Fatal Accident at Ickenham station (28/03/2025)

[AlterEgo]

Looking at not only the reports mentioned, a recent inquest into somebody drowned in Oxford, deaths or missing people in the Bristol Avon etc etc it seems to me that there is a major issue around deaths associated with intoxication.

Thats before we start on Drink Driving, committing and being a victim of crime etc.

While it is outside the RAIB's remit I suggest that taking steps firstly to try and reduce intoxication and a robust approach towards those intoxicated in public (Drunk Tanks anyone) might save lives

In this sad case nobody was in a position to intervene to do anything. The person left a pub in a quiet suburb and walked 7 minutes to a station where they fell onto railway tracks. What really can be done there to stop the person doing that? I'm going to assume you've read the report.

 

[JohnofWessex]

In this sad case nobody was in a position to intervene to do anything. The person left a pub in a quiet suburb and walked 7 minutes to a station where they fell onto railway tracks. What really can be done there to stop the person doing that? I'm going to assume you've read the report

Clearly attempts to reduce intoxication wont necessarily prevent individual incidents but it might reduce the total number of drink related deaths

 

[leonie13]

154 London Underground’s policy states that post-incident drug and alcohol testing of staff should occur ‘as soon as possible after a dangerous incident’.

What the RAIB report doesn't state is what is classified as a "dangerous incident", as per London Underground policy? It is quite plausible, in this specific incident, that the BTP made their "non-suspicious" declaration having reviewed CCTV in the immediate aftermath of this sad event. It is very rare for a train operator to be D&A tested in the aftermath of a PUT incident unless explicit allegations are made - at the time of the incident - regarding actions or behaviours relating to the individual. This report doesn't suggest any wrong-doing or mistakes by the train operator at all. (I acknowledge testers were sent but didn't arrive in time)

 

[Trackman]

This incident also took place in the dark and the deceased was wearing dark clothing. Driver didn't really have a hope of seeing them.

Another thing, nobody saw it happen so it couldn't be reported.

 

[35B]

What the RAIB report doesn't state is what is classified as a "dangerous incident", as per London Underground policy? It is quite plausible, in this specific incident, that the BTP made their "non-suspicious" declaration having reviewed CCTV in the immediate aftermath of this sad event. It is very rare for a train operator to be D&A tested in the aftermath of a PUT incident unless explicit allegations are made - at the time of the incident - regarding actions or behaviours relating to the individual. This report doesn't suggest any wrong-doing or mistakes by the train operator at all. (I acknowledge testers were sent but didn't arrive in time)

I think the question is more about why the TfL policy isn’t actually being applied.

 

[pitdiver]

When I was a Station Supervisor on the Met I had to deal with an intoxicated person who happened to be female. I can confirm it is very difficult to deal with someone in an intoxicated condition even more difficult when that person is female due to the possibility of possible accusations of improper behaviou

 

[Mawkie]

Clarity on the post-incident drug and alcohol testing policy is contained in the TfL FOI - Alcohol and drugs at work information for managers and employees.

Secion 9, Page 16:

The definition of a dangerous incident is generally:
‘An incident causing or having the potential to cause death or major injury or substantial damage to property'.
Post incident testing should occur as soon as possible after every dangerous operational incident. Such tests will also provide information which can be used
during incident investigations.

Incidents of regulatory or public interest:
• where a prosecution could be an outcome
• where subject to regulatory interest
• where public and / or media interest would be high.

(edited from linked FOI document due to formatting issues.)

 

[Falcon1200]

But it did find that TfL hadn't followed its own standards, and had in fact recently added non-compliant cabling under the platform.

I was not aware that TfL was mandated to install under-platform recesses and to keep these clear - Is this unique to this operator due to the 3rd and 4th rail electrification?

 

[Watershed]

I was not aware that TfL was mandated to install under-platform recesses and to keep these clear - Is this unique to this operator due to the 3rd and 4th rail electrification?

LU have imposed this standard on themselves, though it derives from older requirements about platform overhangs dating back to the Board of Trade era.

And yes, I think the main reason is that there is no ability to take refuge in the four-foot due to the presence of the fourth rail.

 

[bramling]

What the RAIB report doesn't state is what is classified as a "dangerous incident", as per London Underground policy? It is quite plausible, in this specific incident, that the BTP made their "non-suspicious" declaration having reviewed CCTV in the immediate aftermath of this sad event. It is very rare for a train operator to be D&A tested in the aftermath of a PUT incident unless explicit allegations are made - at the time of the incident - regarding actions or behaviours relating to the individual. This report doesn't suggest any wrong-doing or mistakes by the train operator at all. (I acknowledge testers were sent but didn't arrive in time)

It may be the case that the initial circumstances weren’t clear. Had the incident been a dragging then clearly there would certainly have been a requirement for D&A, so depending on how quickly CCTV was able to be reviewed it may have been the case that D&A had already been arranged as a precaution.

Reading between the lines, the feeling I get is that the managers were taking a sympathetic line towards the driver. D&A were called, however there is no requirement for a driver to remain on duty beyond their finish time. I imagine that once the driver was next on duty, and presumably by then the circumstances had become fully clear, it was probably felt somewhat unnecessary. I feel the RAIB are nitpicking here.

 

[IanXC]

The stand out issue for me about this report is the fact it adds to a long list of reports regarding similar incidents involving LUL and TfL. While explanations can always be found for specific cases, the sheer number of these compared to the mainline railway gives a strong indication that there are fundamental underlying issues.

As far as the particular report goes this seems like an odd decision:

141 As part of the same work, London Underground considered the cost to upgrade all headlights on the trains in its fleet (apart from Piccadilly line trains due to their imminent replacement) and concluded that this would cost around £1 million. London Underground uses the industry standard value of preventing a fatality (VPF) figure of £2,308,000 when making investment decisions related to safety improvements (this value is determined by the Rail Safety and Standards Board). London Underground guidance document S1521 ‘Safety decision making’, issue A11 dated November 2023, suggests that the recommended fatality/cost ratio for mitigations relating to platform-train interface accidents is anything of 1.0 or above. This means that this upgrade would likely be deemed to be cost effective in terms of safety benefit in the event that the assessor believed it would prevent even one fatality. However, there is no evidence that the upgrade of the headlights was formally assessed in line with S1521 or that the potential safety benefit was calculated.

The argument for not doing so seems to be that trains are not driven on sight, and that it would not reduce the likelihood of people falling onto the tracks. Its quite evident however, that when travelling at a lower speed approaching a station, if the driver can see an obstruction that is the most likely time that they might be able to stop. Given that the cost was £1m and the value put at preventing a fatality £2.3m, you'd only have to presume that a driver would be able to see and stop before a person on the line once every two and a third years, which does not seem unreasonable.

 

[edwin_m]

The argument for not doing so seems to be that trains are not driven on sight, and that it would not reduce the likelihood of people falling onto the tracks. Its quite evident however, that when travelling at a lower speed approaching a station, if the driver can see an obstruction that is the most likely time that they might be able to stop. Given that the cost was £1m and the value put at preventing a fatality £2.3m, you'd only have to presume that a driver would be able to see and stop before a person on the line once every two and a third years, which does not seem unreasonable.

Fitting brighter headlines would be mostly a one-off spend, with only small ongoing costs for periodic replacement of lamps and specifying them for new fleets. However, the safety benefit continues to apply indefinitely, or at least until LU gets platform screen doors on all stations which is probably the same thing. So the brighter headlights are worthwhile even if they only save one life ever.

Any such fitment would however have to consider other hazards such as dazzling drivers of trains in the other direction.

 

[Mawkie]

Fitting brighter headlines would be mostly a one-off spend, with only small ongoing costs for periodic replacement of lamps and specifying them for new fleets. However, the safety benefit continues to apply indefinitely, or at least until LU gets platform screen doors on all stations which is probably the same thing. So the brighter headlights are worthwhile even if they only save one life ever.

Any such fitment would however have to consider other hazards such as dazzling drivers of trains in the other direction.

The headlight brightness thing is a bit of a red herring - particularly in this case, where the S Stock does have very bright LED headlights.

I'm scanning the platform train interface (PTI) when coming into platforms - is anyone beyond the yellow line, are there kids running around, is anyone cycling, fighting, are there any other risks, such as damaged infrastructure, unattended luggage, and on and on and on.

I know it sounds counterintuitive, but the "track" is a supposedly inherently safe space, so very little of my attention is spent scanning the rails as nobody is supposed to be there.

A secondary consideration is that trains don't stop on a dime, so even if I do see a person, there is little chance of stopping at the speeds I enter platforms. I gauge my braking for maximum efficiency to bring the train to a stop at the stopping point at the headwall, not half way along the platform. There may be an argument to say 'enter the platforms slower' but this would obviously have an impact on the service and require a timetable revision.

Lastly, Ickenham has recently had the platform lighting upgraded - they are now very bright LEDs. I don't know if this is a result of the incident last year, or part of LU’s commitment to convert all LU property to LED.

 

[35B]

Fitting brighter headlines would be mostly a one-off spend, with only small ongoing costs for periodic replacement of lamps and specifying them for new fleets. However, the safety benefit continues to apply indefinitely, or at least until LU gets platform screen doors on all stations which is probably the same thing. So the brighter headlights are worthwhile even if they only save one life ever.

Any such fitment would however have to consider other hazards such as dazzling drivers of trains in the other direction.

Those two statements contradict each other fundamentally.

Introducing additional hazards means that changes may increase risk and therefore cost more lives than they save.

That then leads to the “even if they only save one life ever” question. Every system of safety investment has some form of quantification of the value for money of spending money on safety. Generally speaking, that money will come at the expense of something else, so it needs to be justified in terms of actually doing enough.

In this case, I find it really hard to see where that expenditure would have made a serious difference to safety, given what drivers have said about how they pay attention to platforms while stopping. More seriously, it distracts from what for me is the more important and basic requirement to provide and retain a safe space if someone does fall - something that should never have been compromised.

 

[edwin_m]

Those two statements contradict each other fundamentally.

Introducing additional hazards means that changes may increase risk and therefore cost more lives than they save.

That then leads to the “even if they only save one life ever” question. Every system of safety investment has some form of quantification of the value for money of spending money on safety. Generally speaking, that money will come at the expense of something else, so it needs to be justified in terms of actually doing enough.

In this case, I find it really hard to see where that expenditure would have made a serious difference to safety, given what drivers have said about how they pay attention to platforms while stopping. More seriously, it distracts from what for me is the more important and basic requirement to provide and retain a safe space if someone does fall - something that should never have been compromised.

My post was intended to correct a misunderstanding of the assertion made in the report that it would be worthwhile on safety grounds to fit brighter headlights. I was not commenting on the validity of the assertion itself. I am very well aware that an apparent safety measure might introduce extra hazards - hazard identification is a big part of my job - which is why I made that point. Without some more detailed analysis it's not possible to support or oppose the case for brighter headlights.

 

[AY1975]

I can't find anything in the report to say whether the victim was pronounced dead at the scene or was taken to hospital and died of their injuries later.

 

[Jimini]

I can't find anything in the report to say whether the victim was pronounced dead at the scene or was taken to hospital and died of their injuries later.

RAIB report:

“The passenger was fatally injured.”

 

[AlterEgo]

RAIB report:

“The passenger was fatally injured.”

That does not answer @AY1975's question.