The Rail Accident Investigation Branch (RAIB) has released its report into a tragic accident at Stratford London Underground station on December 26, 2023, which resulted in the death of a passenger.

Incident Overview

The incident occurred at approximately 1.57pm when a passenger alighted from a Jubilee line train at Stratford station. The passenger sat on a bench on the platform before standing up around 2.45pm Moments later, they stumbled forward, falling onto the track.

Unable to move to a position of safety, the passenger remained undetected for about five minutes before being struck by an arriving train, which stopped normally at the platform. The passenger was fatally injured.

Subsequently, three more inbound trains entered the terminal platform, each passing over the passenger’s location without detection. The fourth inbound train operator and a customer service assistant became aware of the passenger on the track but failed to stop the train before it entered the station.

Key Findings

The RAIB’s investigation identified several factors that contributed to the fatal accident:

• Automatic Train Operation (ATO): The repetitive nature of tasks under ATO may reduce attentional capacity, leading to decreased alertness or distraction among train operators.
• Platform Awareness: The operator of the first train failed to notice the passenger on the track, possibly due to reduced attentiveness and the distraction of another operator standing on the platform.
• Missed Recognition: The operators of the second and third trains did not identify the passenger on the track. The fourth train operator saw the passenger but failed to stop the train in time.
• Ineffective Risk Controls: Although London Underground Limited had assessed the risk of passengers falling onto the track at Stratford station, the existing safety measures were insufficient to prevent this incident.

Recommendations

The RAIB has issued two recommendations to London Underground Limited:

1. Passenger Detection Technology: Implement technology to detect passengers in dangerous positions and alert train operators or intervene automatically to prevent trains from entering or leaving the platform.
2. Operational and Environmental Review: Examine the factors affecting train operators’ performance under ATO, focusing on reducing risks associated with diminished attentiveness.

Additionally, the RAIB highlighted the importance of safety-critical communication during incident reporting and response.

Conclusions

The RAIB concluded that a combination of human error, operational factors, and insufficient safety measures contributed to the accident. The report underscores the need for improved detection systems and changes to operational practices to prevent similar tragedies in the future.

Next Steps

London Underground Limited is expected to respond to the recommendations and implement changes to enhance passenger safety at Stratford and other stations across the network.

The full report is available on the RAIB website, detailing the findings and recommendations in-depth.