Monday Accident & Lessons Learned: RAIB Investigation of Uncontrolled evacuation of a London Underground train at Holland Park station 25 August 2013

Here’s the summary of the report from the UK RAIB:

At around 18:35 hrs on Sunday, 25 August 2013, a London Underground train departing Holland Park station was brought to a halt by the first of many passenger emergency alarm activations after smoke and a smell of burning entered the train. During the following four minutes, until the train doors still in the platform were opened by the train operator (driver), around 13 passengers, including some children, climbed out of the train via the doors at the ends of the carriages.

The investigation found that rising fear spread through the train when passengers perceived little or no response from the train operator to the activation of the passenger emergency alarms, the train side doors remained locked, and they were unable to open them, and they could not see any staff on the platform to deal with the situation. Believing they were in danger, a number of people in different parts of the train identified that they could climb over the top of safety barriers in the gaps between carriages to reach the platform.

A burning smell from the train had been reported when the train was at the previous station, Notting Hill Gate, and although a request had been made for the staff at Holland Park station to investigate the report, the train was not held in the platform for staff to respond. A traction motor on the train was later found to have suffered an electrical fault, known as a ‘flash-over’, which was the main cause of the smoke and smell.

A factor underlying the passengers’ response was the train operator’s lack of training and experience in dealing with incidents involving the activation of multiple passenger emergency alarms.

The report observes that London Underground Limited (LUL) commenced an internal investigation of the incident after details appeared in the media.

RAIB has made six recommendations to LUL. These seek to achieve a better ergonomic design of the interface between the train operator and passenger emergency alarm equipment, to improve the ability of train operators to respond appropriately to incidents of this type and to ensure that train operators carry radios when leaving the cab to go back into the train so that they can maintain communications with line controllers. LUL is also recommended to review the procedures for line controllers to enable a timely response to safety-critical conditions on trains and to ensure continuity at shift changeover when dealing with incidents. In addition, LUL is recommended to review the training and competencies of its staff to provide a joined-up response to incidents involving trains in platforms and to reinforce its procedures on the prompt and accurate reporting of incidents so that they may be properly investigated.