A person lay on a railway track at a London Underground station for around 30 minutes before being discovered after being fatally struck repeatedly by trains in an incredibly tragic and horrific incident. Emergency services rushed to the London Underground platforms at Stratford on December 26, 2023, after a passenger fell from a platform onto the track.
The incident resulted in no service between Stratford and West Ham on the Jubilee Line until it was reopened sometime later that day. The passenger was killed in the incident.
The Rail Accident Investigation Branch (RAIB) has since carried out a year-long investigation into the circumstances of the tragic accident. Lilli Matson, Transport for London’s Chief Safety Officer, said work has already begun to implement the findings of the independent investigation.
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A report released by the Rail Accident Investigation Branch (RAIB) says the passenger “stumbled forwards” and fell onto the track. Unable to get to a position of safety, the passenger lay on the track undiscovered for around five minutes before being struck by an arriving train which then stopped normally in the platform.
The passenger’s presence on the track remained unknown and a further three inbound trains entered the terminal platform and went through the location where the passenger was lying. The passenger was fatally injured.
The RAIB say the passenger fell when there were no other passengers or staff present on the platform. They found that the operator of the first train did not notice the passenger “possibly because their level of attention as reduced due to the use of automatic train operation”.
“The operator may also have been distracted by the presence of another operator who was standing on the platform as the first train arrived at the station,” they added. The incident was made more severe as the second train operator also did not see the passenger while the third train operator noticed something but did not recognise it as a person.
“The fourth inbound train was not stopped by a customer service assistant who was present on the platform when it was entering the station, even though the assistant was by now aware that a person was on the track,” the report continues. “Although the operator of the fourth inbound train had independently recognised that there was a person on the track, they did not stop their train. The train operators working the trains in the outbound direction were not aware of the passenger because the passenger was underneath their respective trains before they departed.”
The presence of the passenger was unknown between around 14:45 when they stumbled and 15:16 when London Underground staff became aware of a passenger on the track. Before trains could be stopped, a fourth train entered the platform and went through the location where the passenger was lying.
Jubilee line trains parked at the London Underground Stratford Market Depot in London. File image
(Image: PA)
The RAIB investigation concluded that the repetitive nature of the task under automatic train operation may lead to a state of underload, affecting the attentional capacity of train operators. “This can increase the likelihood of effects on performance such as reduced alertness or distraction,” they said. “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 relating to the operation of the train.
“Although London Underground Limited had quantified the risk of a passenger falling from the platform and being struck by a train at Stratford station, the risk controls adopted were not sufficiently effective in this instance to prevent the accident from occurring.”
A learning point has been identified reminding staff of the importance of using safety-critical communications when reporting and responding to incidents. The RAIB has made two recommendations to Transport for London:
- They should consider using technology to detect if passengers are in a dangerous position, allowing them to be warned about moving trains
- Review the environmental, organisational and job factors related to operating trains in automatic train operation mode to understand how underload may affect train operators
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.”
Anyone affected by serious incidents on the TfL network can contact the Sarah Hope Line. The service is run by dedicated TfL staff to provide practical, financial and emotional help and can also make referrals for counselling and specialised support. Tel: 0343 222 5678, Monday-Friday 08:00-18:00