The Rail Accident Investigation Branch (RAIB) has made three recommendations to London Underground in its report into a fatal accident that took place at Waterloo Underground station on 26 May 2020.
A passenger lost his life after falling into the gap between the northbound Bakerloo line platform and the train from which he had just alighted. At the location of his fall was a large gap between the train and the platform due to track curvature.
He was unable to free himself and the train departed while he was still in the gap, crushing him as it moved off. He remained motionless on the track and was subsequently hit by a second train that entered the station.
At the time of the accident there were no staff or members of public nearby to help. Train despatch on the Bakerloo line platforms at Waterloo was undertaken by the train operator using a closed-circuit television system to view the side of the train alongside the platform.
With only his head and arm above platform level, the passenger was difficult to detect on the monitors, and was not seen by the train operator. The operator of the following train was unaware of the passenger because their attention was focused on the platform and the train’s stopping point, until after the train had struck the passenger.
RAIB’s investigation found that London Underground’s risk assessment processes didn’t enable the identification and detailed assessment of all factors that contributed to higher platform-train interface (PTI) risk at certain platforms.
Consequently, although it had implemented some location-specific PTI mitigation measures, it hadn’t fully assessed the contribution of curved platforms to the overall risk.
The investigation also found that the model used by London Underground to quantify system risk makes no allowance for non-fatal injuries, and so understates the risk of harm to passengers at the PTI and presents an incomplete picture of system risk. This has the potential to affect its safety decision making.
In its report into the accident, RAIB made three recommendations to London Underground. The first relates to the need to recognise and assess location-specific risks so they can be properly managed.
The second deals with the need to ensure that safety management processes include the ongoing evaluation of existing safety measures at stations, and provide periodic risk assessment for individual locations at intervals which reflect the level of risk present.
The third related to the need for effective delivery of actions proposed by internal investigation recommendations.
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