Report 06/2019: Train travelling with doors open on the Jubilee line
Train travelling with doors open on the Jubilee line, 1 September 2018.
Summary
Shortly after 09:00 hrs on Saturday 1 September 2018, a London Underground Jubilee line train travelled between Finchley Road and West Hampstead stations with doors open at ten passenger doorways. The train, with approximately 30 passengers on board, reached a maximum speed of 62 km/h during the 56 second journey between the two stations. No-one fell out of the train and nobody was injured.
When the train stopped at Finchley Road station, some of the doors on the train, which was operating in automatic train operation mode (ATO), opened without being commanded to do so by the train operator. The operator’s controls did not allow him to open any doors, nor close any doors. It is likely that the door behaviour was due to control system overload caused by faults elsewhere on the train. While dealing with the door issue, the train operator operated a switch, bypassing the door interlock circuit that was intended to prevent the train departing with doors open. He then did not notice that some doors remained open when departing from Finchley Road station and travelling to West Hampstead. The train operator’s actions were probably influenced by:
- a sudden increase in his workload from the low level associated with automatic train operation
- fatigue from his sleeping pattern; and/or
- low blood-sugar levels from a prolonged period without food
An underlying factor was that, unlike some other London Underground trains and contrary to London Underground standards, the type of train involved in the incident could be driven with the door interlock circuit bypassed without an audible warning being provided to the train operator. A possible underlying factor was that the training of train operators did not adequately prepare them to manage the sudden increase in workload caused by the need to deal with faults, under time pressure, on trains operating in automatic mode.
Recommendations
The RAIB has made four recommendations addressed to London Underground. These include improvements to door control systems on Jubilee line trains; better training to help train operators respond correctly when sudden increases in workload occur while operating trains in automatic mode; raising train operator awareness of the adverse effects on safety from insufficient sleep and inappropriate eating patterns; and improved management of train faults.
The investigation also identified three learning points relating to the incident. These concern making sure that training, rules and procedures highlight the safety implications of operating sealed switches; understanding that careful checking that the correct switch has been operated when attempting to rectify technical faults is more important than timekeeping; and the importance of staff managing their work/life balance so that safety performance is not adversely affected.
Response to recommendations:
- RAIB will periodically update the status of recommendations as reported to us by the relevant safety authority or public body
- RAIB may add comment, particularly if we have concerns regarding these responses.