Date of occurrence Location name Holland Park station Local time 18:35 Latitude 51:30:26 North

Transcription

1 Occurrence Summary What Location Date of occurrence Location name Holland Park station Local time 18:35 Latitude 51:30:26 North Event type Rolling stock events Fire in RS Longitude 0:12:21 West Description At 18:35 hrs, westbound train 003 began to depart normally from Holland Park station. Soon after the train started moving, a passenger operated the emergency alarm within the train, causing its brakes to be applied. It stopped with the first half of the first car in the tunnel. Other emergency alarms were operated within the train soon afterwards. The Train Operator was not aware that a fault with the brakes on one car in the train was generating smoke and fumes. London Underground has also indicated that the train may have simultaneously suffered an electrical fault on one of its motors, which could have created a loud noise. As soon as the train stopped passengers tried to get out. Since the doors had not been opened, people in the train and on the platform attempted to pull the twin-leaf doors apart. However, the doors could not be opened to sufficient width to allow most people to leave the train. Some people outside the train operated the fire alarms on the platform, and this initiated an automatic station evacuation sequence. Evacuation announcements could be heard by the passengers trying to leave the train. Approximately two minutes after the train stopped, a small number of passengers started to exit the train using the inter-car doors at the end of each carriage, and then climbing over the inter-car barriers to reach the platform. During this time, the Train Operator was attempting to establish what had happened, and the train doors adjacent to the platform remained closed. About two and a half minutes after the train stopped, station staff reached the platform and opened one pair of doors from the outside. Approximately one minute later, the Train Operator opened all the doors adjacent to the platform. Nobody was injured in the incident, but the RAIB considers that there was potential for injuries to occur because the train was heavily loaded and a large number of people were prevented from leaving the train for almost four minutes after it stopped. Direct Cause descrip The immediate cause of the incident was that passengers, believing that they were in danger by remaining on the train, self-evacuated by climbing through the gaps between cars or by forcing open a door Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo 0 ERAIL-REP PUBLIC 1 Friday, November 23, 2018

2 What Title Fire in RS, 8/25/2013, Holland Park station (United Kingdom) Occurrence type Rolling stock events Fire in RS Occurrence Class Accident Date of occurrence Local time 18:35 Events Rolling stock events - Fire in RS Descriptions Description At 18:35 hrs, westbound train 003 began to depart normally from Holland Park station. Soon after the train started moving, a passenger operated the emergency alarm within the train, causing its brakes to be applied. It stopped with the first half of the first car in the tunnel. Other emergency alarms were operated within the train soon afterwards. The Train Operator was not aware that a fault with the brakes on one car in the train was generating smoke and fumes. London Underground has also indicated that the train may have simultaneously suffered an electrical fault on one of its motors, which could have created a loud noise. As soon as the train stopped passengers tried to get out. Since the doors had not been opened, people in the train and on the platform attempted to pull the twin-leaf doors apart. However, the doors could not be opened to sufficient width to allow most people to leave the train. Some people outside the train operated the fire alarms on the platform, and this initiated an automatic station evacuation sequence. Evacuation announcements could be heard by the passengers trying to leave the train. Approximately two minutes after the train stopped, a small number of passengers started to exit the train using the inter-car doors at the end of each carriage, and then climbing over the inter-car barriers to reach the platform. During this time, the Train Operator was attempting to establish what had happened, and the train doors adjacent to the platform remained closed. About two and a half minutes after the train stopped, station staff reached the platform and opened one pair of doors from the outside. Approximately one minute later, the Train Operator opened all the doors adjacent to the platform. Nobody was injured in the incident, but the RAIB considers that there was potential for injuries to occur because the train was heavily loaded and a large number of people were prevented from leaving the train for almost four minutes after it stopped. Location name Holland Park station Railway System type Metro Country United Kingdom Location type Station Border Country Line type Double track Line number ERAIL-REP PUBLIC 2 Friday, November 23, 2018

3 Allowed line speed Km number Latitude 51:30:26 North Longitude 0:12:21 West Location description Additional location in Location type details Tunnel Other (Station) Fixed installations Occurrence details Railway vehicles Movement type Metro Train number RU Train speed at mom Vehicle description United Kingdom LUL Other objects involved in the occurrence Other objects Parties involved IM Involved United Kingdom - LUL RU Wagons overturned Passengers onboard United Kingdom - LUL Passengers Staff Level crossing users Unauthorised persons Others Total Fatalities Serious injuries Minor injuries Material consequences Material Damage Estimated total mate < Damage description Images Name Description Type Size Last modified Organization Repository 0 ERAIL-REP PUBLIC 3 Friday, November 23, 2018

4 Causation Causes Direct Cause description The immediate cause of the incident was that passengers, believing that they were in danger by remaining on the train, self-evacuated by climbing through the gaps between cars or by forcing open a door Underlying and root causes description Causal factors: Once the departing train was stopped by a passenger emergency alarm the situation was not sufficiently quickly controlled by LUL staff and passengers formed the perception that they were in danger for the following reasons: a. smoke and a burning smell from a faulty motor and possibly a seized-on (dragging) brake entered the train; b. passengers became increasingly alarmed when there was little or no perceived response from the train operator to the activation of passenger emergency alarms and no passenger information announcements were made; c. the doors to the platform did not open and passengers, both on the train and on the platform, were unable to open them; and d. passengers could not see any staff on the platform responding to the situation. Passengers were able to climb over the inner inter-car barriers to self-evacuate the train. The train was not held in the platform at Holland Park station to allow the requested investigation of the burning smell to be carried out. Underlying factors: Train operators are not equipped to deal with multiple passenger emergency alarm activations. Additional observations: Although not part of the cause of the incident the RAIB observes that the seriousness of the incident was not immediately appreciated by some senior staff involved which resulted in a loss of some evidence and a delay in initiating an internal formal investigation. Causation classification Rolling stock events - Fire in RS s title Passenger emergency alarm driver interface assessment REC End implementer RU ERAIL-REP PUBLIC 4 Friday, November 23, 2018

5 The purpose of this recommendation is to promote a design review of the passenger emergency alarm system on 1992 tube stock and the adoption of ergonomics best practice in an improved design. London Underground Limited should carry out an ergonomics assessment of the driver interface with the passenger emergency alarm system on 1992 tube stock. This assessment should include the functioning of the talkback system and the compatibility between the controls and the display. Taking account of guidelines on alarm handling and prioritisation (such as the, Good Practice Guide for the design of alarms and alerts (T326), RSSB, 2008), London Underground Limited should then take appropriate action to present critical information to the train operator in a way that supports decisions and actions so that they can deal appropriately with the emergency situation (paragraph 129). Relevant outcomes of this ergonomic assessment should also be applied to other stock as appropriate. title Review of multiple emergency passenger alarm procedure REC End implementer RU The purpose of this recommendation is to improve the ability of train operators to handle multiple passenger emergency alarms and other out of course events on 1992 tube stock. London Underground Limited should review the rules, procedures and training applying to the handling of emergency situations on 1992 tube stock where multiple passenger emergency alarms have been activated and/or where only part of the train is stopped in a station. This review should include an assessment of the ways in which train operators can best manage a situation and adequacy of existing training arrangements. Particular attention should be paid to helping operators make appropriate and timely announcements and the safe management of doors in such circumstances. Any necessary changes to existing arrangements should then be implemented and staff briefed and trained as appropriate (paragraph 126b). Relevant outcomes of this review should also be applied to other stock as appropriate. ERAIL-REP PUBLIC 5 Friday, November 23, 2018

6 title Hand-held radio procedure REC End implementer RU The purpose of this recommendation is to ensure that train operators remain in communication with line controllers when they are required to leave the cab to go back into the train. London Underground Limited should put procedures in place to require train operators to carry their hand-held radio when going back into the train, for example, to investigate the activation of a passenger emergency alarm, so that they can communicate with the line controller in a timely manner. ERAIL-REP PUBLIC 6 Friday, November 23, 2018

7 title Line-controller fault-report handling REC End implementer RU The purpose of this recommendation is to make sure that line controllers are enabled to take appropriate and timely action when dealing with potential safety critical faults and conditions on trains. London Underground Limited should: a. review the procedure applying to line controllers for dealing with reports of faults on trains, particularly reports relating to smoke or burning, and improve as necessary, in order that line controllers are provided with a clear process to assist timely decision-making and response; and b. establish a protocol to manage the shift changeover between controllers, so that there is no loss of time or continuity in dealing with an incident. title Staff training for out-of-course events REC End implementer RU ERAIL-REP PUBLIC 7 Friday, November 23, 2018

8 The purpose of this recommendation is to ensure that London Underground Limited s staff are able to respond appropriately to incidents on trains in platforms. London Underground Limited should review the required competencies and training for dealing with out-of-course events on trains in platforms. This should include consideration of how best to prepare station staff, train operators and line controllers to respond to such events in a rapid, coordinated and coherent manner, to protect the safety of passengers and station users. title Reporting and investigation of incidents REC End implementer RU The purpose of this recommendation is to draw attention to the need for the prompt and accurate reporting of incidents. London Underground Limited should devise a time bound programme to reinforce, by briefing and further training if necessary, its procedures on the reporting and investigation of incidents in which there are no reported injuries but which could have led to more serious consequences. This should include the need for the early debriefing of staff involved and, where appropriate, the withdrawal of any trains from service for inspection and testing, to permit such incidents to be properly investigated. ERAIL-REP PUBLIC 8 Friday, November 23, 2018

9 Causation links Rolling stock events - Fire in RS Investigation details Legal Basis Other reason descrip National rules imposed by implementing of the Safety Directive 2004/49/EC - in light of Article 19, 2 of SD - (a) the seriousness of the accident or incident Reporting Body National investigatio Occurrence creation :43:06 Investigator in charge Decision to investigate Declaration date Date of IM/RU notific Report Type Final report Workflow Status Validated Report Version 2 Investigation Status Closed Other Attachments Name Descriptio Type Size Last Organizati Repositor 0 Final Report Name Descriptio Type Size Last Organizati Repositor Inv_Repor Holland applicatio /29/2014 Softeco t Pdf_V Park n/pdf 3:06:46 ersion01.p Report PM df ERAIL-REP PUBLIC 9 Friday, November 23, 2018