Stratford station fatality prompts calls for warning systems to be fitted to trains
A report into a fatality at Stratford station concludes that Transport for London (TfL) should investigate whether it can fit warning systems to its trains to warn their drivers of people on platforms or tracks who are in danger.
The fatality took place on Boxing Day 2023, when an elderly passenger, Brian Mitchell, got off a Jubilee line train at lunchtime, sat on a platform bench for nearly an hour at the far end of the platform of the little-used Platform 13, got up, stumbled forward, and fell onto the railway tracks. A few minutes later, a train arriving at the station struck the passenger, passing over them without being aware of the accident. Three more trains arrived at the station, passing over the passenger before the accident was noticed.
A later toxicology report found the passenger had been three times over the legal drink driving limit, and while that will explain how he fell off the platform, a railway investigation is carried out to see if anything could have been done to prevent the fatality.
Following a review of the accident by the Rail Accident Investigation Branch (RAIB), they suspected that a mix of factors may have contributed to the train drivers’ failure to see the passenger lying on the tracks as they arrived at the station.
The review of the accident suggests that the train drivers may have had their attention reduced because the train was in automatic operation. The RAIB’s investigation concluded that the repetitive nature of the task under automatic train operation could lead to cognitive underload, a state of mind in which lots of repetitive tasks can make it harder to concentrate, and that reduces their alertness to unexpected problems.
The RAIB also found that at terminus stations, some train operators are getting ready to leave their train before it has stopped, meaning they may not be focusing on tasks related to the train’s operation. The report also suggests that the first train driver may have been distracted by another driver who was standing on the platform as the train arrived at the station.
Although London Underground had quantified the risk of a passenger falling from the platform and being struck by a train at Stratford station, the review found that risk controls adopted were not sufficiently effective in this instance to prevent the accident from occurring.
The review recommends that TfL consider using technology to detect if a passenger is in a dangerous position and intervene or warn as necessary to stop an approaching or departing train. TfL has confirmed that it is already developing such plans.
They also recommend that TfL review how automatic train operation can affect train drivers and what could be done to reduce the effects of cognitive underload. TfL completed its first Rail Platform Train Interface Plan last October, which sets out time-bound action to drive improvements to reduce risk in this area.
In a statement, Lilli Matson, TfL’s Chief Safety Officer said: “Our thoughts remain with the family and friends of Mr. Mitchell, who sadly died at Stratford Tube station on 26 December 2023. We welcome the recommendations from the RAIB’s independent investigation into this incident, which align with the findings of our own internal investigation, and work has already begun to implement them We will always strive to learn from incidents and improve operational safety, including by ensuring relevant regulatory bodies are immediately informed, carrying out thorough and extensive internal investigations and prioritising taking action on any recommendations from any review. While serious injuries on our network are rare, we are undertaking a huge range of work to eradicate such incidents and make the network even safer for everyone.”
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In line with best practice for investigating accidents, RAIB investigations are conducted in a blame-free environment, and the report recommends ways to prevent future accidents. RAIB does not establish blame, liability or carry out prosecutions.
Why could the plastic screens n doored barriers not have been built in when refurbishment and renovation work done. It has certainly helped at other stations to prevent people falling, jumping in front of trains.
While some countries use screens to stop people falling, TFL uses them most for ventilation management, so they are generally not used on open stations. As an example, the EL doesn’t have them at Woolwich or Custom house, despite being new builds.
They are relatively expensive too. I found an FOI request stating £84.7m for 16 platforms, so roughly £5m a platform. And from memory, the usual sum used was £2m – ie if the cost per life saved was more than that, you could save more lives by using it elsewhere.
As station track is a relatively static environment, I’d expect camera systems to be fairly straightforward, and be applicable everywhere.
An absolute tragedy for the family.
One has to ask though; would the same level of investigation and remediation be considered if he’d been run over after stumbling intoxicated onto a busy road? I think we all know the answer – it wouldn’t even make the news.
I’m not taking a position of what’s right or wrong here, other than to point out the double standard – an average of 4.5 people killed each day by road collisions in the UK.
Fair point.
If this had happened on the road then there would have been an inquest.
But there are different regulations for incidents on the railway that require additional investigation (separate to an inquest)
@ChrisC
Exactly. The whole system is stacked in favour of private road vehicles.
This matters because there’s so much narrative out there about people feeling unsafe on public transport, and yet by any measure except the psychological one, they’re far safer than in a car.
There aren’t many cases of 4 cars running the same person over before anyone notices!
@Andy T
How do you know that?
This kind of detail is neither reported nor recorded, no-one wants to think about it. On a busy road it wouldn’t be too difficult for it to happen. And in amongst the 4-5 fatalities every day?
@Paul I’m pretty sure there would be an outcry from the family, general public at large along with a few well publicised prosecutions taking place if such a thing we’re to be known to have happened. The fact that nobody wants to think about it and that it would be shocking is what would make it so newsworthy.
A car is only as safe as its driver, and all spectums of the scale are out there on a given day, indeed it is well known that the railways are much safer than the roads for the majority, and again, that fact explains why incidents on railways attract greater media
attention unless it’s a particularly bad RTC
(fitting) “warning systems to its trains” – called the HORN, & already there …
And how does the person on the tracks or the platform sound the horn to warn the driver?
I guess one potential option might be to have cameras that can see the tracks, and connecting these to AI to detect potential hazards which are on or very close to the tracks. If it detects a potential hazard it could then alert a human operative to verify. There may even be the potential to then send an alert to the oncoming train/tube driver’s cabin to take care when approaching the next station.
I know that there has been some AI work on platform camera surveillance. The idea here is to detect people who are acting in a way to suggest that they might be up to no good or else people who might be about to harm themselves in front of a train. I don’t know if these systems have cameras focussed on the track. Maybe they should. From a technical perspective I suspect it is much easier to recognise a person of concern (or any obstruction) on the track than it is on a platform full other other people.