RO-1994-117 Superseded by report 94-117 Revised

Ensure Train Managers are trained to inspect the safety features of the passenger areas of three trains and be required to make such an inspection prior to the departure of each passenger service from the terminal stations.

Ensure the review of the design of the safety rails considers if a secondary safeguard is required where the concertina weather protection is not provided.

Advise all operators of passenger trains of the circumstances of this accident with the recommendation that they: review the adequacy and security of handrails, guard-rails, and gates in areas where passengers may move; ensure that staff who inspect and maintain handrails; guard-rails, and gates are aware of the purpose of and the design intentions for the equipment; and review their passenger management polices in respect of safety briefings, signage, and passenger supervision to reduce the possibility of falls, impacts with trackside objects, or injuries from other causes.

Define the person (or persons) upon whom the responsibility for the inspection of safety equipment and safety features on carriages rests.

Give clear instruction to carriage maintenance staff on the methods and quality of inspection, maintenance and repairs to the safety rails, chains and strops.

Define the person (or persons) upon whom the responsibility rests to ensure that the execution of any remedial repair or redesign work is carried out to a satisfactory standard.

Keep the ban on the use of the viewing platform in force until: a review of all aspects of the design, inspection and maintenance of the safety rails is completed; all remedial action is taken; and the safety management of passengers is reviewed, including an assessment of the need to provide signage, the languages in which any such signage is displayed; the supervision of children, particularly unaccompanied children; and the introduction of a safety briefing by the train Manager as the train departs.

When reviewing the design of the safety rails (or chains or strops as appropriate) take into account the spacing and layout of the safety rails, and the direction and magnitude of the loads which might be applied by passengers. [This safety recommendation was subsequently cancelled and replaced with safety recommendation 125/95.]