Alfonso Sinclair

Transport for London

London Underground cmEeremn
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12 June 2019

Managing Director

London Underground
Palestra

197 Blackfriars Road
SE1 8NJ

Dr Fiona J Wilcox
HM Senior Coroner, Inner West London

Westminster Coroner’s Court
65 Horseferry Road

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Dear Dr Wilcox, PS

Inquest touching on the death of Mr Alfonso Sinclair

Thank you for the Regulation 28 Prevention of Future Deaths Report dated 29
April 2019 in respect of Mr Alfonso Sinclair.

| would, at the outset, offer my sincere condolences, as well as those of all at
TfL and London Underground (LU) to Mr Sinclair’s family and friends.

You raised five matters of concern in your report that | shall respond to in turn.

1. That there is no apparent system for staff to alert odd behaviour and
then track an individual on CCTV.

LU station staff receive initial training and ongoing refresher training
through our competency management system (CMS) to assist in
identifying ‘unusual’ customer behaviour. The training is centred around
three areas of customer behaviour which are:

i) customer welfare which includes identifying passengers who show
signs of illness, distress, intoxication and more generally their fitness to
travel;

ii) identifying those behaviours that may present a security risk through a
British Transport Police / Department for Transport endorsed pan rail
industry process; and

iii) identifying behaviours which may be suicidal.
Registered office is as above.
Registered in England and Wales,
Company Number 1900907

London Underground Limited is a
company controlled by a local
aha, authority within the meaning of
Seve7x Part V Local Government and

& Housing Act 1989. The controlling

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MAYOR OF LONDON sax? authority is Transport for London.

In April 2018, LU established a dedicated suicide prevention team to
increase awareness of this issue and to establish and sustain dedicated
training of front-line station staff in spotting unusual / suicidal behaviour
and what intervention actions to take. The key principles of this training
are transferable to other incidents where customers seem to be displaying
unusual behaviours but may not necessarily be suicidal.

We have undertaken a review the content of our training to ensure that
any lessons learned from Mr Sinclair's tragic death, particularly in relation
to his behaviours at the gate-line, are included in our future training. Such
changes will be implemented with immediate effect.

Moving on to the second part of this concern, CCTV cameras are in place
in all LU stations but it is worth noting that their primary purpose is not to
track the movement or actions of individuals in real time. Station
operations rooms are not continuously staffed and CCTV camera views
are not continuously monitored. Where station staff are alerted to unusual
behaviours, the images from the CCTV can be viewed locally in the
station operations room or remotely in the London Underground Control
Centre (LUCC).

We consider that how we use CCTV in our stations is appropriate in
enabling station staff to manage localised congestion, in support of live
incident management by LUCC command staff and to provide us with the
means of reviewing incidents.

. That there is no alarm at the barriers at the platform ends.

As set out inf) Witness Statement, dated 17 April 2019, the
barriers fitted to platform ends at Underground stations are designed to act
as a visual and physical deterrent and are expressly not there to secure
the tunnel mouth or prevent access to the track. At the majority of
underground stations, it is possible to access the track area (and thus the
tunnels) without going anywhere near the end barriers. We have
concluded that alarming the barriers (and their movement) would make no
beneficial difference in preventing members of the public intentionally
entering the track area without authorisation to do so.

. That if (1) and (2) were in place, odd behaviour and / or entrance into
the tunnels by passengers via the barrier ends of platforms could be
monitored by CCTV. This would have allowed staff to see Mr Sinclair
enter the tunnel, and although not allow sufficient time to have
prevented him from doing so, would allow time for trains to be
stopped and thus prevent loss of life. False alarms at the barriers
could be easily checked and eliminated by viewing CCTV.

We have considered the use of alarms on platform end barriers
previously, but there are some concerns about their effectiveness. Firstly,
any such alarm would need to be acknowledged by a member of staff and

the CCTV cameras viewed manually. Given how LU staffs station
operations rooms and with the technology we have in use, the time taken
to review the system would be longer than the time taken for a person to
access the track, enter the tunnel and be out of sight. This would
potentially lead to many false alarms and an unacceptable disruption to
service as LU control staff would be faced with no option but to issue an
immediate ‘Code Red’ message to immediately stop further train
movements; then discharge traction current and review CCTV and initiate
a track search, with no certainty of whether this was necessary or not.
This, as you will appreciate, will very likely lead to trains ‘stalled’ in tunnels
for prolonged periods, creating other significant risks.

From our analysis, most unauthorised and deliberate access onto the
track in underground stations are directly from the platform edge and do
not involve passing through the platform end barrier. You will be aware of
the challenges and issues of retro-fitting platform edge door systems to all
stations from our letter to you dated 23 April 2018. We are therefore
considering whether there may be any other types of alarm or detection
systems that may be viable.

For any such alarm / detection system to be effective, it would need to
monitor the full length of the platform edge and both tunnel portals. It
would also need to be reliably and repeatedly deactivatable to allow the
passage of trains through a platform and similarly, to allow customers to
board and disembark trains. Any such system would also need to be
immune from accidental and malicious activations so as not to adversely
impact train operation reliability, especially on high frequency lines.

LU only has experience of deploying infra-red tunnel portal alarms to
prevent incursions by trespassers and graffiti vandals on Christmas Day
when no trains are operating and has no knowledge of such a system
being deployed on other high-frequency metro railways. LU is a member
of the Community of Metros (CoMET), that includes 17 of the world’s
largest metros and has already begun to investigate whether other CoMet
members have any experience of this type of technology or have such
systems in place and determine whether they can be reliably and safely
applied to the LU network. We expect to complete this review by early
2020.

. That systems of work by station staff be reviewed to ensure
monitoring of the ticket barriers as a place where irregular behaviour
by passengers is more likely to be observed.

Our existing station operational plans set out the deployment of front line
staff at various times of the day. Criteria for station staff deployment
considers, amongst other issues, customer safety, customer service and
assistance, responsiveness and staff security and safety.

As set out in 1 above, LU has recently undertaken a significant amount of
work to train front line station staff to spot potentially suicidal behaviour
and how to intervene. This has mainly focused on station platforms, but we
will review this training with a view to adapting the content to include
customer behaviours at other locations within stations, specifically at the
key intervention point of the gateline and ticket hall. It shall conclude this
and implement any changes by late 2019.

5. That ease of monitoring of CCTV he facilitated.

LU has invested and continues to invest in updating its remote CCTV
viewing and replay systems and has recently initiated a project to extend
remote accessibility of stations to include not only CCTV but additionally,
public address, fire detection and gate-line systems. We expect to have
concluded our initial trials of the new systems by the end of 2020.

It is not possible for us to continuously monitor every single one of our
roughly thirteen thousand cameras that are positioned around our stations.
We therefore continue to assess and evaluate new and evolving camera-
based detection technologies that can alert staff to certain behavioural
traits and actions that could pre-empt an act of self harm or people
unintentionally putting themselves in danger of being struck by a passing
train.

However, we consider that these technologies are still very immature and
are not sufficiently developed for reliable operation on the LU network.

We are committed to improving the safety of our network through the use
of technology and will continue to evaluate equipment and support
manufacturers wherever possible.

If there is anything that | or my team can assist you with, please contact me.

Yours/sincerely, )

iA (

Managing Director
London Underground