Dear Dr Wilcox, 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:
0) 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 ii) identifying behaviours which may be suicidal: Registered office is as above Registered in England Wales, Company Number 1900907 London Underground Limited is a company controlled by local authority within the meaning of Part V Local Government and Housing Act 1989. The controlling MAYOR OF LONDON authority is Transport for London: @ceeo~ 184 6 fot- DEsLL 3478v/ feon 242 and 5 'Disadl

In April 2018, LU established 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 .
2. That there is no alarm at the barriers at the platform ends As set out in 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.
3. 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 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. such system would also need to be immune 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 when no trains are operating and has no knowledge of such system being deployed on other high-frequency metro railways LU is 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 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 Criteria for station staff deployment considers, amongst other issues, customer safety, customer service and assistance , responsiveness and staff security and safety _ from Any from Day day:

As set out in above, LU has recently undertaken a significant amount of work to train front line station staff to spot potentially suicidal behaviour and to intervene This has mainly focused on station platforms, but We will review this training with view to adapting the content to include customer behaviours at other locations within stations, specifically at the 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 be 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 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, Managing Director London Underground how key