Ezharul Islam
PFD Report
All Responded
Ref: 2016-0214
All 1 response received
· Deadline: 1 Aug 2016
Coroner's Concerns (AI summary)
There is no system in place to alert bus passengers when the vehicle is about to move, unlike previous methods which involved verbal warnings and a bell.
View full coroner's concerns
_ That there was no to alert passengers that the 191 bus was about to move. In the past the signal that a bus was about to move would have been the conductor saying hold on tight and sounding a bell twice in rapid succession: Consideration should be given to introducing system that alerts passengers that the bus they are on is about to move. and system
Her Majesty's Coroner for the Northern District of Greater London
Her Majesty's Coroner for the Northern District of Greater London
Responses
Action Planned
Transport for London will consider the coroner's recommendations about passenger alerts as part of the Bus Safety Standard for London to find the most appropriate solution. (AI summary)
Transport for London will consider the coroner's recommendations about passenger alerts as part of the Bus Safety Standard for London to find the most appropriate solution. (AI summary)
View full response
Dear Dr Walker, We were very to hear of Mr Islam's fall on one of our buses on 23 October 2015 and his subsequent death and wish to pass our condolences to his family: We have reviewed your Regulation 28 report dated 6 June 2016 and your recommendation that we should consider introducing system that alerts passengers that the bus are on is about to move_ We were not present at the inquest and therefore were not able to provide you with information about the actions we take to ensure the safety of our passengers generally and specifically when buses move_ Your report refers to the past in which you say that the bus conductor signalled to customers when the bus was about to move by saying hold on tight and sounding bell twice in rapid succession The traditional role of bus conductor was to collect fares, maintain the safety of the open platform and signal to the driver that it was safe to move away the stop_ The number of bus conductors significantly reduced during the 1990's and early 2000's as the use of the traditional routemaster was phased out of service_ Bus conductors did not indicate to customers when the bus was to move and the use of the bell was to advise the driver that customers wishing to board or alight from the bus had done so. The bell was not used as a method of warning customers that the bus would be moving: MAYOR OF LONDON VAT number 756 2769 90 sorry they from OrsABLe?
2 of 3 With the dominance of one person operated buses bus drivers have been trained to look out for customers boarding and alighting the bus, ensuring that elderly and disabled customer and those who are less able or mobile are seated safely or have taken hold of hand hold before moving off Most of our buses also have a warning signal when the centre doors are about to close and visual display and automated voice system informing customers ofthe approaching bus stops along the route_ Our drivers are also able to speak directly to passengers to ensure that are secure on the bus before move should see anything that concerns them. Much work has been done over the last few years to ensure that safety for our customers on buses continues to improve. installed a large number of appropriately positioned and designed hand holds throughout our buses enabling customers to hold on whilst the bus is moving and departing: We have ensured that there is appropriately positioned priority seating available supported with suitable signage for elderly and disabled customers and those less able to stand or mobile: Also through engine management system of our buses, we limit the acceleration of the bus, which means that drivers cannot move forward quickly, and gives more stability for customers whilst the bus is transitioning from stationary position either at bus stop or in traffic. As mentioned above, we have an ongoing training programme for our bus drivers to ensure that before leave a bus stop or accelerate , elderly and disabled customers have found seats or hand holds We are also currently investing in a 2 year programme for all bus drivers to enhance their customer service skills with particular focus on understanding and empathy for customers' needs which includes allowing time for elderly customers to be securely positioned prior to moving from a stationary position . TfL is also developing a Bus Safety Standard for London Buses which involves the consideration of a range of innovative and new technologies to continue to improve safety on buses_ Such technologies could include collision avoidance systems which utilise sensors to warn bus drivers of potential dangers and trigger Automatic Emergency Braking systems, and Intelligent Speed Assistance_ Other potential design innovations to be considered include improving wing mirror design and windscreen glazing to reduce the impact of any collision. Part of the work of the Bus Safety Standard for London involves London Bus Services Limited trading as ondon Buses whose registered office is Windsor House 42-50 Victoria Street London SWIH OTL Registered in England and Wales Company number 3914787 VAT number 756 2770 08 London Bus Services Limited is company controlled by local authority within the meaning of Part V Local Government and Housing Act
989. The controlling MAYOR OF LONDON 015461+9 authority is Transport for London: Page they they they We have the they
3 of 3 considering the nature of accidents and collisions on or involving buses and identifying measures which can be taken to either avoid such accidents and collisions or mitigate their impact: TfL recently held a seminar with all the bus manufacturers who supply London's buses to ensure that are also fully engaged and contribute proactively with the Bus Safety Standard and lead the trials of both new technology and bus design to identify the most appropriate solutions. Your recommendations will therefore be considered as part of the Bus Safety Standard for London to find the most appropriate solution. We strive to provide an excellent service for our customers and safety is paramount: We continue to consider and implement ways in which to improve our customers' experience of using buses in London, ensuring that are safe and comfortable_
2 of 3 With the dominance of one person operated buses bus drivers have been trained to look out for customers boarding and alighting the bus, ensuring that elderly and disabled customer and those who are less able or mobile are seated safely or have taken hold of hand hold before moving off Most of our buses also have a warning signal when the centre doors are about to close and visual display and automated voice system informing customers ofthe approaching bus stops along the route_ Our drivers are also able to speak directly to passengers to ensure that are secure on the bus before move should see anything that concerns them. Much work has been done over the last few years to ensure that safety for our customers on buses continues to improve. installed a large number of appropriately positioned and designed hand holds throughout our buses enabling customers to hold on whilst the bus is moving and departing: We have ensured that there is appropriately positioned priority seating available supported with suitable signage for elderly and disabled customers and those less able to stand or mobile: Also through engine management system of our buses, we limit the acceleration of the bus, which means that drivers cannot move forward quickly, and gives more stability for customers whilst the bus is transitioning from stationary position either at bus stop or in traffic. As mentioned above, we have an ongoing training programme for our bus drivers to ensure that before leave a bus stop or accelerate , elderly and disabled customers have found seats or hand holds We are also currently investing in a 2 year programme for all bus drivers to enhance their customer service skills with particular focus on understanding and empathy for customers' needs which includes allowing time for elderly customers to be securely positioned prior to moving from a stationary position . TfL is also developing a Bus Safety Standard for London Buses which involves the consideration of a range of innovative and new technologies to continue to improve safety on buses_ Such technologies could include collision avoidance systems which utilise sensors to warn bus drivers of potential dangers and trigger Automatic Emergency Braking systems, and Intelligent Speed Assistance_ Other potential design innovations to be considered include improving wing mirror design and windscreen glazing to reduce the impact of any collision. Part of the work of the Bus Safety Standard for London involves London Bus Services Limited trading as ondon Buses whose registered office is Windsor House 42-50 Victoria Street London SWIH OTL Registered in England and Wales Company number 3914787 VAT number 756 2770 08 London Bus Services Limited is company controlled by local authority within the meaning of Part V Local Government and Housing Act
989. The controlling MAYOR OF LONDON 015461+9 authority is Transport for London: Page they they they We have the they
3 of 3 considering the nature of accidents and collisions on or involving buses and identifying measures which can be taken to either avoid such accidents and collisions or mitigate their impact: TfL recently held a seminar with all the bus manufacturers who supply London's buses to ensure that are also fully engaged and contribute proactively with the Bus Safety Standard and lead the trials of both new technology and bus design to identify the most appropriate solutions. Your recommendations will therefore be considered as part of the Bus Safety Standard for London to find the most appropriate solution. We strive to provide an excellent service for our customers and safety is paramount: We continue to consider and implement ways in which to improve our customers' experience of using buses in London, ensuring that are safe and comfortable_
Sent To
- Transport for London
Response Status
Linked responses
1 of 1
56-Day Deadline
1 Aug 2016
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
Report Sections
Investigation and Inquest
On the 7ih December 2015 opened an investigation touching the death of Ezharul Islam 73 years old. The inquest concluded on the 24"h May 2016 The conclusion of the inquest was "Narrative" , the medical case of death was Ia Aspiration Pneumonia,1b Rehabilitation and treatment following Chronic Subdural Haematoma in 11 Chronic Subdural Haematoma
Circumstances of the Death
On the 23rd October 2015 at about 10.44 Ezharul Islam fell and struck his head as the bus he had just boarded moved forward from the bus stop. Mr Islam was downstairs on a 191 bus and may have been in the process of sitting down when the bus moved causing him to fall:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.