PFD report

Flora Shen · Prevention of Future Deaths report

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Issued 29 May 2020•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Dependence on multiple manual actions to activate the emergency brake
    Part of recurring concern: Failure of emergency alarm response
  2. Dependence on train passengers to notice hazards and contact the Passenger Services Agent in time
  3. Inability of the central CCTV monitoring system to watch all stations simultaneously
    Part of recurring concern: Unreliable railway-station detection and alerting for persons on the linePart of recurring concern: Unreliable safety CCTV monitoring systems
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Research and collaborate on CCTV and train-based hazard-detection technologies, including assessing potential options for a DLR trial.

    Stated by Keolis Amey Docklands (KAD and Transport for LondonStated in progressThe respondent said that this action was in progress when they made their response on 11 June 2020.
  2. Action

    Develop and roll out enhanced platform-alarm signage to improve passengers’ ability to locate alarms.

    Stated by Keolis Amey Docklands (KAD and Transport for LondonStated in progressThe respondent said that this action was in progress when they made their response on 11 June 2020.
  3. Action

    Challenge DLR on the reasonable practicability of providing additional emergency stop facilities throughout the vehicles.

    Stated by Office of Rail and RoadStated completedThe respondent said that this action was complete when they made their response on 11 June 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    On-train and CCTV obstacle-detection technology is considered insufficiently mature for reliable operation on the DLR network.

    Stated by Keolis Amey Docklands (KAD and Transport for LondonUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Dependence on multiple manual actions to activate the emergency brake

Wider context from the report

“(1) If a member of the public on the train sees a person or 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. ”

Is this part of a recurring concern?

Yes — Failure of emergency alarm response.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Dependence on train passengers to notice hazards and contact the Passenger Services Agent in time

Wider context from the report

“(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 Services Agent in time for the train to be stopped. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inability of the central CCTV monitoring system to watch all stations simultaneously

Wider context from the report

“(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. ”

Is this part of a recurring concern?

Yes — Unreliable railway-station detection and alerting for persons on the line; Unreliable safety CCTV monitoring systems.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Dependence on members of the public to notice hazards and activate alarms

Wider context from the report

“(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. ”

Is this part of a recurring concern?

Yes — Failure of emergency alarm response; Unreliable railway-station detection and alerting for persons on the line.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Research and collaborate on CCTV and train-based hazard-detection technologies, including assessing potential options for a DLR trial.

Verbatim wording from the response

“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.”

Source location

2020-0115-Response-from-TFL_Redacted.pdf
Page 6 · response
Published 11 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and roll out enhanced platform-alarm signage to improve passengers’ ability to locate alarms.

Verbatim wording from the response

“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.”

Source location

2020-0115-Response-from-TFL_Redacted.pdf
Page 6 · response
Published 11 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Challenge DLR on the reasonable practicability of providing additional emergency stop facilities throughout the vehicles.

Verbatim wording from the response

“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 can lead 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.”

Source location

2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
Page 2 · response
Published 11 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Discuss with DLR the reasonable practicability of technological solutions to detect people on the track and stop approaching vehicles.

Verbatim wording from the response

“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.”

Source location

2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
Page 3 · response
Published 11 June 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

On-train and CCTV obstacle-detection technology is considered insufficiently mature for reliable operation on the DLR network.

Verbatim wording from the response

“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.”

Source location

2020-0115-Response-from-TFL_Redacted.pdf
Page 6 · response
Published 11 June 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing risk controls were considered appropriate and reasonably practicable, so additional platform screen doors were not required.

Verbatim wording from the response

“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.”

Source location

2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
Page 2 · response
Published 11 June 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Passenger-activated train stops could cause misuse, network disruption, overcrowding and unsafe self-detraining, creating greater risks than they solve.

Verbatim wording from the response

“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 can lead 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.”

Source location

2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
Page 2 · response
Published 11 June 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

DLR, KAD and TfL held responsibility and power to investigate and implement additional technological or operational safety solutions.

Verbatim wording from the response

“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.”

Source location

2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
Page 3 · response
Published 11 June 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Reliable commercial technologies for detecting people on tracks and stopping trains were not yet available off the shelf.

Verbatim wording from the response

“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.”

Source location

2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
Page 3 · response
Published 11 June 2020

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Continuously review operational risks and consider additional safety mitigations for passengers and staff.

    Stated by Keolis Amey Docklands (KAD and Transport for LondonStated in progressThe respondent said that this action was in progress when they made their response on 11 June 2020.
  2. 2

    Verify that DLR and KAD risk assessments cover track incursions and that identified control and mitigation measures are in place.

    Stated by Office of Rail and RoadStated completedThe respondent said that this action was complete when they made their response on 11 June 2020.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The operating model and safety management arrangements are considered appropriate for managing DLR risks as low as reasonably practicable.

    Stated by Keolis Amey Docklands (KAD and Transport for LondonExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. 2

    ORR could require change only where a duty holder failed to meet legal standards; compliant duty holders could not be subject to enforcement.

    Stated by Office of Rail and RoadOutside remitThe respondent said that this matter was outside its role or authority.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continuously review operational risks and consider additional safety mitigations for passengers and staff.

Verbatim wording from the response

“Notwithstanding the ORR’s Safety Certificate, KAD 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.”

Source location

2020-0115-Response-from-TFL_Redacted.pdf
Page 7 · response
Published 11 June 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Verify that DLR and KAD risk assessments cover track incursions and that identified control and mitigation measures are in place.

Verbatim wording from the response

“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.”

Source location

2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
Page 2 · response
Published 11 June 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The operating model and safety management arrangements are considered appropriate for managing DLR risks as low as reasonably practicable.

Verbatim wording from the response

“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 KAD 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.”

Source location

2020-0115-Response-from-TFL_Redacted.pdf
Page 7 · response
Published 11 June 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

ORR could require change only where a duty holder failed to meet legal standards; compliant duty holders could not be subject to enforcement.

Verbatim wording from the response

“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.”

Source location

2020-0115-Response-from-Office-of-Rail-and-Road_Redacted.pdf
Page 3 · response
Published 11 June 2020

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026