RAIB releases report into Stratford Station passenger fatality

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

The incident occurred when the passenger fell from the platform onto the tracks and was subsequently struck by an arriving train. The passenger had alighted from an London Underground Jubilee line train and sat on a platform bench opposite the point where they had left the train, before stumbling forwards onto the track. The investigation found that the passenger went unnoticed by several inbound trains, for approximately five minutes before being fatally injured by an arriving train. RAIB's report has subsequently highlighted concerns about operator distraction and the potential impact of automated train operation on driver vigilance.

The report concluded that the repetitive nature of automated train operation can lead to "underload” (a period where a driver’s workload is low) diminishing the attentional capacity of train operators and was an underlying factor in the cause of the incident.

It said: “When trains are operating in ATO (automatic train operation) mode, Train operator (TO) alertness can decrease because they have less active input into the control of the train. There is also evidence that some TOs may undertake tasks not related to the operation of their trains when approaching terminal platforms using ATO. This can increase the likelihood of reduced alertness or distraction, as may have occurred in this case.”

As part of the investigation, RAIB inspectors observed 34 trains arriving at platforms 13,14 and 15 at Stratford Station. It showed that as the trains entered the platforms, 10 operators remained seated, and 21 standing which is permitted currently. However, the observations showed that three operators were putting on coats or a backpack and one was standing at the cab door away from the controls.

The report however does say that CCTV footage of the drivers involved in this incident was inconclusive as to where they were looking when making their approaches to the station platform.

Furthermore, the investigation found that some train operators begin preparing to leave the station before their train has fully stopped, potentially diverting their focus from safety-critical tasks.

While London Underground had assessed the risk of such incidents, the implemented safety measures were deemed insufficient by RAIB.

The RAIB has issued two recommendations to London Underground including exploring the use of technology that can detect if a passenger is in a dangerous position and review the factors related to “underload” and action any learnings.

It also reminded London Underground of the importance of using safety-critical communications when responding and reporting incidents.