RAIB also found that at terminus stations some train operators are getting ready to leave their train before it has stopped, meaning they may not be focusing on tasks relating to the operation of the train.
....
There is also evidence that some TOs may undertake tasks not related to the operation
of their trains when approaching terminal platforms using ATO. This is a possible underlying factor
....
103 Because ATO is controlling train speed and stopping position when approaching
platforms, this presents an opportunity for TOs to start to prepare to leave the
train before it has stopped, to save time. This would include activities such as
putting on coats, packing bags and other actions not related to operating a train.
RAIB observations suggest that at terminus stations such as Stratford ATO
provides an opportunity for TOs to do this because the train is being automatically
controlled to a stop in the platform. In addition, if the platform is not busy, the risk
of a passenger falling in front of the train is reduced or not present and so less
likely to be perceived to need continuous monitoring
....
105 In early January 2024, RAIB inspectors undertook observations of 34 trains
arriving at platforms 13, 14 and 15 at Stratford station. This showed that, as their
trains entered the platforms, 10 TOs remained seated, 21 TOs adopted a standing
position, which is permitted, and the position of the remaining 3 TOs could not be
clearly determined. Of the standing TOs, 2 were seen to be putting on their coats
as the train entered the platform, 1 was putting on a backpack and another TO
was standing at the cab door, away from the controls. RAIB has also received
evidence from a former LUL TO who operated trains regularly in ATO that TOs
often prepared to leave trains before they had stopped in the platform at terminus
stations.
....
57 The post-mortem toxicology report recorded a blood alcohol concentration for
the passenger of 272 milligrams of alcohol per 100 millilitres of blood. This blood
alcohol concentration is over 3 times the legal drink-drive limit in England, Wales
and Northern Ireland, which is 80 milligrams of alcohol per 100 millilitres of blood.
The post-mortem toxicology report states that coma may occur at a blood alcohol
concentration of 200 milligrams to 300 milligrams per 100 millilitres of blood

A man who died on the London Underground was run over by four Jubilee line trains, the rail safety investigator has revealed.

Brian Mitchell, 72, fell and stumbled on to the track at Stratford station in east London on 26 December 2023 and was struck by a terminating train five minutes later.

Three further trains drove over the track where Mr Mitchell was lying, according to the Rail Accident Investigation Branch (RAIB), who said the operator of the fourth inbound train "had independently recognised that there was a person on the track".

Transport for London (TfL) said its "thoughts remain with the family and friends of Mr Mitchell" who was pronounced dead at the scene.  He was living in Hanwell in west London at the time of his death but was originally from Edinburgh.

The RAIB report said there were no passengers or staff on the platform when Mr Mitchell fell, at about 14:45 GMT, and the driver of the first train didn't see him "possibly because their level of attention was reduced due to the use of automatic train operation".

The report stated: "The operator may also have been distracted by the presence of another operator who was standing on the platform as the first train arrived at the station.  The consequences of the accident were made more severe because the operator of the second inbound train to arrive at the platform also did not see the passenger, while the operator of the third inbound train saw something when they were arriving at the platform but did not recognise what they saw as being a person.  The fourth inbound train was not stopped by a customer service assistant who was present on the platform when it was entering the station, even though the assistant was by now aware that a person was on the track."

Each outbound train departed the station without the drivers noticing "because the passenger was underneath their respective trains before they departed".

The RAIB made two recommendations to London Underground:
* Consider using technology that can detect if a passenger is in a dangerous position and intervene or warn to stop an approaching or departing train
* Review environmental, organisational and job factors related to operating trains in automatic train operation mode

Lilli Matson, TfL's chief safety officer, said: "We welcome the recommendations from the RAIB's independent investigation into this incident, which align with the findings of our own internal investigation, and work has already begun to implement them.  We will always strive to learn from incidents and improve operational safety, including by ensuring relevant regulatory bodies are immediately informed, carrying out thorough and extensive internal investigations and prioritising taking action on any recommendations from any review.  While serious injuries on our network are rare, we are undertaking a huge range of work to eradicate such incidents and make the network even safer for everyone."