambulance and was given instructions over the phone on how to treat him until the paramedics arrived. The driver also found two members of the public who were first aid trained and were able to provide further advice.

The paramedics arrived at 2350hrs, treated Station Assistant A at the scene, and then took him to hospital at 0005hrs, although it later transpired that he died at Purley Station.

Conclusions

The formal inquiry panel concluded that Station Assistant A died from an acute asthma attack, triggered and aggravated by smoke from the fire on board the train which had been started maliciously prior to the train arriving at Purley.

The panel also identified a number of underlying causes which may have contributed to the incident and its severity, these are outlined below:

• Vandalism is prevalent on late night services in the South East of England.
• The Station Assistant placed himself close to the fire in the smoke filled carriage.
• There were incomplete medical records, and no correlation between medical conditions and risk assessment particularly in relation to fires.
• Fire training was focused on tackling minor fires 'if it is safe to do so' and failed to explicitly address employees, whose medical conditions put them at increased risk from tackling or being in close proximity to fires and smoke.
• The coach involved did not meet current Railway Group Standards for fire protection, although did comply with standards applicable at the time it was built.
• There was a lack of formal process for ensuring that seat covers, cushions etc are procured against the latest fire safety standards.
  

Recommendations

The report makes recommendations for improvements in a number of key areas and these are summarised as follows:

• Review under utilised late night services to determine if risks can be eradicated by service withdrawals.
• Systems to ensure employees are able to inform their employers of medical conditions, which might put them at risk when undertaking specific types of work.
• Revision of fire training to include explicit warnings for employees with medical conditions (either permanent or temporary), that may be exacerbated by fire and/or smoke, not to get involved in any aspects of fighting fires.
• Review of which employees receive the on-train fire training module.
• Procedures to ensure that replacement parts fitted through maintenance meet current standards of protection.
• Risk assessment of delays, due to contractual issues, of vehicle refurbishment programmes.

Railway Safety has issued a full copy of the report to each member of the Railway Group and the other organisations involved in the accident. All recipients of the report need to review the findings and recommendations and take actions where appropriate to address identified deficiencies within their own systems. Railway Safety will track the industry's response to this report.