William Israel
PFD Report
All Responded
Ref: 2020-0271
All 2 responses received
· Deadline: 27 Jan 2021
Sent To
Response Status
Responses
2 of 1
56-Day Deadline
27 Jan 2021
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
(1) Evidence heard from an experienced South Eastern Railway witness was that a national survey has found that there is a widespread assumption by members of the public that:
a. Power to the rail tracks is switched off at night
b. Power to the rail tracks is only switched on when trains are due
This supports that the risk of electrocution from train tracks is not well understood by the public. The risk of electrocution is from the live rail in such cases and the signage at Canterbury East Station relating to this is at each end of the platform. This signs in this vicinity contain the word ‘Caution’; the font used warning of the risk of death was not highlighted and significantly smaller than the rest of the sign.
(2) There is insufficient signage warning of the risk of electrocution to the public from the live rail and none present at the palisade gates. The evidence at the inquest established that there has been recent national guidance indicating changes to warning signs at railway stations. Signage has not been updated at this station following this death in accordance with that guidance.
(3) The British Transport Police Designing Out of Crime Unit (BTP DOCU) investigated this incident and has made a recommendation to consider the placement of strategic under-platform warning signage that would be visible where a member of the public jumping or stepping down onto the tracks. This recommendation has not been implemented.
(4) The main entrance to the station is open between the hours of 06:00 -22:00 hours Monday to Saturday and 07:00 – 22:00 hours on Sunday during such hours the station is staffed. First and last trains run outside of the staffed hours. There is signage by the main entrance directing the public to an underpass allowing pedestrians to safely cross between Platforms 1 & 2. The station has steel fencing around part of the perimeter that is approximately 2 metres high with spikes at the top and there is a potential alternative egress and ingress comprising palisade gates set withing that fencing. When the station is open and staffed, the palisade gates are locked. When the station is unstaffed the palisade gates are open and there is no signage in that vicinity directing pedestrians to the underpass.
(5) It appears inconsistent that the palisade gates that deter public entering are closed when the station is open and staffed, then open when the station is unstaffed and after trains have stopped running.
(6) Whilst it is not disputed that William had used the underpass with friends to get to a nightclub that night. He had already been drinking prior to this journey, was not local to the area and was alone when he accessed the station through the palisade gates a few hours later. William was intoxicated at the time he attempted to cross the train tracks at Canterbury East Station, however there have been a number of incidents of individuals on the tracks over the last three years and the station is just meters from a nightclub. There is a significant risk that members of the public using the station as a cut through will be intoxicated.
(7) Evidence at the inquest from the BPT DOCU report was that London & South Eastern Railway staff had informed the investigator that: a. staffing at the station during the entirety of operational hours was not possible due to the timings of the first and last trains, and
b. if the palisade gates were locked overnight and a member of staff did not then attend for work then the public would not be able to enter the station and catch a train
c. changes to the opening hours of the station would be complex and require lengthy consultation with staff
d. locking the palisade gates when the station was unstaffed would require some members of the public who lived in housing on the opposite sides of the track to the main town to take a detour at night (8) There appears to be an absence of a sufficient risk assessment of the risks to the public from electrocution from the live rail particularly when the palisade gates are open and, if the palisade gates should remain open, of any potential risk mitigation that might be implemented to ensure safe use of the underpass.
(9) I understand that the configuration of a live rail is widespread in the South of England and also other areas of the country and many of those stations are unstaffed and accessible by the public out of hours, therefore this is a matter that is of relevance nationally and not just at Canterbury East Railway Station.
a. Power to the rail tracks is switched off at night
b. Power to the rail tracks is only switched on when trains are due
This supports that the risk of electrocution from train tracks is not well understood by the public. The risk of electrocution is from the live rail in such cases and the signage at Canterbury East Station relating to this is at each end of the platform. This signs in this vicinity contain the word ‘Caution’; the font used warning of the risk of death was not highlighted and significantly smaller than the rest of the sign.
(2) There is insufficient signage warning of the risk of electrocution to the public from the live rail and none present at the palisade gates. The evidence at the inquest established that there has been recent national guidance indicating changes to warning signs at railway stations. Signage has not been updated at this station following this death in accordance with that guidance.
(3) The British Transport Police Designing Out of Crime Unit (BTP DOCU) investigated this incident and has made a recommendation to consider the placement of strategic under-platform warning signage that would be visible where a member of the public jumping or stepping down onto the tracks. This recommendation has not been implemented.
(4) The main entrance to the station is open between the hours of 06:00 -22:00 hours Monday to Saturday and 07:00 – 22:00 hours on Sunday during such hours the station is staffed. First and last trains run outside of the staffed hours. There is signage by the main entrance directing the public to an underpass allowing pedestrians to safely cross between Platforms 1 & 2. The station has steel fencing around part of the perimeter that is approximately 2 metres high with spikes at the top and there is a potential alternative egress and ingress comprising palisade gates set withing that fencing. When the station is open and staffed, the palisade gates are locked. When the station is unstaffed the palisade gates are open and there is no signage in that vicinity directing pedestrians to the underpass.
(5) It appears inconsistent that the palisade gates that deter public entering are closed when the station is open and staffed, then open when the station is unstaffed and after trains have stopped running.
(6) Whilst it is not disputed that William had used the underpass with friends to get to a nightclub that night. He had already been drinking prior to this journey, was not local to the area and was alone when he accessed the station through the palisade gates a few hours later. William was intoxicated at the time he attempted to cross the train tracks at Canterbury East Station, however there have been a number of incidents of individuals on the tracks over the last three years and the station is just meters from a nightclub. There is a significant risk that members of the public using the station as a cut through will be intoxicated.
(7) Evidence at the inquest from the BPT DOCU report was that London & South Eastern Railway staff had informed the investigator that: a. staffing at the station during the entirety of operational hours was not possible due to the timings of the first and last trains, and
b. if the palisade gates were locked overnight and a member of staff did not then attend for work then the public would not be able to enter the station and catch a train
c. changes to the opening hours of the station would be complex and require lengthy consultation with staff
d. locking the palisade gates when the station was unstaffed would require some members of the public who lived in housing on the opposite sides of the track to the main town to take a detour at night (8) There appears to be an absence of a sufficient risk assessment of the risks to the public from electrocution from the live rail particularly when the palisade gates are open and, if the palisade gates should remain open, of any potential risk mitigation that might be implemented to ensure safe use of the underpass.
(9) I understand that the configuration of a live rail is widespread in the South of England and also other areas of the country and many of those stations are unstaffed and accessible by the public out of hours, therefore this is a matter that is of relevance nationally and not just at Canterbury East Railway Station.
Responses
Southeastern plans to replace warning signs at Canterbury East station, engage with a local nightclub to educate its clientele about railway risks, review and update station risk assessments, and share the inquest findings with the wider railway community, with specific timelines for these actions.
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Dear Ms Hayes Regulation 28 Report: William Steven Israel (ref: ) 1 I write in response to your Regulation 28 report dated 3 December 2020 regarding the death of William Steven Israel on railway tracks at Canterbury East railway station on 15 March
2020. 2 I would like to begin by expressing my condolences to Mr Israel’s family and my sorrow for their loss. I can assure you and them that we will learn lessons from this tragedy to prevent recurrence of similar events. 3 I, my colleagues at Southeastern and indeed the whole railway community are very aware of the risks associated with unauthorised access to railway tracks – particularly where it is electrified using the DC conductor rail system – and we take this issue very seriously. Regrettably, it is a matter of record that the vast majority of deaths on Britain’s railways arise from unauthorised access onto the tracks. For that reason, we implement a wide range of strategies and initiatives with the aim of reducing and preventing unauthorised access. 4 The strategies and initiatives Southeastern take range from physical deterrents and barriers to community engagement (to educate and raise awareness). For example, Southeastern (sometimes in conjunction with British Transport Police and/or Network Rail) take part in regular school visits, media campaigns such as “Respect the Edge”, “Next Day Regrets” and “You vs Train” as well as installing enhanced fencing (where appropriate) and gating platform ends. We also take part in localised activities around level crossings and other “hot spots” for trespass and have recently worked with Network Rail to develop a “Life Centre” for youth
education at Margate station, which includes a full-size mock-up of a platform with track, conductor rail and train. 5 In addition to our initiatives to reduce and prevent unauthorised access to railway tracks, we fund a number of Welfare Officers dedicated to identifying and engaging with vulnerable persons at stations, and significant numbers of our station staff have been trained by Samaritans to be aware of people who may be vulnerable and, where appropriate, how to intervene and support them. 6 At Canterbury East Station, there were already a range of measures to prevent unauthorised access prior to Mr Israel’s death, including: (i) red anti-trespass signage at the booking hall entrance and at the side gate providing access and egress to platform 2 from Station Road; and (ii) barriers, anti-trespass matting, trespass warning and danger of live rail signage at the platform ends. Following Mr Israel’s death, we considered whether there were any additional measures which could be put in place at Canterbury East Station. As a result, we have already installed new signage at each of the three station entrances (the main entrance and the palisade gates on platforms 1 and 2) to emphasise the danger of crossing the tracks. Photographs of these signs were provided to the Inquest as exhibits CC 15, 16 and 17 appended to our witness statement. 7 Turning to the specifics of the report, I shall respond to the detailed points which you raised in section 5. Response to Paragraph (1) 8 It is correct that – except for when engineering work takes place – the live DC conductor rails are energised at all times. It is also the case that surveys show that many members of the public are not aware of this fact and assume either that the power is routinely turned off at night or that it is only switched on when a train is approaching. Existing industry educational and campaign material – for both conductor rail and overhead line electrification systems – addresses this point directly and emphasises that the power is always on. 9 We wish to clarify the signage which was present prior to the accident, and the signage that has been installed post-accident. Prior to this accident there were four signs at Canterbury East station which warned of the danger of the live DC conductor rails. These were the four platform end signs, photographs of which were provided to the Inquest as exhibits CC 3, 4, 5 and 6. These signs carry the wording “Danger. Do not touch the live rail” and the word “Danger” is the largest on the sign. 10 After the accident, we took the initiative to design and install a further three signs at or close to the palisade side entrance gates to platforms 1 and 2 and at the main station entrance. Photographs of this signage were provided to the Inquest as exhibits CC 15, 16 and 17. These signs carry the wording “Caution – Do not cross the tracks – Danger of Death – High voltage power rails live at all times”. The intention of these new signs was to highlight more
prominently the risks of the live DC conductor rails. We believe that it is these additional signs to which you refer in paragraph (1). We note your concerns regarding the use of the word “Caution” and the size of the text relating to the risk of death and have addressed these through a revised design (see Annex A). 11 Action (a): we will replace the three additional signs at Canterbury East station with a new design based on that shown at Annex A. Response to Paragraph (2) 12 We wish to correct the statement in your paragraph (2) that there is no signage present at the palisade gates. As explained at paragraph 10 above, we installed three additional signs at or close to the palisade gates as well as at the main station entrance following the accident (see our witness statement at paragraph 19.3). 13 We note that you refer to “national guidance” on the changes to warning signs at railway stations. We apologise if our evidence was unclear on this point. The Effective Signage Project (led by the University of Birmingham’s Centre for Railway Research and Education) is an academic study not national guidance. The study was commissioned by Network Rail’s Trespass Improvement Group and led to a recent report1. The aim of the study and report is to assist Network Rail in the design of future signage to deter unauthorised access to the railway. 14 Southeastern provided input into this research via Network Rail, and a copy of the report was provided to us on 16 November 2020. Section 4.1.1.1 of this report states that “Signal words ‘Danger’ and ‘Warning’ are more likely to attract attention than ‘Caution’ or ‘Notice’ and have stronger connotations of risk.” 15 We are considering the findings of the research report and how the recommendations could improve our signage. This includes the redesign of the station entrance signs described at paragraph 10 above. Response to Paragraph (3) 16 The provision of under-platform signage is a matter for Network Rail as the platform faces concerned are their asset. Southeastern has made representations to Network Rail for such signage to be installed but this has been refused due to concerns that under-platform signs are difficult to maintain, and there is a risk they may obscure developing structural defects in the platform itself. In view of this, Southeastern are unable to take any further action in relation to under-platform signage at Canterbury East or elsewhere.
1 “Effective signage to prevent trespass” - ., University of Birmingham, 7 September 2020
Response to Paragraph (4) 17 Before the accident, directional signage to the station subway was provided in the form of a double-sided sign affixed perpendicular to the wall of the station building adjacent to the top of the subway stairs. 18 Following the Inquest, we have installed an additional directional sign adjacent to the entrance when entering platform 2 from the palisade gate which indicates the presence of the subway. I append a photograph of this sign in situ as Annex B. 19 Action (b) completed: A new directional sign has been installed adjacent to the side gate to platform 2. Response to Paragraph (5) 20 The purpose of the palisade gates is to permit access and egress to and from the station during the hours that the booking hall is closed and the station is unstaffed, and not to act as a deterrent to such access. They are not required to be open during the day as it is possible to enter the station via the booking hall and, as there are Automatic Ticket Gates provided to protect revenue, they are closed whilst the booking hall is open and the ticket gates in operation. 21 The booking hall is closed at 20:00 each evening and it is at this point that the palisade gates on platforms 1 and 2 are opened. They are closed again when the booking hall opens in the morning at 06:00 (Monday – Saturday) or 07:00 (Sunday). There are several reasons why the palisade gates need to be opened during these hours including passengers needing to access and egress the station for train services scheduled after 20:00 and before 06:00/07:00. Response to Paragraph (6) 22 We note the comments in paragraph (6) in relation to previous incidents of individuals on the track although we note that none of these incidents involved a person leaving the Chemistry nightclub. We also note that some members of the public using the subway may be intoxicated but given the large numbers of passengers that use the station each day we would not describe this as a significant number or a “significant risk”. 23 Notwithstanding this, in light of the accident we consider that the provision of relevant information to nightclub attendees may reduce the likelihood of other individuals making an attempt to cross over the tracks. This could potentially be achieved by using leaflets, messages on menus or drinks mats, posters in lavatories or use of the industry “You vs. Train” video materials. 24 Action (c): we will engage with the operators of the Chemistry nightclub with a view to highlighting the dangers of the rail tracks to their clientele.
Response to Paragraph (7) 25 We note the contents of the BTP DOCU report, and the comments provided by our staff. 26 We do not propose to alter staff shift patterns or station opening hours. We believe that there are more effective methods of preventing unauthorised track access which we have set out in this letter together with the detail provided in our witness statement (see paragraphs 23 –
26). Response to Paragraph (8) 27 We do not agree with the comment regarding risk assessment in paragraph 8. We have set out at paragraph 9 above the details of the four signs which were in place prior to the accident which warned of the danger of the live rail. Following the accident, we installed additional signage at all station entrances to highlight this risk and, as set out in paragraphs 10 and 13 above, we have redesigned this signage to take into account your comments and the findings of the University of Birmingham research (see Annex A). In addition, the risk assessments applicable to Canterbury East will be reviewed as part of our routine review processes following an incident and will be updated if appropriate. 28 Action (d): we will review the risk assessments applicable to Canterbury East as part of our routine review processes and will update if appropriate. Response to Paragraph (9) 29 Action (e): we will share details of this Inquest and Regulation 28 report with the wider railway community via the industry Passenger Operators’ Safety Group and Passengers on Trains and Stations Risk Group. We provided an initial briefing to the Passenger Operators’ Safety Group on 9 December. Summary 30 In summary, the actions that we propose to take in light of this report are as follows: (a) We will replace the three warning signs provided at the main entrance and palisade gates at platforms 1 and 2 at Canterbury East station with a new design as shown at Annex A. These signs reflect the concerns raised in you report and take into consideration the University of Birmingham’s findings and include replacing the word “Caution” with the word “Warning” and giving greater prominence to the risk of electrocution. (b) We have already provided signage at the side entrance to Platform 2 at Canterbury East station which directs users to the subway at the middle of the platforms.
(c) We will engage with the operators of the Chemistry nightclub to seek ways to inform and educate their clientele in relation to the risks associated with people going on to railway tracks. (d) We will review the risk assessments applicable to Canterbury East as part of our routine review processes and will update if appropriate. (e) We will share the findings of the Inquest, the Regulation 28 report and details of our actions with the wider railway community via the industry Passenger Operators’ Safety Group and Passengers on Trains and Stations Risk Group. 31 Our current intention is to complete actions (a), (d) and (e) by 31 March 2021, action (b) is already complete, and to complete action (c) by 30 June 2021. These timescales may need to be altered dependent upon the impact of the Covid-19 lockdown/Tier restrictions. We do not intend to progress any other actions at this stage for the reasons indicated above.
2020. 2 I would like to begin by expressing my condolences to Mr Israel’s family and my sorrow for their loss. I can assure you and them that we will learn lessons from this tragedy to prevent recurrence of similar events. 3 I, my colleagues at Southeastern and indeed the whole railway community are very aware of the risks associated with unauthorised access to railway tracks – particularly where it is electrified using the DC conductor rail system – and we take this issue very seriously. Regrettably, it is a matter of record that the vast majority of deaths on Britain’s railways arise from unauthorised access onto the tracks. For that reason, we implement a wide range of strategies and initiatives with the aim of reducing and preventing unauthorised access. 4 The strategies and initiatives Southeastern take range from physical deterrents and barriers to community engagement (to educate and raise awareness). For example, Southeastern (sometimes in conjunction with British Transport Police and/or Network Rail) take part in regular school visits, media campaigns such as “Respect the Edge”, “Next Day Regrets” and “You vs Train” as well as installing enhanced fencing (where appropriate) and gating platform ends. We also take part in localised activities around level crossings and other “hot spots” for trespass and have recently worked with Network Rail to develop a “Life Centre” for youth
education at Margate station, which includes a full-size mock-up of a platform with track, conductor rail and train. 5 In addition to our initiatives to reduce and prevent unauthorised access to railway tracks, we fund a number of Welfare Officers dedicated to identifying and engaging with vulnerable persons at stations, and significant numbers of our station staff have been trained by Samaritans to be aware of people who may be vulnerable and, where appropriate, how to intervene and support them. 6 At Canterbury East Station, there were already a range of measures to prevent unauthorised access prior to Mr Israel’s death, including: (i) red anti-trespass signage at the booking hall entrance and at the side gate providing access and egress to platform 2 from Station Road; and (ii) barriers, anti-trespass matting, trespass warning and danger of live rail signage at the platform ends. Following Mr Israel’s death, we considered whether there were any additional measures which could be put in place at Canterbury East Station. As a result, we have already installed new signage at each of the three station entrances (the main entrance and the palisade gates on platforms 1 and 2) to emphasise the danger of crossing the tracks. Photographs of these signs were provided to the Inquest as exhibits CC 15, 16 and 17 appended to our witness statement. 7 Turning to the specifics of the report, I shall respond to the detailed points which you raised in section 5. Response to Paragraph (1) 8 It is correct that – except for when engineering work takes place – the live DC conductor rails are energised at all times. It is also the case that surveys show that many members of the public are not aware of this fact and assume either that the power is routinely turned off at night or that it is only switched on when a train is approaching. Existing industry educational and campaign material – for both conductor rail and overhead line electrification systems – addresses this point directly and emphasises that the power is always on. 9 We wish to clarify the signage which was present prior to the accident, and the signage that has been installed post-accident. Prior to this accident there were four signs at Canterbury East station which warned of the danger of the live DC conductor rails. These were the four platform end signs, photographs of which were provided to the Inquest as exhibits CC 3, 4, 5 and 6. These signs carry the wording “Danger. Do not touch the live rail” and the word “Danger” is the largest on the sign. 10 After the accident, we took the initiative to design and install a further three signs at or close to the palisade side entrance gates to platforms 1 and 2 and at the main station entrance. Photographs of this signage were provided to the Inquest as exhibits CC 15, 16 and 17. These signs carry the wording “Caution – Do not cross the tracks – Danger of Death – High voltage power rails live at all times”. The intention of these new signs was to highlight more
prominently the risks of the live DC conductor rails. We believe that it is these additional signs to which you refer in paragraph (1). We note your concerns regarding the use of the word “Caution” and the size of the text relating to the risk of death and have addressed these through a revised design (see Annex A). 11 Action (a): we will replace the three additional signs at Canterbury East station with a new design based on that shown at Annex A. Response to Paragraph (2) 12 We wish to correct the statement in your paragraph (2) that there is no signage present at the palisade gates. As explained at paragraph 10 above, we installed three additional signs at or close to the palisade gates as well as at the main station entrance following the accident (see our witness statement at paragraph 19.3). 13 We note that you refer to “national guidance” on the changes to warning signs at railway stations. We apologise if our evidence was unclear on this point. The Effective Signage Project (led by the University of Birmingham’s Centre for Railway Research and Education) is an academic study not national guidance. The study was commissioned by Network Rail’s Trespass Improvement Group and led to a recent report1. The aim of the study and report is to assist Network Rail in the design of future signage to deter unauthorised access to the railway. 14 Southeastern provided input into this research via Network Rail, and a copy of the report was provided to us on 16 November 2020. Section 4.1.1.1 of this report states that “Signal words ‘Danger’ and ‘Warning’ are more likely to attract attention than ‘Caution’ or ‘Notice’ and have stronger connotations of risk.” 15 We are considering the findings of the research report and how the recommendations could improve our signage. This includes the redesign of the station entrance signs described at paragraph 10 above. Response to Paragraph (3) 16 The provision of under-platform signage is a matter for Network Rail as the platform faces concerned are their asset. Southeastern has made representations to Network Rail for such signage to be installed but this has been refused due to concerns that under-platform signs are difficult to maintain, and there is a risk they may obscure developing structural defects in the platform itself. In view of this, Southeastern are unable to take any further action in relation to under-platform signage at Canterbury East or elsewhere.
1 “Effective signage to prevent trespass” - ., University of Birmingham, 7 September 2020
Response to Paragraph (4) 17 Before the accident, directional signage to the station subway was provided in the form of a double-sided sign affixed perpendicular to the wall of the station building adjacent to the top of the subway stairs. 18 Following the Inquest, we have installed an additional directional sign adjacent to the entrance when entering platform 2 from the palisade gate which indicates the presence of the subway. I append a photograph of this sign in situ as Annex B. 19 Action (b) completed: A new directional sign has been installed adjacent to the side gate to platform 2. Response to Paragraph (5) 20 The purpose of the palisade gates is to permit access and egress to and from the station during the hours that the booking hall is closed and the station is unstaffed, and not to act as a deterrent to such access. They are not required to be open during the day as it is possible to enter the station via the booking hall and, as there are Automatic Ticket Gates provided to protect revenue, they are closed whilst the booking hall is open and the ticket gates in operation. 21 The booking hall is closed at 20:00 each evening and it is at this point that the palisade gates on platforms 1 and 2 are opened. They are closed again when the booking hall opens in the morning at 06:00 (Monday – Saturday) or 07:00 (Sunday). There are several reasons why the palisade gates need to be opened during these hours including passengers needing to access and egress the station for train services scheduled after 20:00 and before 06:00/07:00. Response to Paragraph (6) 22 We note the comments in paragraph (6) in relation to previous incidents of individuals on the track although we note that none of these incidents involved a person leaving the Chemistry nightclub. We also note that some members of the public using the subway may be intoxicated but given the large numbers of passengers that use the station each day we would not describe this as a significant number or a “significant risk”. 23 Notwithstanding this, in light of the accident we consider that the provision of relevant information to nightclub attendees may reduce the likelihood of other individuals making an attempt to cross over the tracks. This could potentially be achieved by using leaflets, messages on menus or drinks mats, posters in lavatories or use of the industry “You vs. Train” video materials. 24 Action (c): we will engage with the operators of the Chemistry nightclub with a view to highlighting the dangers of the rail tracks to their clientele.
Response to Paragraph (7) 25 We note the contents of the BTP DOCU report, and the comments provided by our staff. 26 We do not propose to alter staff shift patterns or station opening hours. We believe that there are more effective methods of preventing unauthorised track access which we have set out in this letter together with the detail provided in our witness statement (see paragraphs 23 –
26). Response to Paragraph (8) 27 We do not agree with the comment regarding risk assessment in paragraph 8. We have set out at paragraph 9 above the details of the four signs which were in place prior to the accident which warned of the danger of the live rail. Following the accident, we installed additional signage at all station entrances to highlight this risk and, as set out in paragraphs 10 and 13 above, we have redesigned this signage to take into account your comments and the findings of the University of Birmingham research (see Annex A). In addition, the risk assessments applicable to Canterbury East will be reviewed as part of our routine review processes following an incident and will be updated if appropriate. 28 Action (d): we will review the risk assessments applicable to Canterbury East as part of our routine review processes and will update if appropriate. Response to Paragraph (9) 29 Action (e): we will share details of this Inquest and Regulation 28 report with the wider railway community via the industry Passenger Operators’ Safety Group and Passengers on Trains and Stations Risk Group. We provided an initial briefing to the Passenger Operators’ Safety Group on 9 December. Summary 30 In summary, the actions that we propose to take in light of this report are as follows: (a) We will replace the three warning signs provided at the main entrance and palisade gates at platforms 1 and 2 at Canterbury East station with a new design as shown at Annex A. These signs reflect the concerns raised in you report and take into consideration the University of Birmingham’s findings and include replacing the word “Caution” with the word “Warning” and giving greater prominence to the risk of electrocution. (b) We have already provided signage at the side entrance to Platform 2 at Canterbury East station which directs users to the subway at the middle of the platforms.
(c) We will engage with the operators of the Chemistry nightclub to seek ways to inform and educate their clientele in relation to the risks associated with people going on to railway tracks. (d) We will review the risk assessments applicable to Canterbury East as part of our routine review processes and will update if appropriate. (e) We will share the findings of the Inquest, the Regulation 28 report and details of our actions with the wider railway community via the industry Passenger Operators’ Safety Group and Passengers on Trains and Stations Risk Group. 31 Our current intention is to complete actions (a), (d) and (e) by 31 March 2021, action (b) is already complete, and to complete action (c) by 30 June 2021. These timescales may need to be altered dependent upon the impact of the Covid-19 lockdown/Tier restrictions. We do not intend to progress any other actions at this stage for the reasons indicated above.
Southeastern has replaced the three warning signs at Canterbury East station with a new design, engaged with a local nightclub to provide railway safety posters and drinks mats, completed an update of risk assessments for the station, and shared learning from the incident with the wider rail industry.
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Dear Ms Hayes Regulation 28 Report: William Steven Israel
1 I wrote to you on 6 January in response to your Regulation 28 report regarding the tragic death of William Steven Israel at Canterbury East railway station on 15 March 2020. 2 In that letter I committed Southeastern to taking to following actions: (a) Replacing the three warning signs provided at the main entrance and palisade gates at platforms 1 and 2 at Canterbury East station with a new design. (b) Engaging with the operators of the Chemistry nightclub to seek ways to inform and educate their clientele in relation to the risks associated with people going on to railway tracks. (c) Reviewing the risk assessments applicable to Canterbury East as part of our routine review processes and updating them as appropriate. (d) Sharing the findings of the Inquest, the Regulation 28 report and details of our actions with the wider railway community via the industry Passenger Operators’ Safety Group (POSG) and Passengers on Trains and Stations Risk Group (PTSRG). 3 I now write to update you on progress with the implementation of those actions. a) Warning signs at station entrances 4 We have replaced the three warning signs at the various entrances to the station with a new design as promised and photographs of these signs are attached as Annex A.
5 In addition to this we have also engaged with the wider rail industry with a view to establishing a project to review and replace existing station warning signs with more informative alternatives that highlight the “Danger of Death” message. b) Chemistry Night Club 6 We have engaged with the operators of the Chemistry Night Club and developed a constructive working relationship with them. As part of this we have agreed to provide the night club, free of charge, with a supply of A4 posters and several thousand drinks mats which highlight three key railway safety messages in a “fun facts” format intended to engage and inform. These are drawn from our Travel Smart Travel Safe campaign and highlight: (a) The fact that the conductor rail is never switched off (b) The extended stopping distance for trains (equivalent to 20 Premier League football pitches or 2 km) (c) The weight of trains (equivalent to 80 elephants or 400 tonnes) c) Review of Risk Assessments 7 We have completed our review of the risk assessments at Canterbury East station and have updated them in the light of this accident and physical changes to the station, including the recent completion of an “Access for All” footbridge with lifts. d) Sharing findings 8 We have shared all our learning from this tragic accident with the wider industry via the POSG and PTSRG and this has prompted both discussions and actions, including work on signage reference in paragraph 5 above.
1 I wrote to you on 6 January in response to your Regulation 28 report regarding the tragic death of William Steven Israel at Canterbury East railway station on 15 March 2020. 2 In that letter I committed Southeastern to taking to following actions: (a) Replacing the three warning signs provided at the main entrance and palisade gates at platforms 1 and 2 at Canterbury East station with a new design. (b) Engaging with the operators of the Chemistry nightclub to seek ways to inform and educate their clientele in relation to the risks associated with people going on to railway tracks. (c) Reviewing the risk assessments applicable to Canterbury East as part of our routine review processes and updating them as appropriate. (d) Sharing the findings of the Inquest, the Regulation 28 report and details of our actions with the wider railway community via the industry Passenger Operators’ Safety Group (POSG) and Passengers on Trains and Stations Risk Group (PTSRG). 3 I now write to update you on progress with the implementation of those actions. a) Warning signs at station entrances 4 We have replaced the three warning signs at the various entrances to the station with a new design as promised and photographs of these signs are attached as Annex A.
5 In addition to this we have also engaged with the wider rail industry with a view to establishing a project to review and replace existing station warning signs with more informative alternatives that highlight the “Danger of Death” message. b) Chemistry Night Club 6 We have engaged with the operators of the Chemistry Night Club and developed a constructive working relationship with them. As part of this we have agreed to provide the night club, free of charge, with a supply of A4 posters and several thousand drinks mats which highlight three key railway safety messages in a “fun facts” format intended to engage and inform. These are drawn from our Travel Smart Travel Safe campaign and highlight: (a) The fact that the conductor rail is never switched off (b) The extended stopping distance for trains (equivalent to 20 Premier League football pitches or 2 km) (c) The weight of trains (equivalent to 80 elephants or 400 tonnes) c) Review of Risk Assessments 7 We have completed our review of the risk assessments at Canterbury East station and have updated them in the light of this accident and physical changes to the station, including the recent completion of an “Access for All” footbridge with lifts. d) Sharing findings 8 We have shared all our learning from this tragic accident with the wider industry via the POSG and PTSRG and this has prompted both discussions and actions, including work on signage reference in paragraph 5 above.
Report Sections
Investigation and Inquest
On 2nd April 2020 an investigation was commenced into the death of WILLIAM STEVEN ISRAEL, 23. The investigation concluded at the end of the inquest on 24th November 2020. The conclusion of the inquest was ACCIDENT the medical cause of death electrocution.
Circumstances of the Death
William Israel had visited a friend who lived near Canterbury East Railway Station. They had a drink before they travelled to a nightclub crossing from one platform to the other at Canterbury East Railway Station using an underpass at around midnight. The station was closed but the palisade gates at Platforms 1 & 2 were open routinely out of ours. William left the nightclub at around 03:30 hours alone with the keys to go back to his friend’s flat. Toxicology evidence establishes he was intoxicated. He was seen on CCTV walking normally and entering the station through palisade gates. He then hopped down on the track and caught the toe of his shoe and tripped landing on the live rail at approximately 03:45 hours. He was found by a member of the public and the cause of death was given as electrocution.
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