London Underground: Man died after falling into gap, RAIB finds

[Rambler2978]

It has just been announced that an awful tragedy at LU Waterloo, Bakerloo line, in May 2020 was due to the fact that a man who fell into the gap between the train and platform while getting off a London Underground service was not seen by two drivers. The full details can be found here - London Underground: Man died after falling into gap, RAIB finds - BBC News

A man who fell into the gap between the train and platform while getting off a London Underground service was not seen by two drivers, a report has found.
He was crushed by the Tube train he had been on and then hit by another one. He died at the scene.
The curve of the track meant the passenger was difficult to detect on the drivers' CCTV, the Rail Accident Investigation Branch (RAIB) found.
It happened on the Bakerloo line at Waterloo station in May 2020.

The man was crushed by the Tube train he had been on and then hit by another one. He died at the scene.

Although it is unlikely that this made any any difference to the awful outcome, it appears that the man was hit by a second train after the the first had left the station. The driver of that train was unaware of the passenger because their attention was focused on the platform and the train's stopping point

Condolences to the man's family and the drivers. RIP

 

[24Grange]

Very sad. Should this not be in the Underground forum however ?

 

[duncanp]

The accident happened during the first lockdown, and the BBC report says there were no other passengers present on the platform who, in normal circumstances, could have pushed the emergency button, or ran to alert the train driver.

 

[rebmcr]

The accident happened during the first lockdown, and the BBC report says there were no other passengers present on the platform who, in normal circumstances, could have pushed the emergency button, or ran to alert the train driver.

There is no emergency button on the Bakerloo line. However, it seems that an increased risk of incidents being unwitnessed is built-in to lockdown measures, and I can't recall any indications of any industry taking that into account. It certainly didn't occur to me before today.

The report's comparison images of the OPO monitors showing a mannequin in the position of the fallen man, versus no mannequin, are particularly notable. It certainly supports LUL's conclusion that those monitors are not capable of providing a safe PTI for any person or object that's already off the platform.

 

[duncanp]

There is no emergency button on the Bakerloo line. However, it seems that an increased risk of incidents being unwitnessed is built-in to lockdown measures, and I can't recall any indications of any industry taking that into account. It certainly didn't occur to me before today.

The report's comparison images of the OPO monitors showing a mannequin in the position of the fallen man, versus no mannequin, are particularly notable. It certainly supports LUL's conclusion that those monitors are not capable of providing a safe PTI for any person or object that's already off the platform.

Why is there no emergency button on the Bakerloo Line?

Does the report say what time of day and day of the week that the accident happened?

Because even during the first lockdown, it is surely unusual that there was no-one else on the platform or on the train who saw the accident and could have alerted staff.

 

[rebmcr]

Why is there no emergency button on the Bakerloo Line?

It's more a question of "why are there emergency buttons on the Central Line and the DLR?". They were only installed there when ATO was added in the late 1980s/early 1990s and trains started driving themselves, otherwise they are far from widespread nor standard.

The Victoria, automated from the start in the 1960s, didn't feature them because the technology for them didn't exist yet. This is incorrect.

A choice was made when the Jubilee was automated not to include them, based on a mix of reasons including: risk of vandalism; lack of use in the locations already using them; and most importantly, analysis that only a small number of potential accidents could actually be prevented using emergency buttons.

I wouldn't be surprised to see them disappear from the Central when its signalling is upgraded as part of the Deep Tube Upgrade (prev. New Tube for London).

Does the report say what time of day and day of the week that the accident happened?

Because even during the first lockdown, it is surely unusual that there was no-one else on the platform or on the train who saw the accident and could have alerted staff.

Mid-morning on a weekday. Certainly a quiet time on the southern Bakerloo even outside of a pandemic. Many more passengers choose the Jubilee or the Northern lines to travel north from Waterloo, or National Rail from Elephant & Castle.

 

[Dstock7080]

The Victoria, automated from the start in the 1960s, didn't feature them because the technology for them didn't exist yet.

The Victoria Line had platform emergency stop plungers from opening.

 

[Taunton]

If I witnessed someone fall from the train doorway I wouldn't search for a platform plunger; I'd step instantly into the train and operate the alarm in there, which is much more accessible.

 

[Dave W]

A terrible case, which to happen needed just about everything to go wrong.

I suspect the media will probably focus on how two drivers have failed to see the man, but certainly for the self-dispatching driver I can’t see how he could. Figures 9 and 10 on page 21 (para 49) show a reconstruction. It took me several seconds to see that and I knew what I was looking out for.

For the second driver, it seems to be a combination of factors - a different driving technique (accelerating from an unusual signal stop) and the very quiet platform, coupled with the knowledge a train had just successfully departed, seems to have caused her to focus on her stopping point - notably RAIB state she did nothing contrary to LU driving rules and training.

The platform entrances here are odd and several routes bring you out at the headwall - if a passenger boards a train immediately from this entrance - as the two people did - they’d never have seen him. It was unfortunate the lady who joined the platform after the train departed was using her phone, but by this point the gentleman was apparently already motionless on the tracks. The report suggests noticed when she looked up as the train entered but this was too late.

As for quietness during lockdown, Bakerloo loadings are - self anecdotally - pretty weak in this direction by mid-morning at the best of times. During the first lockdown there were entire trains running with under ten passengers on. I travelled regularly to my job (essential, of course) - there were instances where, so far as I could tell, I had carriages and even entire trains to myself, even on the Victoria. So it doesn’t surprise me at all that it was so quiet.

What is particularly sad is that the fault tree at figure 13 (page 27) suggests that in certain circumstances, there are 9 interventions which might have happened which would have prevented the man’s death - a lot of these were made impossible by the low number of passengers and platform staff.

Finally, and sadly I think it is relevant... that BBC article doesn’t mention the unfortunate fact that the gentleman‘s body contained 360mg of alcohol per 100ml of blood (4.5 times over the drink drive limit). This doesn’t absolve LUL of responsibility regarding their risk management and so forth, but does show the devastating impairment severe alcohol intake can have.

All in all, a dreadfully sad and tragic event. I can’t imagine how that poor woman who saw it unfold must feel, let alone the drivers involved.

 

[rebmcr]

Finally, and sadly I think it is relevant... that BBC article doesn’t mention the unfortunate fact that the gentleman‘s body contained 360mg of alcohol per 100ml of blood (4.5 times over the drink drive limit). This doesn’t absolve LUL of responsibility regarding their risk management and so forth, but does show the devastating impairment severe alcohol intake can have.

While it was clearly a factor in this incident, the same thing could easily have happened to an elderly person, or someone with reduced mobility — so the lessons to be learned by the industry are irrespective of the man's personal condition. I think it's a deliberate choice of the RAIB to de-emphasise it, in order to avoid victim-blaming, which seems to have been reflected in the BBC item that is pretty much just the RAIB summary reworded.

 

[Dave W]

While it was clearly a factor in this incident, the same thing could easily have happened to an elderly person, or someone with reduced mobility — so the lessons to be learned by the industry are irrespective of the man's personal condition. I think it's a deliberate choice of the RAIB to de-emphasise it, in order to avoid victim-blaming, which seems to have been reflected in the BBC item that is pretty much just the RAIB summary reworded.

I expect that’s probably a fairer summary than mine.

It is a rather nasty platform, there.

 

[Taunton]

While it was clearly a factor in this incident, the same thing could easily have happened to an elderly person, or someone with reduced mobility — so the lessons to be learned by the industry are irrespective of the man's personal condition. I think it's a deliberate choice of the RAIB to de-emphasise it, in order to avoid victim-blaming, which seems to have been reflected in the BBC item that is pretty much just the RAIB summary reworded.

I think we should not go for inflated "what if" speculation. The fact is that it did not happen to an elderly person, nor one with reduced mobility, and as far as we are aware has never done so here, which rather dispels "easily have happened".

It has common factors with the James Street, Liverpool accident, which outcome caused much disquiet on here.

 

[ComUtoR]

I think we should not go for inflated "what if" speculation. The fact is that it did not happen to an elderly person, nor one with reduced mobility,

The victim was 59 and had mobility issues

and as far as we are aware has never done so here, which rather dispels "easily have happened".

LUL have recorded 17 incidents since 2005 on the Southbound platform (person falling into the gap)

It has common factors with the James Street, Liverpool accident, which outcome caused much disquiet on here.

Care to explain ?

 

[GB]

It has common factors with the James Street, Liverpool accident, which outcome caused much disquiet on here.

The common factors were someone found themselves between the platform and train and sadly died as a result. Lets not try and tenuously link things.

 

[Bikeman78]

If I witnessed someone fall from the train doorway I wouldn't search for a platform plunger; I'd step instantly into the train and operate the alarm in there, which is much more accessible.

Holding the doors open is another option. Then get someone else to alert the driver.

 

[Vespa]

Some of gaps on Bakerloo is very wide, probably the widest in the whole LU system, I had to virtually leap across and often wondered on what if I misjudged and fall between the gaps, doesn't bear thinking about and wondered why didn't they remodel the platforms to take this into account.

 

[MikeWh]

wondered why didn't they remodel the platforms to take this into account.

What could they actually do? Where a platform is curved it has to allow the ends of each carriage to pass without obstruction. Doors towards the centre of the carriage will always have a large gap.

 

[AlbertBeale]

Some of gaps on Bakerloo is very wide, probably the widest in the whole LU system, I had to virtually leap across and often wondered on what if I misjudged and fall between the gaps, doesn't bear thinking about and wondered why didn't they remodel the platforms to take this into account.

You couldn't remodel the platforms - you'd have to re-bore the tunnel alignment in order to straighten the track and hence the platform edge. On curves like those at Waterloo on the Bakerloo, there's no way to avoid doors in the middle of a carriage being well away from the platform edge on account of the simple geometry, since there has to be enough space for the ends of the carriages to not hit the platform! I think Piccadilly Circus southbound is also very bad at the north end. Perhaps the Met through platforms at Baker Street are the other place with such an extreme gap?

There is the New York approach of having some sort of strong mesh which springs out from under the platform edge and presses against the side of the train (at the places where the doors have the worst gaps) after the train stops but before the doors open - this gives reasonable protection against someone falling into the gap. Though there might well be a difference - as between the NY subway and the tube here - in the relative height of the platforms and the base of the train sides, so perhaps that wouldn't work here.

 

[mmh]

If I witnessed someone fall from the train doorway I wouldn't search for a platform plunger; I'd step instantly into the train and operate the alarm in there, which is much more accessible.

I'd assume the vast majority of passengers have no idea there are emergency plungers on platforms. They'll be shielded or surrounded by "do not press this" signs, or both. They can only be sensibly useful for platform staff.

 

[richardcoughla]

Some of gaps on Bakerloo is very wide, probably the widest in the whole LU system, I had to virtually leap across and often wondered on what if I misjudged and fall between the gaps, doesn't bear thinking about and wondered why didn't they remodel the platforms to take this into account.

Bank on the Central Line has to be up there as the worst?

 

[bramling]

What could they actually do? Where a platform is curved it has to allow the ends of each carriage to pass without obstruction. Doors towards the centre of the carriage will always have a large gap.

The Northern Line platform at Embankment is permanently staffed, and I believe the platform will be closed should a member of staff not be available.

The only other comparable platforms are Bank (Central) and Waterloo (Bakerloo), so that would be an immediate mitigation. It isn’t ideal though - spending extended amounts of time on curved platforms would be very unpleasant for staff due to the noise, earplugs would be a necessity for a start, and rotating things so one person doesn’t spend too long.

It also introduces an issue that the member of staff is essentially being burdened with the responsibility should anything happen, so you have to consider the possibility of being distracted. Passengers tend to have a habit of thinking any member of staff is at liberty to drop any task they might be performing in order to answer their query, which straight away introduces a distraction risk.

As RAIB allude to, the platform monitors weren’t designed to deal with this specific scenario, and even the latest systems aren’t really either. The driver will only be focusing on the doors when it’s time to dispatch the train, so anything happening before that is unlikely to be picked up.

Not easy solutions unfortunately, and one scenario where users need to do their bit and present themselves for travel in a fit state, unlike for example the James Street incident.

 

[ThisIsSurbiton]

While it was clearly a factor in this incident, the same thing could easily have happened to an elderly person, or someone with reduced mobility — so the lessons to be learned by the industry are irrespective of the man's personal condition. I think it's a deliberate choice of the RAIB to de-emphasise it, in order to avoid victim-blaming

I'm surprised that the report names the victim, especially as they (now) don't give names of any employees, as of course they shouldn't. The Sandilands tram derailment report gives the victim's names, but more as a memorial and of course it's obvious that they couldn't have shared any of the responsibility, however small, for what happened.

What could they actually do?

Short of rebuilding, gap fillers are a possibility, and is obstacle detection good enough to ignore a train but see a person? Done with cameras pointing into the gaps, perhaps it is. Having staff there has been mentioned, there are only a handful of platforms of this type and it doesn't take flawed risk analyses (one finding that this platform had as much risk as the other found for the whole of the line) to know which they are. Reading the report has reminded me to check where the alarms are every time I get on a train, but people have short memories and I don't suppose I'll keep it up, unfortunately. You never know when that knowledge could be important.

 

[philthetube]

If I witnessed someone fall from the train doorway I wouldn't search for a platform plunger; I'd step instantly into the train and operate the alarm in there, which is much more accessible.

Blocking the doors is a better solution, guaranteed to prevent the train from moving.

 

[Highlandspring]

I'm surprised that the report names the victim, especially as they (now) don't give names of any employees, as of course they shouldn't. The Sandilands tram derailment report gives the victim's names, but more as a memorial and of course it's obvious that they couldn't have shared any of the responsibility, however small, for what happened.

The RAIB's sister agency the Marine Accident Investigation Branch names victims of fatal accidents in their reports, always with the agreement of the families.

 

[bramling]

Blocking the doors is a better solution, guaranteed to prevent the train from moving.

The jury could be out on this one. Blocking a door prevents the train from motoring, but it doesn’t prevent it from rolling. Operating the alarm *should* in a station platform result in the driver securing the train and investigating.

On balance I’d go for a passenger alarm, unless the doors are already starting to close in which case that’s the only viable option. You could also achieve the same effect with using a butterfly cock, but again this doesn’t guarantee the train won’t depart, albeit it would require a freak combination of circumstances (which, incidentally, can and has happened).

 

[Dstock7080]

You could also achieve the same effect with using a butterfly cock, but again this doesn’t guarantee the train won’t depart, albeit it would require a freak combination of circumstances (which, incidentally, can and has happened).

Unfortunately, many Stock have been modified to only allow key operation of the butterfly cock.

 

[Bletchleyite]

The jury could be out on this one. Blocking a door prevents the train from motoring, but it doesn’t prevent it from rolling. Operating the alarm *should* in a station platform result in the driver securing the train and investigating.

On balance I’d go for a passenger alarm, unless the doors are already starting to close in which case that’s the only viable option. You could also achieve the same effect with using a butterfly cock, but again this doesn’t guarantee the train won’t depart, albeit it would require a freak combination of circumstances (which, incidentally, can and has happened).

I witnessed a dangerous occurrence on LU a while back (someone trapped in the doors by their bag straps, but with the doors closed enough for the hazard lights to go out) and I did the "both hands in the air" stop signal towards the DOO cameras alternating with pointing, it seemed to work though it might be that the driver just noticed the incident rather than noticing me.

 

[bramling]

I witnessed a dangerous occurrence on LU a while back (someone trapped in the doors by their bag) and I did the "both hands in the air" stop signal towards the DOO cameras alternating with pointing, it seemed to work though it might be that the driver just noticed the incident rather than noticing me.

Both hands in the air is a stop signal, but not an emergency one - that would be to wave both hands.

The risk with using a handsignal is that this is often done by people who want to board after the doors have closed. Whilst this is likely to result in the driver paying extra attention to the spot in question, it isn’t a guarantee - especially if not from staff.

 

[Taunton]

Short of rebuilding, gap fillers are a possibility,

The Gap Fillers some may have seen on the New York Subway (where platforms like the streets are generally straight but there are some extreme curved ones at eg terminal loops) are a mechanical nightmare, as they, obviously, obstruct the loading gauge when deployed, so they have to be interlocked with the signals as being fully retracted, both for arrival and departure, and are well known for failures. Being typically at line ends, such as South Ferry on the 1 Line (where many visitors encounter them on their way to the Staten Island ferry), when they do fail/jam/have debris fall into them, etc, the service can be suspended one station short, with trains reversing there, which New York, unlike London, has plenty of crossover provision for. I believe the signalling does not now allow a train to depart the preceding station until the one ahead has departed the loop with the gap fillers, to guard against being stopped in the section with the train ahead delayed by a gap filler problem.

 

[Bikeman78]

The jury could be out on this one. Blocking a door prevents the train from motoring, but it doesn’t prevent it from rolling. Operating the alarm *should* in a station platform result in the driver securing the train and investigating.

Is that specific to underground trains? Pulling the doors open on a class 150 (and presumably all similar BR EMUs) definitely applies the brakes. I've not tried it myself but a load of kids did on a 150 several times and each time it ground to a halt.