Dear Ms Hamilton-Deeley, THE LATE CARL RICHARD KLIMAYTYS Thank you for your Regulation 28 report dated 7th August 2019 addressed to John Halsall, Regional Managing Director Southern Region, who has asked me to respond on his behalf and on behalf of Network Rail. am the Support Services Director of the Southern Region, which includes Preston Park Station: Your Regulation 28 report expresses a concern in relation to signage on the platform at Preston Park station to (1) warn customers of the existence of ground laid electric rails and (2) to keep customers from the edge of the platform_ You identify that these concerns are matters for consideration by the train operator, namely, Govia Thameslink Railway Ltd (GTR) and a copy of vour report is sent to Network Rail in its capacity as landlords for GTR who may need to seek Network Rail's permission to carry out works at the station_ Firstly, we confirm that GTR is the lessee and Station Facility Owner of a number of stations within its area of franchise, including the station at Preston Park. In keeping with other stations identified within GTR's lease, the station at Preston Park is specified to be used for orin connection with the provision ofthe services for carriage of passengers by railway provided by the Station Facility Owner pursuant to its Franchise Agreement with the Department for Transport: Part Il of the Landlord and Tenant Act 1954 does not apply. Under the terms of its lease, GTR has the responsibility for all signage at the station and does not require Network Rail' s permission for it_ GTR is required to such signage in good order; clear and clean, while in all other regards GTR is obligated to respond to industry standards and to be compliant with them By way of background it is perhaps appropriate to identify that the railway is made up of many Nebwork Rail Infrastructure Limited Registered Olfice: Netwark Rall , Znd Floor; Cne Eversholt Street London, NWI 2DN Registered England and Wales No, 2904587 WMnetvorkrail,couk away the keep

NetworkRail companies and organisations delivering different parts of the railway: Those parts need to collaborate to make the railway work and to ensure it is safe. This means there is no single organisation which leads. Instead , different aspects of leadership are provided or supported different places with the aim of delivering a consistent and safe railway benefiting from wider railway knowledge One such part is the Rail Safety and Standards Board (RSSB) which is a membership-based rail industry body designed to help the railway become safer and more sustainable. Its work helps to reduce risk and cost for passengers, the workforce and the wider public: It enables and informs safety leadership, assesses whole system risk, provides tools, guidance, standards, analysis, and research, informs on progress against strategy, facilitates safety collaboration and advises on good safety management Your investigation received evidence that RSSB provides the industry standards including Railway Group Standards, Rail Industry Standards, Codes of Practice, Guidance Notes and National Safety Rules etc. drafted with the benefit of collaboration, safety research, risk assessment and inter-operational working: RSSB has, by way of example, produced: Rail Industry Standard for Station Infrastructure RIS-7700-INS; Railway Group Standard GIRT7033 relevant to Lineside Signs; and Rail Industry Standard RIS-7016-INS for the Interface between Station Platforms, Track, Trains and Buffer Stops. There are many more standards which include the requirements for the specification and positioning of operational safety signs: In this regard GTR is expected to be compliant with all those standards and does not require Network Rail permission: We care about making sure passengers and members of the public understand how to stay safe and we support a number of safety awareness programmes, including the You vs Train film about the dangers of the third rail part of our work in the community is education and we regularly attend schools and community events to promote safety on the railway: Educational resources have also been developed with teachers and pupils about electrification on the railway, level crossings and railway safety: A life-size indoor train station has even been built at Sutton Life Educational Centre to bring home safety messages to young people and is a part of our safety outreach programme for young people. We note from the Record of Inquiry that the presence of alcohol is listed under the medical causes of death: The inherent dangers of the railway are of course exacerbated by excessive alcohol intake Anything you, as one of Her Majesty's Senior Coroners, could do to draw attention to the significant risks associated with drinking and impaired judgements and the significant risk of death on the railway whether being struck by a train or by electrocution would be very much appreciated: Network Rail regularly runs seasonal publicity campaigns warning the public of the risks of excessive alcohol intake and travelling on the railway: Network Rail has expressed its deepest condolences to the family for their tragedy and we appreciate their unimaginable loss. Our thoughts remain with them: Network Rail Infrasiruciure Limiled Registered Olfice: Network Rail, Znd Floor; One Eversholt Streel Landon: NWI 2DN Registered England an3 Wvales No 2904587 Cnenenoria co uk from key " heavy

Dear Madam , RE: The_late_Carl Richard KLIMAYTYS Thank you for your Regulation 28 report dated 7th August 2019 addressed to Patrick Verwer; Chief Operating Officer for Govia Thameslink Railway (GTR) who has asked me to respond on his behalf and on behalf of GTR_ The first of your Regulation 28 reports, expresses a concern in relation to signage on the platform at Preston Park station to (1) warn customers of the existence of ground laid electric rails and (2) to keep customers away from the edge of the platform. The second report refers to facts presented to the inquiry, that identified areas of improvement in the call handling of the Rail Operating Centre. GTR is Station Facility Owner at 235 stations, including Preston Park and is responsible for ensuring that each operate safely in compliance with industry standards. These stations include those with traction current supplied by 3rd Rail (Conductor Rail), Overhead Lines and some non-electrified lines. Staff working at stations are trained and are familiar with the specific Govia Thameslink Railway Monument Place_ 24 Monument Streel, London; EC3R 8AJ Registered in land under number: 7934305. Registered otfice: 3rd Floor; 41-51 Grey Street, Newcastle upon Tyne, NEI GEE and Engi

GTR risks at their locations, pertaining to electrification: The risk of trespass onto the railway track is a widely recognised industry wide issue; one which nationally accounts for hundreds of people each year unintentionally injured or killed. We recognise that the railway is full of hidden dangers, which includes the risk of being hit by an unexpected train or encountering lethal current in rails and power lines. To help publicise and manage these risks the industry recently launched the 'You vs Train' campaign. This campaign, based on extensive research, targets specific groups identified as more vulnerable from trespassing onto the railway track; it is accessible in several ways including TV , Poster and Social Media specific to the risk at varying locations. One of the messages and accompanying video focuses on the dangers of the 3rd Rail. The campaign having received a high degree of visibility has received an award from the Institute of Occupational Safety and Health (IOSH): YouvsTrain The third rail iS probably Ine hardest danger I0 see_ loaks juSI like an ordinary rail, but carries 750 volls easily eolgh to kill yu Il"s designed Io send poxur Io Ihe Hrain bJl YOu are 70 per cent water ad the perfecl conductor 'or this electricity: you tcuch the rail, YDU Will "slick" l # The DC current that Ilos Ihrough it rili you in and nat lel g0 unlil Ihe emeigency services are able l0 swilch the power off: Neariy half of the UK rail network now eleclrilied ard more than 30 per cent uses Ihid rail l0 poner The electrified third rail carries the train. The arly way lo avoid stepping on this 750 volts of direct cunent that hidden danger is rot lo stop on the tract Will attract rather than repel you http Iwww youvstrain Co Ukl Govia Thameslink Railway Monument Place_ 24 Monument Street; London_ EC3R 8AJ Registered In England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street, Newcastle upon Tyne, NET 6EE Pull _

GTR GTR continues to work with groups such as the industry Trespass Risk Group to learn and promote good practice , monitor the effectiveness of current trespass management and be involved and sponsor work in this area to raise public awareness. This broader approach is combined with the local notifications at specific locations to reduce the likelihood of trespass_ Wamri Revars' Lock b0 Preston Park Station In recent years there has been significant investment in anti-trespass measures at stations_ This includes barriers and anti-trespass matting at platform ends, in addition to the trespass warning and danger of live rail signs. These signs are compliant with Railway Group Standard GIIRT7033 in both design and positioning (CBOT Electrical Hazard: Warnings to the Public; CA0? Danger_ No Unauthorised Access) To supplement our planned general inspection regime, GTR are currently surveying all its sites to access anti-trespass and suicide measures Govia Thamesiink Railway Monument Place. 24 Monument Street, London; EC3R BAJ Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street; Newcastle upon Tyne; NE1 6EE

GTR including Samaritans signage We recognise the significant risks associated with drinking in how it potentially impairs judgement and the increased risk of death on the railway for those affected. In preparation for this year's festive season, GTR made use of the Respect the Edge campaign messaging to keep people and staff safe. In this festive Season don { let alcohol afiect you and your friencs ability to keep a clear head Stay safe on the ptatform BESRECL THE EDGE RSSB' Respect the Edge Social Media graphic (2019) festive socialising campaign was used as a timely reminder to take extra care during the festive season, when we see more people out socialising, to the extent where they are more likely to have an accident: This campaign was supported by posters at stations that have a high frequency of slips, trips, falls was heavily pushed to GTR's 333,000 Twitter followers and in briefing to staff. It's key messages for customers are to not let alcohol affect you and your Govia Thameslink Rallway Monumen: Place, 24 Monument Streel, London, EC3R 8AJ Registered in England under number: 7934306. Registered otfice: 3rd Floor, 41-51 Grey Street; Newcasiie upon Tyne, NEI 6EE heavy RESP EDLz THE The

GTR friends' ability to keep a clear head and to stay safe on the platform. messages for staff were to pay extra attention during the festive season as some customers may be affected by alcohol and may be vulnerable; be on the look-out for anyone who needs help on the platform or while getting on or off the train: As well as advice on how to manage people who may be under the influence_ Consideration for the use of cross-hatching to demark the platform edge is a recommendation made regularly by the Designing Out Crime Unit and is based on a theoretical basis that it could influence people in suicide crisis to not cross the psychological barrier _ However, there is no evidence to support that this either influences the behaviours of those in crisis or travelling passengers generally_ This recommendation has been selected by the report author, a member of BTP's Designing Out Crime Unit; from an industry document which has subsequently been formally reviewed by the industry (published in 2018 (ref: T1118 Optimising the design and position of platform markings to keep people away from the platform edge)): The aim of this review was to develop good practice guidance on the design and position of platform markings for keeping people away from the platform edge_ This included an appraisal of the efficacy of platform markings such as the yellow line and cross hatching_ The research concluded that platform marking are a weak control method and strong safety benefits should not be attached to them. To try and maximise their effectiveness as a weak control, a consistent approach to the location of the yellow line should be adopted, but could be modified considering local risks and constraints, and other markings should be avoided It can be observed in the report (CRU 2018 2255) that the consistent approach endorsed in T1118 of tactile paving and painted lines is in place at Preston Park Station: The Resilience Customer Ambassador (RCA) role provides a valuable interface for our customers which can respond directly to their questions about live network operations_ Where we anticipate greater demand, agency staff will supplement the normal establishment: Temporary staff are subject to the same and competency assessment regime as permanent staff. This now includes safety-critical communications training, which is assessed as part of the Customer Ambassador standard, so there is no longer a reliance on a Team Leader to establish a clear understanding about an emerging situation. Govia Thameslink Rallway Monument Place , 24 Monument Sireel, London; EC3R 8AJ Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Grey Street; Newcaslle upon Tyne, NE1 GEE Key May any yellow training

GTR The new training for Help Point Assessment includes functional tasks such as launching and logging into the system, answering calls and making calls back to the help point: This enhanced competency development cycle includes a 'Quiz' which tests personal knowledge and was established in February 2019 as an action from the learnings from this tragic incident: Competencies are managed through a Competency Management System (CMS), as used for other safety critical roles; this establishes an assessment cycle and maintains records of assessments, which are subject to audit: Information resources now include access to a 'Track Access' system that can be viewed on line with video and associated track map, and the Stations Made Easy section of National Rail Enquiries, to provide an interactive view of the station and its facilities such as ticket offices etc Hoiencaic EenTi es [e A0016c9 Briphlon [0 Ea3t CroydonVE Ouji} Uincs1zaJol 80 05} Repcc:- Vdoo 387 TTAS Preston Park {374 All _fL edtl Lleniies AE TONS #atmv LK Titre HI 4146 {*# C aatenE J Fanaeann Wttr Jut unruui Track Access @ image Govia Thareslink Railway Monurent Place_ 24 Monument Streel; London; EC3R 8AJ Registered in England under number: 7934306. Registered office: 3rd Floor, 41-51 Street, Newcasile upon Tyne; NE1 6EE Grey

GTR 61;;: Amunsborebulcouk ;{"cn./F4}/eukNJI Fatn Flooding in the north of England (1) ToltAcceUT [ Khatt Goiton Ersen A Taapn TESCQ Mmr Jlc Ect Eedete mane e Jaetd LiIen YAHALEAa suar mudt5y A#IEBEHAul National Rail Enquires We at GTR express our deepest condolences to the family for their tragedy and we appreciate their unimaginable loss. Our thoughts remain with them.