Recommendation Status Report: Uncontrolled evacuation of a partially platformed train at Clapham Common London Underground station
This report is based on information provided to the RAIB by the relevant safety authority or public body.
The status of the recommendation(s), as reported to us, are described by the following categories:
                                                                 Key to Recommendation Status
Open                                 Actions to address the recommendation are ongoing.
 (replaces Progressing and
 Implementation On-going)
Closed                               ORR consider the recommendation to have been taken into consideration by an end implementer and
 (replaces Implemented, Implemented   evidence provided to show action taken or justification for no action taken.
 by alternative means, and Non-
 implementation)
Insufficient response:               The end implementer has not provided sufficient evidence that the recommendation has been taken into
                                      consideration, or if it has, the action proposed does not address the recommendation, or there is
                                      insufficient evidence to support no action being taken.
Superseded:                          The recommendation has been superseded either by a newer recommendation or actions have
                                      subsequently been taken by the end implementer that have superseded the recommendation.
Awaiting response:                   Awaiting initial report from the relevant safety authority or public body on the status of the
                                      recommendation.
RAIB concern over the way that an organisation has responded to a recommendation are indicated by one of the following:
Red – RAIB has concerns that no actions have been taken in response to a recommendation.
Blue – RAIB has concerns that the actions taken, or proposed, are inappropriate or insufficient to address the risk identified during the investigation.
White – RAIB notes substantive actions have been reported, but the RAIB still has concerns.
Recommendation Status Report
Report Title            Uncontrolled evacuation of a partially platformed train at Clapham Common London Underground station
Report Number           03/2024
Date of Incident        05/05/2023
Rec No.            Status                RAIB Concern     Recommendation                                                              RAIB Summary of current status
03/2024/01         Open                  None             The intent of this recommendation is for London Underground to review
                                                          how it enables its staff to effectively respond to out-of-course events
                                                          which may occur when a train is positioned partially in a platform.
London Underground should undertake a risk-based review of its current
                                                          Rule Book, operating procedures and associated training material
                                                          considering the findings from this incident. This review should seek to
                                                          ensure that staff have clear guidance and instructions regarding the
                                                          actions to be taken when dealing with out-of-course events, such as
                                                          emergency evacuations, on trains that are partially positioned in a
                                                          platform. The review should particularly examine how staff communicate
                                                          with passengers during such events and if existing guidance and
                                                          instructions enable staff to make effective decisions in the timeframes
                                                          typically available during such events. London Underground should make
                                                          any changes to rules, procedures and training material identified as
                                                          appropriate following this review. London Underground should also
                                                          ensure that any changes are appropriately briefed and trained to relevant
                                                          train operations, station and control staff. This training should, where
                                                          appropriate, include practical elements such as simulation exercises
                                                          (paragraphs 154a, 154b and 155a).
03/2024/02         Closed - I            None             The intent of this recommendation is for London Underground to ensure
                                                          that learning from previous incidents is not lost and that safety
                                                          recommendations are captured and tracked through to implementation.
London Underground should continue its review of its processes for
                                                          learning lessons from operational experience. This review should ensure
                                                                                                                                               Created on 07 April 2025
Recommendation Status Report
that it is robustly applying and retaining the safety learning identified from
                           accidents and incidents and using this information to enhance its
                           understanding and control of risk (paragraph 155b).
03/2024/03   Open   None   The intent of this recommendation is for London Underground to review
                           its risk assessment processes to ensure that the risks associated with out-
                           of-course incidents involving trains and stations are effectively identified
                           and assessed.
London Underground should review its risk management processes to
                           ensure it is able to identify and effectively assess the risks associated with
                           low frequency and potentially high-impact incidents involving trains and
                           stations, such as passenger self-evacuation from partially platformed
                           trains. As part of this review, London Underground should consider if the
                           effect of factors associated with specific locations which could pose an
                           increased risk to passengers, such as stations with narrow island
                           platforms, is being appropriately considered within risk assessment
                           processes (paragraph 155c).
Created on 07 April 2025

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