Hassan Zubair
PFD Report
All Responded
Ref: 2022-0150
All 1 response received
· Deadline: 14 Jul 2022
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
14 Jul 2022
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. The failure of the signals controller to advise trains travelling through to proceed with caution.
Responses
Network Rail enhanced its reporting system between signallers and MTR station staff to facilitate rapid assistance and conducted workshops to train relevant staff. They clarified that a caution was placed on the relevant platform line, and further action was deemed unnecessary for other lines due to Mr Zubair's direction and existing safety measures.
AI summary
View full response
Dear Senior Coroner Irvine
Regulation 28 Report – Hassan Zubair
I refer to your report dated 19 May 2022 made under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
I would like to take this opportunity to express my sincere condolences to the family of Mr Hassan Zubair on behalf of Network Rail. I hope from Network Rail's participation in the Inquest into Mr Zubair's death that you are aware that we take all incidents of this nature on the railway incredibly seriously.
I have carefully considered the concern raised in your report in respect of the signaller not advising trains travelling through both Platforms 2 and 3 to proceed with caution. As was explained during the Inquest into Mr Zubair's death, when the concern for welfare report was made by a train driver, Mr Zubair was stood on Platform 3 of on a publicly accessible platform, physically separated from Platform 2 (which I address below). I understand that from the CCTV footage Mr Zubair was seen walking in the opposite direction from the end of Platform 3 towards the station exit. As a precautionary measure based upon the information provided to the Signaller and on their detailed knowledge of the station and its layout, a caution was put in place on the line interfacing with Platform 3 where Mr Zubair had been observed. In addition to the caution, timely calls were placed by Network Rail to the train operating company staff, MTR, to immediately check on the welfare of Mr Zubair.
OFFICIAL In terms of the layout of the station and its infrastructure, although Platforms 3 and 2 are back to back, there are a significant number of measures in place to deter members of the public from accessing Platform 2, which services non-stopping trains and is not generally accessible by the general public. Most significantly, a metal fence physically separates Platforms 3 and 2 to deter access by the public to Platform 2. The fencing mitigated the need to caution trains on Platform 2 because it is designed to prevent people from crossing from Platform 3 to Platform 2. Therefore, it was reasonable for the Signaller to caution the trains on Platform 3 only.
In addition, other mitigation measures are in place to deter and/or prevent access by members of the public and these include:
1. White and yellow lines indicating the edge of the platform and the 'keep clear' area respectively;
2. Electronic help points;
3. Platform end barriers;
4. Signs warning against trespass;
5. Anti-trespass panels on the ground;
6. Samaritans signs in situ; and
7. Patrol by nine mobile security teams which specialise in reducing antisocial behaviour and suicide prevention that operate on a 24/7-hour basis.
If Mr Zubair had been seen trying to access the track on platform 2, trains which would proceed over the affected portion of the line would have been cautioned or stopped in accordance with the procedure Network Rail must follow under section
18.1 of the Rail Safety and Standards Board GERT8000 Rule Book (Rule Book). A copy of section 18.1 of the Rule Book is at Annex 1. As Mr Zubair was seen heading towards the exit and we already had a number of mitigation measures in place regarding platform 2 (including, in particular, a fence physically preventing access from platform 3 to platform 2) a stop or caution was not considered for this line.
We receive many calls reporting concerns in relation to the welfare of users each day and takes many measures to ensure the safety of all individuals using the railway. We are also responsible for maintaining the operation of the railway network and the safe passage of trains and passengers across the network. Signallers play a huge role on this. In response to any welfare report, Signallers will make a decision as to the most appropriate action to take based on the nature of the information reported and their detailed knowledge of the infrastructure and the location. This is done in
OFFICIAL accordance with the Rule Book, which purposely provides a degree of flexibility to ensure that Signallers are empowered to make appropriate decisions based on all factors within their knowledge.
Following this tragic incident, Network Rail did take action and enhanced the reporting system between Network Rail and MTR for Signallers to contact the station directly. This allows station staff to provide rapid assistance to individuals in these types of situations. Workshops have also been undertaken to train relevant staff. Network Rail takes its safety obligations incredibly seriously and we are committed to reducing opportunity for members of the public to come to harm on or near the railway.
I hope that this response answers your concerns but if I can be of any further assistance please do not hesitate to contact me.
Regulation 28 Report – Hassan Zubair
I refer to your report dated 19 May 2022 made under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
I would like to take this opportunity to express my sincere condolences to the family of Mr Hassan Zubair on behalf of Network Rail. I hope from Network Rail's participation in the Inquest into Mr Zubair's death that you are aware that we take all incidents of this nature on the railway incredibly seriously.
I have carefully considered the concern raised in your report in respect of the signaller not advising trains travelling through both Platforms 2 and 3 to proceed with caution. As was explained during the Inquest into Mr Zubair's death, when the concern for welfare report was made by a train driver, Mr Zubair was stood on Platform 3 of on a publicly accessible platform, physically separated from Platform 2 (which I address below). I understand that from the CCTV footage Mr Zubair was seen walking in the opposite direction from the end of Platform 3 towards the station exit. As a precautionary measure based upon the information provided to the Signaller and on their detailed knowledge of the station and its layout, a caution was put in place on the line interfacing with Platform 3 where Mr Zubair had been observed. In addition to the caution, timely calls were placed by Network Rail to the train operating company staff, MTR, to immediately check on the welfare of Mr Zubair.
OFFICIAL In terms of the layout of the station and its infrastructure, although Platforms 3 and 2 are back to back, there are a significant number of measures in place to deter members of the public from accessing Platform 2, which services non-stopping trains and is not generally accessible by the general public. Most significantly, a metal fence physically separates Platforms 3 and 2 to deter access by the public to Platform 2. The fencing mitigated the need to caution trains on Platform 2 because it is designed to prevent people from crossing from Platform 3 to Platform 2. Therefore, it was reasonable for the Signaller to caution the trains on Platform 3 only.
In addition, other mitigation measures are in place to deter and/or prevent access by members of the public and these include:
1. White and yellow lines indicating the edge of the platform and the 'keep clear' area respectively;
2. Electronic help points;
3. Platform end barriers;
4. Signs warning against trespass;
5. Anti-trespass panels on the ground;
6. Samaritans signs in situ; and
7. Patrol by nine mobile security teams which specialise in reducing antisocial behaviour and suicide prevention that operate on a 24/7-hour basis.
If Mr Zubair had been seen trying to access the track on platform 2, trains which would proceed over the affected portion of the line would have been cautioned or stopped in accordance with the procedure Network Rail must follow under section
18.1 of the Rail Safety and Standards Board GERT8000 Rule Book (Rule Book). A copy of section 18.1 of the Rule Book is at Annex 1. As Mr Zubair was seen heading towards the exit and we already had a number of mitigation measures in place regarding platform 2 (including, in particular, a fence physically preventing access from platform 3 to platform 2) a stop or caution was not considered for this line.
We receive many calls reporting concerns in relation to the welfare of users each day and takes many measures to ensure the safety of all individuals using the railway. We are also responsible for maintaining the operation of the railway network and the safe passage of trains and passengers across the network. Signallers play a huge role on this. In response to any welfare report, Signallers will make a decision as to the most appropriate action to take based on the nature of the information reported and their detailed knowledge of the infrastructure and the location. This is done in
OFFICIAL accordance with the Rule Book, which purposely provides a degree of flexibility to ensure that Signallers are empowered to make appropriate decisions based on all factors within their knowledge.
Following this tragic incident, Network Rail did take action and enhanced the reporting system between Network Rail and MTR for Signallers to contact the station directly. This allows station staff to provide rapid assistance to individuals in these types of situations. Workshops have also been undertaken to train relevant staff. Network Rail takes its safety obligations incredibly seriously and we are committed to reducing opportunity for members of the public to come to harm on or near the railway.
I hope that this response answers your concerns but if I can be of any further assistance please do not hesitate to contact me.
Report Sections
Investigation and Inquest
On 3rd December 2021, this court commenced an investigation into the death of Hassan Zubair, The investigation concluded at the end of the inquest on 11th May 2022. I arrived at a narrative conclusion, “Mr Hassan Zubair was declared deceased at 14.06 on 2nd December 2021 at Goodmayes Railway station after he was . Mr Zubair deliberately at the station but it has not been possible to determine his intentions at the time.” The medical cause of death was:
1.a. Multiple injuries
2. Alcohol Intoxication
CIRCUMSTANCES OF THE DEATH Goodmayes station consists of four platforms, 1-4. The station is oriented east to west, Platform 1 situated to the south, Platform 4 to the north and platforms 2 & 3 occupying a central island between the lines. At 13:40 on 2 December 2021, Network Rail was made aware of a concern for welfare by a report from the driver of train 2W34 staionary at Platform 4, who reported seeing a member of the public on Platform 3 of Goodmayes station with no shoes on, carrying a blanket. That person was later identified as Hassan Zubair. The call resulted in two actions;
1. At 13:43, the Signaller advised the driver of train 2W59 (the next train due into Goodmayes station on the Up Electric line on Platform 3) to approach at caution because of a concern for welfare.
2. The operator of Goodmayes station was contacted to alert staff at the station and the local security team of the concern. Moments later, Mr Zubair was struck at 13:45 by the 13:33 London Liverpool Street to Southend Victoria, train 1K50 on the Down Main line ( ). Critically, this train had received no warning to approach with caution and accordingly was travelling at a speed estimated to be between 80-85 mph. Mr Zubair was killed instantly.
1.a. Multiple injuries
2. Alcohol Intoxication
CIRCUMSTANCES OF THE DEATH Goodmayes station consists of four platforms, 1-4. The station is oriented east to west, Platform 1 situated to the south, Platform 4 to the north and platforms 2 & 3 occupying a central island between the lines. At 13:40 on 2 December 2021, Network Rail was made aware of a concern for welfare by a report from the driver of train 2W34 staionary at Platform 4, who reported seeing a member of the public on Platform 3 of Goodmayes station with no shoes on, carrying a blanket. That person was later identified as Hassan Zubair. The call resulted in two actions;
1. At 13:43, the Signaller advised the driver of train 2W59 (the next train due into Goodmayes station on the Up Electric line on Platform 3) to approach at caution because of a concern for welfare.
2. The operator of Goodmayes station was contacted to alert staff at the station and the local security team of the concern. Moments later, Mr Zubair was struck at 13:45 by the 13:33 London Liverpool Street to Southend Victoria, train 1K50 on the Down Main line ( ). Critically, this train had received no warning to approach with caution and accordingly was travelling at a speed estimated to be between 80-85 mph. Mr Zubair was killed instantly.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.