Prevention of Future Deaths reports · 2020

Jordan Aira

Regulation 28 report to prevent future deaths, reference 2020-0082, written 30 Mar 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report30 Mar 2020
Reference2020-0082
DeceasedJordan Aira
CoronerCaroline Topping
Coroner areaSurrey
CategoryRailway related deaths · Child Death (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

IN THE SURREY CORONER’S COURT 

IN THE MATTER OF: JORDAN MICHAEL AIRA  

__________________________________________________________ 

The Inquest Touching the Death of JORDAN MICHAEL AIRA  

A Regulation 28 Report – Action to Prevent Future Deaths 

__________________________________________________________ 

THIS REPORT IS BEING SENT TO: 

  Andrew Haines CEO Network Rail  
  Mark Hopwood Managing Director South Western Railway  
  The Right Honourable Gavin Williamson Secretary of State for Education  

1 

CORONER 

Caroline Topping HM Assistant Coroner, for the County of Surrey 

3 

INVESTIGATION and INQUEST 

An inquest into the death of Jordan Michael Aira was opened on 4th April 2019 and 
resumed and concluded on 24th January 2020. Evidence in respect of matters pertaining 
to this report was heard on the 21st February 2020.  I concluded that Jordan Michael 
Aira  died on the 23rd March 2019 at Ashford Railway Station, Surrey and that the 
medical cause of his death was; 

1a Electrocution on railway line and electrical burns. 

I concluded he died of an accident. 

4 

CIRCUMSTANCES OF THE DEATH 

Jordan Aira was walking home from a party in the early hours of the morning on the 23rd 
March 2019. He gained access onto the platform of Ashford Station, sat for over an hour 
on a bench and then walked down an unsecured ramp onto the railway lines. He fell 
onto the live third rail and was electrocuted.  

 
 
 
 
 
 
 
 
 
 
 
 
 5 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths could occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  –  

The evidence showed that: 

1.  There were no physical boundaries at the end of the platform preventing 

members of the public accessing the railway tracks.  

2.  The emergency telephone which may be used by members of the public is 

located adjacent to the railway track.  

3.  The warning signs in place which are standard in the rail industry do not in terms 

warn of the risk of immediate death if you touch the live rail.  

4.  There is no requirement in the national curriculum to teach pupils about the risk 

posed by the live rail.  

.  

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe your 
organisation has the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 25th May 2020. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons; 

I am also under a duty to send the Chief Coroner a copy of your response.  

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it useful 
or of interest. You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

 
 
 
 
 
 
 
 
 
 
 
 9 

Signed: 

Caroline Topping 

Dated this 30th March 2020.

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Network Rail (PDF)
Ms Caroline Topping 
HM Assistant Coroner, for the County of Surrey 
HM Coroner’s Court 
Station Approach 
Woking  
Surrey  
GU22 7AP 

9 June 2020 

Reference: Regulation 28 report – Jordan Michael Aira 

Network Rail 
Basingstoke Campus 
Gresley Road 
Basingstoke 
Hampshire 

Dear Ms Topping 

Regulation 28 report – Jordan Michael Aira 

I write in relation to the above Inquest heard on 21st February 2020 following the sad 
death  of  Jordan  Aira on  23  March  2019 near  Ashford  station. In  particular  I  seek  to 
address the concerns set out in the Regulation 28 report dated 30 March 2020. We are 
grateful to you for drawing these concerns to our attention.  

We have noted your findings that Jordan Aira was walking home from a party in the 
early hours of the morning on the 23rd March 2019. He gained access onto the platform 
of Ashford Station, sat for over an hour on a bench and then walked down an unsecured 
ramp onto the railway lines. He fell onto the live third rail and was electrocuted.  

This was a very tragic accident as your inquest recorded and our thoughts and deepest 
sympathies go out to Jordan’s family and friends. 

Network Rail was not granted Interested Person status and so could not address the 
Inquest directly. But I understand the evidence led to some concerns about: 

1.  physical  boundaries  at  the  end  of  the  platform  preventing  members  of  the 
public accessing the railway tracks;  
2. the emergency telephone located by the railway track;  
3. the statutory warning signs not directly warning of the fatality risk if you touch 
the live rail; and  
4. there being no requirement in the national curriculum to teach pupils about 
the risk posed by the live rail.  

Before specifically addressing these concerns, I wish to emphasise that Network Rail 
and  the  wider  rail  industry  invest  considerable  time  and  effort  seeking  to  prevent 

Network Rail Infrastructure Limited Registered Office: Network Rail, 2nd Floor, One Eversholt Street, London, NW1 2DN Registered in England and Wales No. 2904587 
www networkrail.co.uk 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 members  of  the  public  accessing  the  infrastructure  and  to  warn of  the  dangers  this 
poses. Unlike access to other private land, unlawful access to the railway has been a 
criminal offence since Victorian times. 

Network  Rail  works  with  railway  industry  partners  including  South  Western  Railway 
(SWR) and British Transport Police, and other organisations such as local authorities 
and schools  
Page 2 
Reference: Regulation 28 report – Jordan Michael Aira contd. 

to prevent trespass by members of the public. Our extensive campaigns warn of the 
dangers and target people at risk and high-risk areas referred to as “trespass hotspots”. 

In addition to national campaigns using internet, broadcast, print and social media, our 
safety  teams  target  trespass  hotspots  and  have  made  significant  reductions  in  the 
number  of  trespass  incidents.  Evidence  demonstrates  the  campaigns  make  more 
people  aware  of  the  dangers  of  railway  trespass.  Our  risk  assessments  identify  the 
appropriate types of fences along the boundary of the 20,000 miles of railway in Great 
Britain, but certain locations such as stations must by their very nature permit people 
to access trains.  

How the railway is managed 

The  railway  industry  involves  many  companies  who  collaborate  to  operate  safely. 
Network Rail owns and operates the rail infrastructure i.e. the track, signalling, bridges, 
level  crossings  etc.  Other  companies  operate  the  trains  and  most  stations.  The  Rail 
Safety  and  Standards  Board  (RSSB)  coordinates  standards  that  apply  across  the 
industry. 
South  Western  Railway  is  responsible  for  the  station  at  Ashford  under  a  franchise 
agreement. They are responsible for the signs at the station and applying standards 
set by the RSSB.  

Network Rail is responsible for the infrastructure serving the station, including placing 
statutory signs warning people that trespass is an offence and determining whether 
barriers are required at the platform ends. And for applying the relevant standards set 
by RSSB. Only trained and authorised railway staff are permitted to go off the platform 
ends.  
RSSB  has  by  way  of  example  produced  a  Rail  Industry  Standard  for  Station 
Infrastructure  RIS-7700-INS;  Railway  Group  Standard  GI/RT7033  relevant  to  Lineside 
Signs; Rail Industry Standard RIS-7016-INS Interface between Station Platforms, Track, 

 
 
 
 
 
 
 
 Trains  and  Buffer  Stops  and  many  more  which  include  the  requirements  for  the 
specification and positioning of safety signs and platform safety features.  

Turning now to the specific concerns: 

1.  There  were  no  physical  boundaries  at  the  end  of  the  platform  preventing 
members of the public accessing the railway tracks.  

As  at  all  other  stations,  signs  at  the  ends  of  the  platform  at  Ashford  prohibit 
unauthorised  access  and  warn  of  the  dangers,  including  of  electrocution.    But  in 
addition, we target trespass hotspots with additional measures to help further deter 
unlawful access. The Inquest heard evidence that Ashford station is not such a hotspot 
making it less of a priority than some of the other 2500 stations for additional safety 
initiatives and resources. 

At most stations the clear signs are sufficient to deter unauthorised access and avoid 
the risks. Platform ramps enable railway staff to access the track when required and 
enable passengers to access the station if for example a broken-down train meant they 
had to be evacuated along the track. 

Page 3 
Reference: Regulation 28 report – Jordan Michael Aira contd. 

Ashford was not therefore a priority  station  for additional barriers. However, as was 
explained at the Inquest, work to improve that station is planned and will now include 
extra platform markings and barriers to further deter trespass. 

2.  The  emergency  telephone  which  may  be  used  by  members  of  the  public  is 
located adjacent to the railway track.  

At Ashford there is a “help point” telephone on the station for passengers to speak 
directly with SWR customer support staff. But the emergency telephone quoted is not 
for  public  use.    The  two  railway  telephones  attached  to  the  signal  post  are  for 
operational contact with the signaller and electrical control.  They are located by the 
track beyond the platform sign prohibiting public access. That they are in a prohibited 
area demonstrates they are not intended for public use.   

The signal post telephones are intentionally sited where they are required for railway 
operations and safe use by railway staff. Passengers have the help point available if 
needed.  We therefore do not accept this observation needs to be addressed. 

 
 
 
 
 
 
 
 
 
 
 3.  The warning  signs  in  place  which  are  standard  in  the  rail  industry  do  not  in 
terms warn of the risk of immediate death if you touch the live rail.  

The  signs  displayed  at  the  station  clearly  warn  of  the  danger  of  electrocution  and 
comply with the Railway Group Standard GI/RT 7033. To avoid confusion at different 
locations, there is safety benefit in consistent and clear signs that meet British Standard 
ISO 3864 – 1.2011: ’Graphical symbols’ and the Health and Safety (Safety  Signs and 
Signals) Regulations 1996. 

Network  Rail’s  own  company  standard  NR/L2/ELP/21131  applies  the  industry  and 
national  standards  and  follows  appropriate  risk  assessments.  The  signs  provided  by 
Network Rail at Ashford remain compliant with those standards. 

The signs include a clear direction that passengers must not go onto the track or cross 
the line; a sign giving the contact number for the Samaritans; and a graphic ’electric 
bolt’  sign  with  large  words  stating  “Danger  do  not  touch  the  live  rail”.  Research 
evidence  highlights  the  benefit  of  clear  and  simple  communication  of  risks.  Adding 
additional words would run counter to our professional assessment.  

Adding words suggesting a “risk of immediate death” may even increase the risk to 
anyone with mental health issues and suicidal thoughts. Network Rail is a national and 
world  leader  in  combatting  suicide  on  the  railway  and  yet  last  year  for  every  death 
resulting from railway trespass, there were around 16 suicide deaths.  

4. There is no requirement in the national curriculum to teach pupils about the 
risk posed by the live rail.  

Network  Rail  does  not  determine  the  curriculum  and  we  would  welcome,  and  be 
supportive of, any addition to the curriculum educating young people on the risk posed 
by accessing  
Page 4 
Reference: Regulation 28 report – Jordan Michael Aira contd. 

the railway. However we would like to take this opportunity to highlight the work we 
do with schools and other organisations to raise awareness of the dangers of accessing 
the railway, including from electrification risks.  

Network  Rail  works  with  schools,  sport  and  community  partners  to  educate  young 
people about the dangers. Our schools’ partner LearnLive has reached over five million 
children in the past 18 months alone. 

 
 
 
 
 
 
 
 
 
 
 The English Football League (EFL) Trust and StreetGames each help with face-to-face 
education on railway safety and the dangers associated with trespass.  While impacted 
more recently by the COVID-19 pandemic, their work has continued with social media 
reaching millions of young people in at-risk groups and locations, especially trespass 
hotspots. 

Other  work  by  the  industry  with  the  Scouts  Association  and  the  Duke  of  Edinburgh 
awards also help share the same railway safety messages.   

Underpinning all this work is our social media campaign branded “YouVsTrain” which 
specifically  targets  11-18-year  olds.  The  material  used  in  that  campaign  and  on  the 
YouVsTrain.co.uk  website  specifically  features  the  dangers  from  electrification  with 
three dramatic films reconstructing real events. Those films have been seen by many 
millions of people and have won awards for effective community engagement. Other 
work with Fun Kids Radio and a book featuring Thomas the Tank Engine target younger 
age groups. 
In just two years this combination of activity has reduced overall trespass incidents by 
24% and youth trespass particularly by 32%. 

I hope my letter addresses the concerns raised but would be happy to provide further 
information about our extensive work to deter trespass if that would help. 

Yours faithfully 

Route Director 
Wessex Route
Response from South Western Railway (PDF)
South Western Railway 
      4th Floor, South Bank Central  
                         30 Stamford Street 
                        London  
SE1 9LQ 

         Ms Caroline Topping 
         HM Assistant Coroner  
         HM Coroner’s Court 
         Station Approach 
         Woking 
         Surrey 
         GU22 7AP 

                                                                                                                            22 May 2020 

Email: 

Dear Ms Topping 

I write for and on behalf of First MTR South Western Trains Limited, which brands its services as South 
Western Railway (SWR). I refer to your Regulation 28 Report of 30th of March 2020 in relation to the 
inquest into the death of Jordan Michael AIRA to which you have requested a response from SWR by 
the 25th of May 2020. 

The purpose of this letter is to respond to and address the matters of concern raised in the Report as 
point three in the list of “Matters of Concern”. Network Rail (NR) will provide a response to the “Matters 
of Concern” under points one and two. 

On behalf of SWR, I would like to take this opportunity to express my sincere condolences to the family 
of Mr Aira. 

Details of signage at Ashford station 

At the time of the incident, the following signage was in place at Ashford station: 

(a)  Signs at the end of each platform, at or near the top end of platform ramp, which state that 

passengers must not pass those points. They also show the 
warning “Danger: Do not touch the live rail”. These signs also contain symbols denoting 
“do not enter” and “danger – electrical hazard” and are designed to be visible at or near the 
top end of each ramp i.e. the point at which trespass may occur.  

(b)  Red  signs  saying  “Warning  –  do  not  trespass  on  the  railway”  outside  the  entrance  on 
platform two and the out of hours gate on platform two. Two signs have been added to the 
entrance of platform one since the incident.  

(c)  Yellow signs saying, “Please keep behind the yellow line until the train has stopped”. Four 
signs are placed along platform two and there are five signs along platform one. Platform 
one is busier in the morning with services going towards London. 

(d)  Samaritans signs at all four of the platforms ends and station entrance(s). These are similar 

to the design in place at other stations across the network.  

Passengers  are  therefore  required  to  pass  close  to  signs  warning  them  not  to  trespass,  and  of  the 
dangers of trespass, at the station entrances and on the platforms in the ordinary course of accessing 
the station and when waiting for trains.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The signage in place at Ashford station conforms with the Station Infrastructure Standard (Rail Industry 
Standards 7700-INS – Issue 3, June 2018) which is applied nationally by the wider rail industry.  

In  addition  to  SWR’s  response  to  point  three,  I  would  like  to  provide  you  with  an  overview  of  the 
initiatives we take to educate pupils about the risks posed by the live rail, which may be relevant to point 
four in the list of “Matters of Concern”. 

SWR works very closely with NR to deliver Safety Awareness sessions at schools located near stations 
on our network. These educational sessions have been ongoing since 2017 and are delivered to pupils 
from Reception Year to Year 11. The focus of the sessions is to make the pupils aware of the dangers 
of the railway including the third rail, and how to behave without putting themselves and others in danger 
when on a station or near a level crossing.  

These  sessions  are  delivered  by  NR’s  Community  Safety  Manager  with  the  support  of  SWR’s  Rail 
Community Officers and since 2017 have been delivered to 136 schools located on our network and 
reached 52,499 pupils. 

Additionally,  in  2018  the  “You  vs  Train”  campaign  was  launched  to  the  public  using  social  media 
channels, targeting a younger audience making them aware of the dangers of the railway through Virtual 
Digital  sessions  delivered  to  primary  and  secondary  schools  as  well  as  colleges.  The  campaign’s 
effectiveness is enhanced by the use of video accounts of survivors who came into contact with the 
third rail. The aim of this campaign was to: 

•  Raise awareness about the dangers of trespassing, including the risk of electrocution 
•  Evolve attitudes towards trespassing. 
•  Reduce the likelihood of future trespassing and harm. 

Since 2018, on a national scale, the Virtual Digital sessions have been delivered to approximately 4.5 
million students and the “You vs Train” campaign has had approximately 2.8 million hits on YouTube. 
In addition to this, the number of incidents involving young people trespassing on the railways has since 
fallen by 31.25%.  

To  complement  the  classroom  and  online  learning,  live  operations  occur  such  as  the  Trespass 
Awareness  week  (23-27  March  2020),  led  by  Network  Rail,  British  Transport  Police  and  the  wider 
industry enhancing the public’s awareness around the dangers linked to trespassing on  the railway. 
This was achieved through the use of our social media channels, pledging our support to the campaign 
and spreading the “You vs Train” safety message. 

Locally  to  SWR,  we  have  Rail  Safety  Accredited  Security  Officers  (Rail  Community  Officers)  whose 
core activities include the following:   

•  Hi-vis uniform patrols to deter trespass and anti-social behaviour 
•  Working with the BTP and Network Rail to target hotspot locations 

In conclusion, the signage in place at Ashford station at the time of the incident was in line with the 
approach taken by the wider rail industry and is visible throughout the station, except for the entrance 
to  platform  one.  The  red  sign  saying  “Warning  –  do  not  trespass  on  the  railway”  was  subsequently 
installed. In light of this, SWR does not consider that any further action is required to be taken further 
to the Report. 

However, as an active member of the National Suicide Prevention Working Group and the Trespass 
Risk Group, SWR will continue to  engage  with the  wider rail group from which consideration  will be 
taken in relation to warning signage.    

I hope that this response addresses your concerns. 

Yours Sincerely, 

Mark Hopwood 
Managing Director

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