“An underlying factor to the incident was that operational staff were not provided with the procedures or training needed to effectively identify and manage incidents where passenger behaviour can rapidly escalate”
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At around 17:43 hrs on Sunday 5 May 2023, a London Underground train departing from Clapham Common station was brought to a halt by a passenger emergency alarm activation after smoke and a smell of burning entered the train. The train came to a stand with two cars inside the tunnel and four cars adjacent to the platform. The train’s doors remained closed. Around 100 of the train’s (estimated) 500 passengers subsequently self-evacuated onto the platform through the interconnecting doors between the train’s cars and the train’s windows, some of which were broken by passengers either inside the train or on the station platform. Station staff began opening the train’s doors around four and a half minutes after the train came to a stand.
An incident last May at Clapham Common underground station where around 100 passengers self-evacuated from a tube train after smoke and a smell of burning entered it “had the potential to have more serious consequences” a RAIB (Rail Accident Investigation Branch) report released today says.
“Clapham Common station has a narrow island platform which increases the risk of passengers falling onto the track and potentially being exposed to conductor rails and trains approaching on the adjacent southbound line.
“RAIB’s investigation found that passengers perceived a significant risk from fire, and that they became increasingly alarmed when the train’s doors remained closed and they did not receive suitable information or see any effective action from Underground staff.
“An underlying factor to the incident was that operational staff were not provided with the procedures or training needed to effectively identify and manage incidents where passenger behaviour can rapidly escalate.
“A possible underlying factor was that London Underground did not fully apply and retain learning from a previous similar incident at Holland Park station.
“Additionally, a further possible underlying factor was that London Underground had not identified the risk of passenger self-evacuation from partially platformed trains, including those taking place at narrow island platforms.”
The report says the smoke and the smell of burning was associated with material on the brake resistor grid of car four which was detected by passengers on the train, says the report. CCTV station footage shows that, as the train entered the platform and came to a stand, smoke was emanating from around the underneath of car four.
LUL images in the report show closed-circuit television (CCTV) footage from Clapham Common station. One image shows a passenger breaking a bodyside window, a second image shows passengers beginning to evacuate from the train via the broken window.
LUL (London Underground Limited) Rule Book 6 ‘General train operations’, issue 7 dated November 2021, states that train operators should sound one long whistle to attract the attention of station staff. But the requirement to sound the train’s whistle in response to a PEA (passenger emergency alarm) activation was not included in Rule Book 7.
This analysis shows that there was a disparity between the Rule Book instructions and the training material provided to new and existing train operators, with the training material also not including the requirement to inform the passengers on the train…
Following a similar incident at Holland Park station in 2013, LUL amended its annual refresher training for train operators and introduced another leaflet to provide guidance on how to respond to multiple PEA activations causing a train to stop within station limits.
This directed train operators to:
• ‘Inform controller.
• Request assistance [from station staff, although this is not stated, says the report].
• Make a general public address announcement to all customers.’
Witness evidence shows that the only staff member on the platform – referred to as CSA customer service assistant ‘A’ – was not aware of the Holland Park incident.
RAIB’s investigation into the Holland Park incident in 2013 (RAIB report 16/2014, see paragraph 127) found that this Rule Book instruction was, at that time, generally understood to mean that the train operator should make an announcement to the whole train.
But the evidence from LUL training staff concerning training material suggests that the Rule Book instruction to ‘tell customers what had happened’ following a PEA activation may no longer be generally understood to mean that there is a need to make a passenger announcement.
RAIB have made three recommendations, all addressed to London Underground:
- The first relates to procedures and training to ensure that staff have clear guidance on how to deal with out-of-course events.
- The second relates to learning from previous incidents not being lost and to recommendations being tracked through to
implementation. - The third recommendation is that “London Underground review its risk assessment processes so that the risks associated with out-of-course events and at specific locations are effectively identified and assessed.”
The report also reveals:
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CSA ‘A’ did not open the train doors because they did not apply the emergency Rule Book procedure for ODODs (outside door opening devices). Having decided authorisation was needed, there was a delay in CSA ‘A’ gaining authorisation to use ODODs.;
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The instructions in Rule Book 8 do not provide a definition of an ‘emergency’. Witness evidence shows LUL training material and guidance on the circumstances where this emergency procedure would apply was provided to some station staff. There was no evidence that CSA(A) was aware of the emergency procedure shown within Rule Book 8.
- CSA ‘A’ had no means of directly making station announcements when on the platform (as these are controlled from the station control room) and therefore had little or no ability to inform passengers or to calm their escalating behaviour;
- LUL’s Northern line service is controlled from Highgate Service Control Centre (SCC) who can make station announcements remotely at some Northern line stations, but this facility was not installed at Clapham Common station at the time of the incident.
- Witness and voice recording evidence shows that, until the train operator informed the signaller that a passenger self-evacuation was happening, the staff at Highgate SCC remained unaware of the escalating situation on the platform and train 065. The lack of communication and a fault with the CCTV link resulted in control room staff having reduced situational awareness and oversight of the incident.
- The operator of the train stated they had no knowledge of the events surrounding the Holland Park incident as it was not included within their initial training in 2019 or their subsequent annual refresher training.
- Subsequent inspection of the underframe of car 4 found burnt residue and a red clay-like substance on the brake resistor grid. Independent analysis of the substances found had shown this was a mixture of organic material and a red magnetic clay substance. LUL confirmed the substance was grinding paste which is used for rail grinding activities on LUL infrastructure.
To read the full report please go to: R032024_240508_Clapham Common
* Holland Park reference: https://www.orr.gov.uk/sites/default/files/om/raib-holland-park-2015-10-13.pdf.
Further reading:
RAIB has today released its report into an uncontrolled evacuation of a partially platformed train at Clapham Common London Underground station, May 5th 2023. (Source: newsandcommunications.gov.uk)
NEWS FROM CRYSTAL PALACE 