03.09.18
LU not properly preparing drivers to deal with ATO operation, RAIB says
London Underground’s training programme does not adequately prepare operators for some of the particular demands associated with train despatch, especially when running ATO stock – an issue that was likely linked to an accident which saw an elderly woman dragged into a tunnel after getting her bag trapped in the doors.
In a report released today, the RAIB outlined recommendations for London Underground in response to the accident, which took place on 31 January this year when a 78-year-old passenger became trapped in the doors of a Central Line train. She was dragged for around 75m along the platform, and 15m further into the tunnel, before the emergency brakes were applied.
The woman suffered multiple bone fractures and a serious soft tissue injury to her right leg. She was then taken to hospital and was only discharged in March.
In its investigation, the RAIB said the fact that the train operator did not see the passenger before driving off is likely related to the nature of his automated task; an inadequate view of the person in the CCTV monitor; and a reliance on cues to depart rather than a thorough check of the monitor before starting the train.
For example, trains running with an active ATO system present a relatively low workload compared to manual operation, as well as repetitive actions at stations. According to RSSB research, under such circumstances it is possible for people to enter an automatic mode of responding due to a mix of faster reaction times but reduced attention and more errors.
“Witness evidence suggests that the ATO train operator’s task can require effort to maintain attention, and that it can result in a reliance on the ATO system,” the investigator stated.
The RAIB also found no evidence that operators on the Central Line are “consistently or formally advised” on a technique for scanning the images on the in-cab monitor in order to optimise the check of the platform-train interface.
There is also “little awareness” amongst London Underground staff that the door interlock might not detect small objects trapped in the doors, with training handbooks implying that the pilot light will only illuminate if all the doors are closed.
This is, of course, not always the case: just last week, for example, the RAIB urged TOCs to conduct proper safety checks after a passenger was trapped in the closing doors of a train which failed to detect her forearm.
In its recommendations, RAIB said LU should ensure future rolling stock has the capability to detect small objects by reviewing available technology; support operators of ATO trains in maintaining attention and awareness; review the presentation of images on platform monitors; and look at its competence management programmes in order to ensure training technique consistency.
The organisation also argued that more timely and effective implementation of recommendations in its 2016 Clapham South station report “could have addressed the causal factors in this accident.”
(Top image c. Gareth Fuller, PA images)