Flora Shen

HM Principal Inspector of Railways 

Email: 

@orr.gov.uk 

23 July 2020 

FAO: Assistant Coroner Mr Jonathan Stevens 
St Pancras Coroners Court, 
Camley Street, 
London 
N1C 4PP 

Also by email to: 

@camden.gov.uk  

By email only 

Regulation 28 Report to Prevent Future Deaths dated 29 May 2020 
Arising out of the inquest touching the death of FLORA SHEN opened on 
10 January 2020.

Dear Assistant Coroner Stevens 

The ORR is grateful for your letter and accompanying Regulation 28 report to prevent future 
deaths dated 29 May 2020. 

This letter is intended to be the ORR’s formal response under Regulation 29 of the Coroners 
(Investigation) Regulations 2013 (the ‘Regulations’), as set out in section 5 of the Regulation 
28 report. 

As you are aware from existing correspondence, ORR did not conduct a formal investigation 
into  this  fatality.  This  is  in  line  with  our  policy  on  mandatory  investigations1  where  the 
individual is an  adult and  the  circumstances  appear to  indicate  a deliberate  act.  In  those 
situations ORR does not normally investigate.  

Consequently the information in  our response is based on our wider  regulatory oversight 
monitoring of DLR and KAD rather than the outcome of a specific investigation of Ms Shen’s 
death. 

We have considered the circumstances of the incident and your concerns carefully and as 
we  explain  further  below,  we  do  not  believe  that  we  have  the  power  to  take  the  actions 
proposed in sections 5 and 6 of the report. With this in mind we recommend that the report 
should  be  directed  towards  Docklands  Light  Railway  Limited  (DLR)  and  Keolis  Amey 
Docklands (KAD) and copied to TfL as the overarching body within which the DLR system 
resides. 

1 https://orr.gov.uk/__data/assets/pdf_file/0020/23717/rig-2014-02-investigation-of-deaths-including-
suicides.pdf  

Head Office: 25 Cabot Square, London E14 4QZ     

T: 020 7282 2000  

orr.gov.uk 

Page 1 of 3 

 
 
 
 
 
 
 
 
                                            
 
 
 
 
  
 
 
 
 
 
 
 ORR’s understanding of the Coroner’s concerns in section 5 of the report is 
that fundamentally the technical features of the DLR vehicles and the operational practices 
used on the system do not facilitate rapid response to circumstances where a person might 
fall onto the running lines. 

It is a requirement of health and safety law that all businesses are obliged to undertake an 
assessment of the risks that their operations create, both to their own staff and to others not 
in their employment who may be affected (e.g. users of the transport system), and then put 
in place measures that control those risks so far as is reasonably practicable. As a health 
and safety regulatory body and enforcing authority ORR can only require that organisations 
fulfil this duty to deliver ‘reasonably practicable’ risk control measures. 

ORR has confirmed that the risk assessments jointly undertaken by DLR and KAD include 
for the events  of  a  person falling  or jumping  onto the  track  and  the  consequent potential 
events.  This  assessment  identifies  a  range  of  control  and  mitigation  measures  for  these 
events. These include, amongst other things, the alarm points on stations and random CCTV 
monitoring,  and  station  signage,  platform  markings  and  surface  finish.  Measures  also 
include  wider  initiatives  such  as  proactive  liaison  with  local  police  and  mental  health 
services. 

ORR has confirmed that these control measures are in place and were in place at the time 
of the death of Ms Shen. 

Given  the  existing  technology  of  the  railway  ORR  considers  that  these  measures  were 
appropriate  and  reasonably  practicable.  DLR  and  KAD  have  jointly  revisited  the  existing 
assessment to consider the provision of platform screen doors at stations, similar to those 
used on the sub-surface platforms of the LUL Jubilee Line. It has determined that installation 
of these have such a high cost in relation to the frequency of RIDDOR reported incursions 
onto the track by  members of the public that they cannot be considered as a  reasonably 
practicable  solution. The  railway  is  nonetheless  investigating  the  potential to  improve  the 
visibility  of  platform  alarms  for  public  use,  and  undertaking  a  programme  of  platform  slip 
resistance improvement at targeted locations. 

The  view  of  ORR’s  inspector  is  that  the  risk  assessments  made  by  DLR  and  KAD  are 
‘suitable  and  sufficient’  as  required  by  the  Management  of  Health  and  Safety  at  Work 
Regulations 1999, and that the actions and controls & mitigations identified were in place at 
the time of the incident. As such DLR and KAD are fulfilling their legal duties. 

ORR  has  challenged  DLR  on  the  reasonable  practicability  of  providing  emergency  stop 
facilities within all the vehicles on the system. DLR have advised us that the vehicles already 
have 10 locations where a member of staff can activate an emergency brake application. 
Two of these are within the manual driving panels at each end of the vehicle and the other 
eight are located one at each doorway and activated by the member of staff inserting their 
key. This does appear to give a reasonable level of access to staff. Experience in mainline 
trains suggests that providing passengers with means to stop trains leads to misuse, which 
in turn can create different risks; including significant disruption to networks, overcrowding 
on trains, and ultimately passengers self-detraining from stalled trains with all the risk this 
brings. The unintended consequences of providing a passenger activated train stop is that 
they could easily cause more problems than they solve. 

Page 2 of 3 

  1772246 

 
 
 
 
 ORR has discussed with DLR the reasonable practicability of providing further 
technological  solutions  that  could  detect  persons  on  the  track  and  take  action  to  stop 
approaching vehicles. DLR have advised us that they have investigated the availability of 
such technologies and are currently seeking a partner to conduct a study into potential on-
train obstacle detection systems. It is clear that DLR is keeping this topic under review and 
actively seeking solutions. 

ORR  is  aware  that  this  is  a  complex  area  and  that  there  are  no  off-the-shelf  technical 
solutions of  this nature  currently  available.  Separately,  the  Department for Transport has 
included in the June 2020 round of innovation funding a project2 to look at this issue. We 
believe this underscores the fact that this is a technical area that continues to be the subject 
of research and development and where reliable commercial products do not yet exist.  

As indicated earlier the ORR’s authority to intervene extends only to circumstances where 
the duty holder falls short of the legal standards required of them.  In the event that a duty 
holder is in compliance with the minimum standards required by the law, the ORR is able to 
provide  advice  and  guidance  but  is  not  in  a  position  to  take  any  enforcement  action.  In 
essence the ORR’s ability to require change is limited to where the legal requirements are 
not met by the duty holder. 

It is for these reasons that ORR considers that the concerns in the Coroner’s report would 
be  better  directed  to  DLR,  KAD  and  TfL.  These  organisations  hold  the  responsibility  for 
health and safety and have the power to investigate and implement additional or alternative 
new technological and operational solutions that could reduce further the risks to persons 
on the track. 

Yours sincerely 

HM Principal Inspector of Railways 

Enc.  Extract from DfT research funding re obstruction detection project in Wales 

cc.  ORR: 
DLR: 
Keolis Amey Docklands: 

2 
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/
892665/Competition_Results_-_SBRI_Rail_Demonstrations_-_First_of_a_Kind_2020.pdf ; relevant 
extract attached to this letter for information as annex A 

Page 3 of 3 

  1772246

Transport for London 

FAO: Assistant Coroner Mr Jonathan Stevens 
St Pancras Coroners Court, 
Carnley Street, 
London 
N1C 4PP 

23 July 2020 

Dear Assistant Coroner Stevens, 

Inquest into the death of Flora Shen 

Thank  you  for the  Regulation  28  Prevention  of Future  Deaths  Report  (the  report) 
dated  29th  May  2020  in  respect  of  Flora  Shen.  This  letter  has  been  prepared  in 
response  to the report. It addresses the matters of concern  raised  and also provides 
background  information  relevant  to the  operating  model  of the  Docklands  Light 
Railway (DLR). 

Keolis  Amey  Docklands (KAD)  operate the  DLR  on  behalf of Transport  for  London 
(TfL), under contract. After liaison with KAD, we have developed a joint response with 
the  General  Manager for TfL and  the  Managing  Director for  KAD to the  questions 
which have been raised on behalf of both organisations. 

Keolis  Amey  Docklands  (KAD)  and  Transport  for  London  (TfL)  offer  our  sincere 
condolences to Flora Shen's family and friends. 

If there is anything further that I can assist you with, please contact me. 

Yours sincerely 

Director, Rail &  Sponsored Services 
Transport for London 

MAYOR OF LONDON 

 ~ Transpor t  for London 
~ Docklands Light Railway 

1<e □ L1s amey 

DOCKLANDS 

Page 2 of 7 

The report has raised three matters of concern that we shall respond to in turn. 

1.  If a member of the public on the train sees a person or a hazard on 
the track ahead they have to go to one of the doorways to activate 
the passenger alarm. The Passenger Services Assistant then goes 
to the telephone which is accessed by a key to ask why the 
passenger alarm has been activated. In order to stop the train the 
Passenger Services Agent then needs to replace the phone, lock 
the phone compartment and use a key to activate the emergency 
brake. 

Every DLR train has a  Passenger Service Agent (PSA) on board when it is in 
service. There are a number of methods of stopping the train which can be 
used if a passenger alarm is activated on the train.  These involve either the 
PSA or the DLR Control Centre 1  establishing the nature of the alarm before 
taking action such as stopping the train.  In all cases, without active intervention 
by the PSA or Control Centre, trains will continue to the next station, but will not 
then proceed beyond the next station until the alarm has been investigated and 
reset. This is a commonly used  practice across other UK rail operators. 

There are a number of methods by which trains can be stopped once a 
passenger has pressed an on-train alarm. 

There are four passenger alarms in each vehicle of a train (two or three vehicles 
make up a train) and if a passenger spots a hazard on the track, they can locate 
the nearest alarm and activate it.  Alternatively,  if the PSA was in the same 
vehicle as the passenger, then the passenger could notify the PSA verbally, 
which will then start the following process. 

As noted above, the alarm does not cause the train to automatically apply the 
brake. However, when an alarm is activated on board the train,  it sends an 
alarm both to the Control Centre as well as sounding an audible alarm on the 
train which the PSA can hear regardless of which vehicle they are in and from 
which vehicle the alarm was pressed. 

The alarm can be acknowledged by the Control Centre, who can speak directly 
to the passenger to ascertain the nature of the alarm. On the newer vehicles in 

1 The DLR Control Centre is where the railway is controlled from, and includes all signalling and 
communications controls. 

 e Transport for London 

Docklands Light Railway 

1<e □ L1s amey 

DOCKLANDS 

Page 3 of 7 

the fleet (2007 stock), the PSA can  also hear this conversation as it would be 
broadcast over the radio system.  If necessary, the Controller in the Control 
Centre can remotely apply the emergency brake to that specific train, or if 
needed they can halt all trains in  the area by pressing the Emergency Train 
Stop button within the Control Centre. 

The PSA is also able to respond to an alarm from  several places within the train 
being the Emergency Driving Position (EDP) at the front of the train; at any 
Door Control Panel (DCP), located at every door; and from a staff-only 
equipment cupboard. The emergency train stop can be activated from any DCP 
or the EDP, however,  if the alarm is  responded  to from the cupboard, the PSA 
will need to go to either the DCP or EDP. It is more likely that the PSA will either 
be close to a DCP or at the EDP driving the train and can  then take between 1-
5 seconds to apply the emergency brake. 

Depending on the nature of the emergency, the PSA will either stop the train 
immediately, using one of the methods described above, or, if appropriate, 
allow the train to proceed to the next station where the emergency can be dealt 
with more effectively / safely. 

Should the alarm be activated on the older vehicles in the fleet (892 stock), the 
alarm notification still goes to both the Control Centre and the PSA.  In this 
instance, the Control Centre would speak to the PSA to establish what the issue 
is and have the capability to stop the train if required . 

2.  The ability to respond to a danger or hazard on the line seems 

sometimes to be dependent on this being noticed by a member of 
the public on a train and them being able to contact the Passenger 
Service Agent in time for the train to be stopped. 

We have described above the ways in which a passenger on-board the train 
can press an alarm and speak to the PSA and / or Control Centre, and 
appropriate action can be taken. 

However, there are a number of other preventative controls used to manage 
this risk. 

 .0.. Transpor t  for London 
~ Docklands Light Railway 

Page4 of 7 

1<e □ L1s amey 
DOCKLANDS 

On platforms, the DLR has yellow lines on all platforms, consistent with London 
Underground and National Rail services, to encourage customers to stand away 
from the platform edges. This message is periodically reinforced by poster and 
announcement campaigns.  If the Control Centre is informed of (via one of the 
methods described below), or observes via CCTV, a passenger close to the 
platform edge, they can make direct announcements to customers telling them 
to step backwards from the platform edge. 

On  every platform area on DLR, there is a Passenger Emergency Point (PEP) 
which is identified by UAlarm" signage on the platforms. These points are a 
further method by which passengers (or mobile staff such as Travel Safe 
Officers or maintenance staff) can notify the Control Centre of an issue or 
incident on  the railway, and a means by which  the passenger can directly stop 
trains themselves. The PEP contains: -

(a) a Passenger Alarm, which connects directly through a two-way voice link to 
a staff member in the Control Centre (usually the Information Assistant - this is 
a role in  Control Centre specifically dedicated to reviewing CCTV cameras and 
making public announcements); 
(b) an "Emergency Train Stop" button. Pressing this button has the same effect 
as pressing the "Emergency Train Stop" button in the Control Centre and will 
immediately bring all trains in  the surrounding area to a controlled stop. 

In the event of the Emergency Train Stop button being pressed on  a platform, 
the Control Centre is immediately notified through the signalling system. CCTV 
screens automatically change to display the location of the button being 
pressed and can talk directly to the passenger or member of staff on site. 

All platform areas of the DLR network are monitored by CCTV screens from the 
Control Centre. All staff members within the Control Centre have their own 
CCTV screen, with the 'Information Assistant' role specifically including 
monitoring a bank of CCTV screens. 

In the event an incident is identified by any staff member within the Control 
Centre, all desk positions have "Emergency Train Stop" buttons within arms' 
reach. Pressing this button  removes signal authority from all automatic trains 
within or immediately approaching the station, which activate the trains' 
"emergency brakes". Any other automatic train will be brought to a controlled 
stop outside the station area, using the normal service brake. 

 e Transport  for London 

Docklands Light Railway 

1<e □ L1s amey 

DOCKLANDS 

Page 5 of 7 

The Control Centre also has the ability to immediately remove traction power, 
which  is activated if a person or object is believed to be near the conductor rail 
(which is electrified to 750V DC). 

In  addition to the above, there are a number of other elements of the DLR's 
operation which help to control this risk. Although some of these are more 
focused  at identifying vulnerable people, they also have benefits for the safety 
of all passengers. 

•  A core theme running through all frontline staff training is the need to be 

vigilant 

•  Dedicated Travel Safe Officers patrol the DLR every day. 
•  KAO  have a team of Community Ambassadors, who work with  the 

Community Mental Health Teams in Newham and Tower Hamlets, to 
educate and mentor specific groups of DLR customers on  safe travel. 

•  British Transport Police (BTP) officers routinely patrol the DLR 
•  The Public address system is available for the Control Centre to make 

announcements to passengers, as needed (e.g. "please stand back from 
the platform edge" or "please stand back behind the yellow line"). 

•  Passenger awareness campaigns also take place around the risks at the 

platform-train interface, aligned with TfL poster campaigns. 

3.  The central DLR CCTV monitoring system cannot watch all stations 

at the same time and the safety of persons slipping, falling or 
collapsing on to a line on the DLR system seems to rely on ability of 
members of the public to notice the hazard and activate the alarm 
on either the platform or the train. 

The DLR has more than 1,000 CCTV cameras covering all 45 DLR stations.  It is 
correct to state it is  not possible to monitor all these cameras simultaneously. 
As mentioned above, there is a specific role within the Control Centre (the 
Information Assistant) who continuously monitors the bank of CCTV monitors, 
they can also bring up and view any particular camera view as required. 

The operating model does, nevertheless, rely in  many instances on passengers 
notifying train staff, mobile staff, or the Control Centre when noticing a hazard. 

 Transport  for London 
Docklands Light Railway 

Page6 of 7 

l<e □ LIS amey 
- - ----- - -

DOCKLANDS 

Your letter specifically asks for the actions that we propose to take following the 
incident and the associated timescales in order to address your areas of 
concern. These are as follows: 

1.  Enhancing the signage on the platform alarms - the intention of this work 
is to give passengers a greater chance of locating the alarms on the 
platforms should they notify a hazard on the track. The timescale for 
completion is July 2021; the programme is now being developed and 
would be rolled  out on a risk-basis. 

2.  We will continue to research and collaborate with suppliers to identify 
potential solutions and  improvements in the area of hazard/obstacle 
detection. We are currently exploring an emerging CCTV product that 
can detect persons and/or objects on the track, and  have held 
preliminary discussions with its developer to assess its potential for 
testing on the DLR.  We should know by December 2020 if a trial can be 
taken forward.  However, this is partly dependent on the existing CCTV 
network being capable of supporting such a trial. 

In  addition to this , we are continually reviewing what other technologies exist 
around obstacle detection fitted to the trains. Technology in this area is still 
considered immature when applied  in  a railway environment and is not 
sufficiently developed for reliable operation at this time on the DLR network. 

For any such on-train or CCTV-based system to be effective, it would  need to 
be able to distinguish between trains entering platforms, hazards as well as 
non-hazards. Any system would also need to avoid both malicious activations 
and false positives to avoid adversely impacting the high frequency train 
service. 

The DLR is a member of the international benchmarking community of 20 light 
rail operators, Nova. The operators regularly review advances in detection 
technology. One of the most commonly reviewed areas of interest is protecting 
the train-platform interface to ensure that it is safe for passengers to 
alight/board trains and the operators share best practice. 

In summary, there are currently, as referred to above, a number of control 
measures to identify and respond to a person slipping, falling or collapsing on to 
the line. We will progress as soon as possible with enhancing the visibility of the 

 e Transpo ct for Lo ndon 

Docklands Light Railway 

1<e □ L1s amey 

DOCKLANDS 

Page 7 of 7 

platform alarms and continue to work towards the possibility of an initial trial of 
the CCTV obstacle detection option. 

The Office of the Rail and Road (ORR) is the independent safety and economic 
regulator for Britain's railways and is responsible for ensuring that railway 
operators comply with  health and safety law. The ORR is also responsible for 
issuing safety certificates to all UK rail operators which are valid for a period of 
5 years.  The ORR reissued KAD's safety certificate on November 27th 2019 
which  is necessary for KAO to operate the DLR, and deems DLR's operating 
model, and specifically its safety management arrangements, to be appropriate 
for managing risk to a level "as low as is reasonably practicable" as defined in 
the Railways & Other Guided Transportation Systems (Safety) Regulations 
2006. Safety Certificates. 

Notwithstanding the ORR's Safety Certificate, KAO and Tfl are committed to 
continually improving safety on the DLR.  We continuously review the risks 
associated with our operation and consider the additional mitigations that can 
be put  in  place to maintain the highest levels of safety on our network, for both 
passengers and staff. 

If there is anything further that we or any member of our respective team can 
assist you with , please contact us. 

Yours sincerely 

General Manager DLR 

Managing Director KAO