Derailment at Chancery Lane on 25 January 2003 Interim Report – 20 February 2003 Executive Summary

At approximately 13.52 on Saturday, 25th January 2003 a westbound Central line train derailed as it entered the westbound platform at Chancery Lane Underground station. Unfortunately, 32 people required medical attention; the most serious physical injury reported was a broken ankle.

The train involved was service train No. 002, which had started service at 05.36 at White City. There were a number of traction effort faults recorded on the trains on board data system during the morning; indication of such faults is not available to the Train Operator or the Line Controller.

As the train approached Leytonstone station at 13.28 unusual noises were heard coming from the train, the Line Controller received this report at 13.29. Reports sought by the Line Controller from station staff at Leyton and Liverpool Street were received at 13.36 and 13.48 respectively, these did not give any confirmation of unusual noises. The Train Operator of the following train 036 reported abnormally dusty and murky conditions. On receiving further information the Line Controller decided to take the train out of service. As the train was leaving St. Paul’s station the Line Controller ordered the Train Operator to detrain at Holborn and go into the sidings there. Unfortunately the derailment occurred on the approach to Chancery Lane at 13.52.

Following the derailment the train involved was evacuated and the emergency services quickly arrived on the scene. Others trains affected by the turning off of the traction current were detrained at St. Paul’s and Bank stations.

The incident occurred when the train was approaching Chancery Lane station on the single westbound track. The accident was caused by a traction motor becoming detached from the rear bogie on the fifth car, falling on to the track causing that and subsequent cars to derail. This led to the front corner of the sixth car (92256) colliding with the tunnel wall and platform edge. The only breaches of passenger space were broken windows and one door being pulled off. There was considerable damage underneath the train, the track and adjoining assets. Debris and minor damage to tunnel equipment has been found from 800m west of St. Paul’s to the incident site, about a train’s length from Chancery Lane.

An Inquiry Panel has been formed with the appointment of an independent chairman, Dr. Roger Aylward. A support team drawn from within LU, Infraco BCV, Trade Union Health and Safety Representatives and external resources has been selected to assist the inquiry panel with research and interviews of the people concerned. The work of the inquiry is well underway and most parts will be completed by the end of March 2003. However, it is not possible to say with confidence yet, when the technical investigation will be completed.

The Health and Safety Executive (HSE) is conducting its own inquiry parallel to the LU Investigation and all parties are ensuring information is shared to the best effect. The cars they had impounded were returned to LU on Wednesday 19 February 2003.

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Contents

1.0 Introduction Page 3

2.0 Terms of Reference Page 4

3.0 Description of Events Page 5

4.0 Injuries Page 8

5.0 Description of Damage Page 9

6.0 Work Underway Page 10

7.0 Operations on Day Page 11

8.0 Maintenance Practices and Procedures Page 11

9.0 Engineering Issues Page 12

10.0 Post Accident Events Page 13

11.0 Timescales Page 13

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1.0 Introduction

This is the interim report following an initial statement published on the 31 st January 2003. Since then one formal meeting of the Inquiry Panel has been held, on 12th February 2003. This dealt with events on the day of the incident. The terms of reference and working of the inquiry team have now been established and 9 further Formal Panels are being planned. Observers from the London Transport Users Committee, LU and Infraco BCV Management are attending the formal panel sessions. Trade Union Health and Safety Representatives are actively participating in the inquiry.

This report outlines the evidence revealed to date and the way in which the overall inquiry is organised and topics that are being addressed.

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2.0 Terms of Reference

The formal investigation into the derailment at Chancery Lane on Saturday 25 January 2003 is to consider the circumstances prior to, during and immediately following the derailment. The investigation is to determine the root causes of whatever went wrong and recommend actions to address them.

An initial report, setting out the facts of the accident is required by Friday 31 January. An interim report setting out early conclusions is required by 21 February 2003. The interim report should propose a date for the final report based on the progress to date.

The investigation should cover, in particular, the following:

1. Determining the immediate and underlying causes of the incident, and in so doing to consider the relevance or otherwise of the known difficulties and relevant incidents with traction motor fixings with this rolling stock, the efficacy of the interim engineering arrangements in this respect, the adequacy of any associated operational arrangements and the status of work to achieve a permanent engineering solution. This may include, if thought necessary, reference to the original train specification and design and arrangements for their maintenance.

2. The events leading up to the derailment on the day and the adequacy or otherwise of the measures and decisions taken.

3. The circumstances of the derailment itself, including the failure mode(s) of the equipment involved and the performance of the train, other infrastructure and systems during the derailment compared with design standards (where relevant - e.g. rolling stock crash worthiness, means of escape, etc.)

4. The adequacy or otherwise of the response to the incident by all LU staff, the emergency services (insofar as this is relevant to LU's performance) and any of LU's partners or contractors involved. This is to include the handling of other trains and customers involved during and after the incident.

5. The adequacy or otherwise of assistance given to customers affected both at the time of the incident and during the follow up to the incident.

6. The quality and adequacy of information given to customers about service impacts and alternative services.

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3.0 Description of Events

From interviews, data and voice recordings and other evidence, it has been possible to piece together the following chronology of events that best describes what led up to the derailment of Train 002 at Chancery Lane.

 At 05.36 Train 002 entered passenger service at White City station proceeding eastwards on to the Central line. The 1992 Tube Stock train comprised of cars numbers 91005, 92005, 92142, 93142, 93256, 92256, 92001, 91001, with car number 91005 being the lead car at the time of the derailment.

 The Data Transmission System (DTS) indicated a number of events during the day, which are still being investigated. The panel has yet to determine the significance of these recorded events. It should be noted that not all of these normally come to the attention of the Train Operator or the Line Controller.

 Train 002 was operated by three other Train Operators before the incident occurred (duty numbers, 303, 403 and 611) without any incident of note.

 The Train Operator at the time of the incident worked Train 002 from 12.35 Leytonstone eastbound to Epping without hearing unusual noises or experiencing any difficulties with the train.

 Train 002 departed Epping travelling westbound at 13.09. At 13.26 Train 002 entered Leytonstone station via Platform 2 as Train 041 entered platform 1 eastbound. The Train Operator of Train 041 heard unusual noises coming from Train 002, and discussed this with another Train Operator, who was waiting to pick up Train 041, and an off-duty Train Operator who described the noise as similar to nails being rolled around in a can.

 Train Operator of Train 041 called the Line Controller as he left Leytonstone heading east.

 The Line Controller and Duty Line Control Manager (DLCM) were sitting beside each other at the Central line Service Control Centre. They received the call at 13.26 from the Train Operator of Train 041 about the noise coming from around car 5 of the train.

 At 13.27 the DLCM called up the CCTV picture of the train leaving Leytonstone but saw no obvious sign of defect. The Line Controller spoke to the Train Operator on Train 002 and advised him of the reported noise and that a member of station staff would travel in the 5th car from Leyton to Stratford and report to him at Stratford.

Note: The description given above is based on the evidence reviewed to date and provides an indication of the events, this is subject to final review by the panel. All timings quoted have been amended where necessary to “Rugby” time and rounded down to the nearest minute

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 The Station Assistant got into the 5th car at Leyton and rode to Stratford where he reported to the Train Operator of Train 002 that he had not heard any unusual noise.

 At 13.34 the Train Operator of Train 002 reported from Stratford that the Station Assistant did not hear any unusual noise and that he was proposing to continue his westbound journey; the Line Controller agreed with this course of action.

 Because of the initial report by the Train Operator of Train 041, the DLCM and Line Controller decided to continue to monitor Train 002 on the CCTV but could see no sign of a problem. The Line Controller then called Liverpool Street Station Control Room and asked them to organise a member of staff to go to the westbound platform and listen to Train 002 as it departed.

 The Train Operator on Train 002 was not experiencing any problems with the train; the train appeared to be running satisfactorily and the train management system was not advising of any defect.

 At 13.47 the Train Operator of Train 036, following Train 002, reported to the Line Controller that Bethnal Green and Liverpool Street stations were “dusty and murky” and asked whether there were problems with the tunnel ventilating fans. On hearing that there might be a problem with Train 002 in front, Train Operator of Train 036 reported that he had heard a rattle when Train 002 had left Leytonstone when Train 036 was then in the adjacent westbound platform.

 When the Line Controller contacted Liverpool Street Station Control Room at 13.48 he was informed that the Station Assistant had listened to Train 002 but did not hear any unusual noises. The Line Controller and the Station Control Room Assistant switched the CCTV screens to Liverpool Street westbound and agreed that it looked murky. The Line Controller advised the Station Control Room Assistant the train would be withdrawn from passenger service.

 Meanwhile at 13.50 the DLCM contacted the Power Control Room (PCR) and spoke to the Operator about the occurrence of any earth faults. The PCR Operator said that he had had a couple of “kicks” on section 22 (east of Leyton tunnel mouth) and that it had moved to section 15 (west of Leyton tunnel mouth). Later it transpired this information was incorrect.

 The Line Controller called the Train Operator on Train 036 at Bank at 13.50 and asked if it was murky there as well, the Train Operator confirmed that it was. The Train Operator was then asked to call control when he arrived at St. Paul’s. Subsequently the Train Operator confirmed murky conditions at St. Paul’s.

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 The Station Assistant, working on the westbound platform at Bank, advised the Bank Station Control Room that westbound Train 002 was making an unusual noise as it departed from Bank. This message reached the Line Controller at 13.50.

 The Line Controller then called Train 002 as it was leaving St. Paul’s and advised the Train Operator to detrain the passengers at Holborn and to take the train into the siding there.

 A “Mayday” call from Train 002 was received at 13.52 and traction current discharged by Tunnel Telephone operation; it is not yet known exactly how this occurred. As a result of this discharge Train 036 was stalled in St. Paul’s station and Train 065 stalled approximately half a car from Bank westbound platform.

 An off-duty Revenue Control Inspector (RCI) was travelling in the 2nd or 3rd car of Train 002. Approaching Chancery Lane he noticed that the train was not stopping normally but “dragging”. The train stopped with a jolt and the Train Operator used the Train Public Address system (PA) to request customers to move to the front of the train, as there appeared to be smoke at the rear of the train. The RCI then heard a “Mayday” call over the train PA. (These PA announcements are subject to further investigation). Some of the doors opened and he heard a preliminary evacuation warning message over the station PA. He pressed the platform alarm, stopping the message and sounding the evacuation alarm.

 The Duty Station Manager (DSM) was with the Station Supervisor at Chancery Lane station when a message was received at 13.54 from the Line Controller advising that the Station Supervisor should go to the westbound platform as there appeared to be a lot of “smoke”. Subsequently, this proved to be dust rather than smoke. The Station Supervisor and DSM met the off- duty RCI at the top of the escalator.

 An off-duty Station Supervisor was travelling on Train 002 in the 3rd car. He reports that the train started to judder approaching Chancery Lane and then stopped with a loud bang. He heard the “Mayday” message and saw passengers moving down the train. He calmed the passengers down and motioned to a member of the public on the platform to operate the butterfly cock to open a pair of doors. This was not achieved but by then other doors had been opened by the Train Operator of Train 002. The off-duty Supervisor then detrained all of the passengers whilst walking to the rear of the train to check that it was empty.

 A total of approximately 750 people were believed to be travelling on Train 002 at the time of the derailment. This figure is subject to verification.

 The off-duty Station Supervisor met the Train Operator on the platform and used the auto telephone on the platform to the Line Controller who confirmed the traction current was off.

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 The off-duty Station Supervisor escorted the London Fire Brigade (LFB) on to the train where they searched for any passengers who might have fallen from the train. He supervised the LFB placing a Short Circuiting Device (SCD) on to the track at the front of the train. He then escorted the LFB to the rear of the train where a further SCD was placed on the track.

 The Duty Station Manager, having phoned the Line Controller from the eastbound platform, proceeded to the Station Supervisor’s office and assumed “Silver Control” with the Station Supervisor as “Bronze” in accordance with the Incident Management procedure Na100.

 Train 036 was stalled in St. Paul’s westbound platform where all passengers were detrained and evacuated by 14.25.

 Train 065 was stalled approximately half a car from Bank westbound platform. To enable the train to be moved, the Line Controller instructed the Duty Station Manager and the Station Supervisor at Bank to open the motorised section switches 734 and 735. Switch 735 failed to operate so the Duty Station Manager decided to detrain passengers from Train 065 on to the track and walk them to the platform. All of the passengers, approximately 750 in number, were detrained by 14.55.

4.0 Injuries

Following the incident it was reported that 32 people had been treated for mainly minor injuries (cuts and bruises). The most serious injury reported was a broken ankle and it is believed that this was sustained whilst the customer was evacuating the train. These injuries were treated either at Chancery Lane or at near by hospitals.

Since the derailment a substantial number of customers who were on the train have contacted London Underground to provide further information about their experience and injuries. These are being followed up as part of the inquiry.

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5.0 Description of Damage

The train came to rest with the front cab approximately 30.5 metres from the west end headwall of the tunnel. The first four cars in the direction of travel (91005, 92005, 92142, 93142), remained on the track and did not appear to have suffered any damage.

The leading bogies of car five remained on the track but all remaining bogies to the rear of the train where derailed. “W” door window on car five (93256) was smashed but otherwise the car appears to have suffered little damage.

Car six (92256) ended up with the front corner resting on the platform edge. This car’s single leaf leading door “W” had become detached from the car ending up on the platform adjacent to the car. The following window had been broken, possibly by one edge of “W” door as it came away. Damage had been inflicted to the front lower edge of the car and the upper door support track and cover. The car also suffered denting and scratches to the body sides. Two interior glass draught screens between “F” and “E” doors had also broken.

Cars seven and eight (92001 and 91001) received minor scrapes and dents on the outside and two broken glass draught screens in car eight between doors “F” and “E”. All four rear cars appear to have remained structurally intact, with the exception of 92256, which lost “W” door (see above). This initial view is subject to further examination of the cars.

In derailing, shoe gear and other components were damaged on the bogies. In becoming detached the traction motor was caught between the underside of the cars and the track, inflicting damage on the underside equipment cases of the rear cars, their bogies and inter-car connections.

The motor also damaged the track in the tunnel; smashing several sleepers and insulating pots on the power rails. The derailment also pushed the running and power rails out of their mountings for around 15 metres. The sides of the derailed cars also inflicted damage on the tunnel cable brackets, associated cables and tunnel telephone wires. Some debris appears to have entered the passenger saloon.

The platform edge was damaged for about 15 metres from the rear tunnel wall.

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The Inquiry into the Chancery Lane derailment commenced immediately after the incident on 25th January 2003. The panel consists of:

 Dr Roger Aylward, independent chair  Daniel Howarth, LU representative  Mac Mackintosh, IBCV representative  Peter Wickham, LU SQE representative

An initial statement describing the events surrounding the derailment was produced on Friday 31 January 2003.

The Inquiry is pursuing four main lines of investigation each sponsored by a member of the panel as follows:

 Operational: What happened on the day, both before and after the derailment including customer handling issues. Daniel Howarth

 Fleet Maintenance: Arrangements made for the maintenance of the rolling stock prior to and following previous incidents. Mac Mackintosh

 Process of incident investigation: What investigations took place into previous incidents and how were recommendations implemented and communicated between the parties. Peter Wickham

 Technical: Underlying causes leading to the failure of the traction motor mountings and why measures taken since the Loughton incident had failed to prevent the accident. Roger Aylward

The Inquiry team continues to liase closely with HMRI.

The Inquiry is adopting a two-stage approach to the investigation. This involves a fact finding investigation in each of the four areas, summarised by a nominated manager followed by a formal panel hearing where the summary is reviewed. The panel met formally on Wednesday 12 February and heard the results of the operational fact finding regarding events prior to the derailment which had been conducted in conjunction with staff representatives and was based on interviews with 20 operational staff and managers. Observers from BCV Infraco, BCV Service Delivery Unit, Chief Engineers Directorate and the London Transport Users Committee were present, as were a number of nominated Trade Union Health and Safety staff representatives.

10 of 14 03/05/18 Derailment at Chancery Lane on 25 January 2003 Interim Report – 20 February 2003 Further formal hearings have been arranged for the 4-6, 11-13 & 18-20 March.

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6.0 Operations on Day

Fact finding interviews have been held with most of the operating staff who were involved with the incident in any way. More interviews are planned as other people are recognised as having some influence on the incident and its outcomes and where people may not yet be available for formal interview, statements have been gained detailing their involvement. These were conducted by the Train Operations Standards Manager (TOSM) and Trade Union Health and Safety representatives. Using this and other evidence (data and voice records, CCTV etc.) the TOSM has produced a draft report of the events of the day.

7.0 Maintenance Practices and Procedures

Infraco BCV has now carried out some preliminary interviews of maintenance staff. The inquiry team will complete further fact finding interviews of these staff and others. The panel will then take formal evidence.

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8.0 Engineering Issues

Staff of Infraco BCV and the Chief Engineers Directorate (LU) have been working extremely hard to get the modifications designed, case for safety made and the changes implemented to get the Central line trains running again.

Consequently, it was decided to take on additional resources to investigate the root cause of motor detachment and selected issues. Atkins Consultants Limited have been retained to undertake this role. Their terms of reference are:

 To determine the root cause of traction motors becoming detached from their fastenings on 1992 Tube Stock.

 To examine the engineering efficacy of the modifications and procedures that have been previously implemented concerning traction motors becoming detached and the tightening of their mounting bolts.

 To examine the behaviour of the 1992 Tube Stock in the collision regarding crash worthiness and to make recommendations if appropriate.

Atkins Consultants are based in Canary Wharf and will be working closely with Infraco BCV and LU Chief Engineer staff.

Work recently completed on existing recordings taken on 12 November 2002 on 1992 Tube Stock indicates that at high speed there is a resonant condition that produces high fatigue loads on the motor mountings. This has strong similarities with problems occurring with traction drive systems on Networker trains running on National Rail in the late 1990s where couplings made by Hygate were found to be a major contributor to the failure of welds supporting traction motors.

There are strong indications that there have been gearbox failures associated with the detachment of traction motors. Input shaft bearings have failed and the input pinion has been stripped of its teeth; this fits in with the reported traction failures from the train data system. A significant number of gearbox cover plates have been recovered from the track.

It is still not possible to determine the sequence of events but it is clear that there have been a series of failures in the traction drive before the motor has become detached. Further work is needed before it is possible to determine with confidence the initiating problem and the resulting sequence of failure.

Work is being rigorously pursued to understand the underlying cause but it is not yet clear when these technical issues will be resolved.

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9.0 Post Accident Events

Train 002, half in the westbound platform at Chancery Lane, was evacuated in a timely fashion. It is not understood how some of the doors were opened and why passengers on the train heard the “Mayday” message. These matters are still under investigation.

There were problems in deploying a Short Circuiting Device (SCD) at Bank. The Central line SCDs vary slightly in design from others used on LU. Current work is being accelerated to modify their containment in the cabs so that the standard design, which is more satisfactory, can be used on the Central line.

The detrainment near the westbound platform at Bank had some minor problems. Firstly, one of the motorised sectional switches, No. 735, could not be operated. Secondly, the detrainment ramp was difficult to place into position. Location lugs were bent and members of staff took some time to secure it satisfactorily. Thirdly, the emergency lighting in the train only lasted for 25-35 minutes and after that the only light available was from the tunnel lights, shining into the train.

Infraco BCV is actively addressing these three problems. Detrainment ramps will be inspected before the trains go back into service. The motorised section switches are being investigated. Infraco BCV is aware of the poor performance of the emergency lighting. This rectification programme is being examined to ensure that this is remedied as soon as practicable.

10.0 Timescales

It is expected that most parts of the investigation will be complete by the end of the March 2003. However, it is not possible to say with confidence yet when the technical investigation will be completed. Extra resources have been deployed but the root cause may take some time to understand and then confirmatory tests may be needed. As soon as a firm prediction for the completion of this work is available all relevant parties will be informed.

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