Two are directed at Southeastern and concern ensuring that it has a suitably large pool of staff to support train crews during incidents and that the essential needs of train passengers during extreme weather emergencies are reasonably met. The length of time during which train 2M50 was prevented from moving into a platform was extended due to a decision to route it directly behind train 2M48, which then struggled to move. This meant that train 2M50 came to a stand at a signal beyond the point at which it could have been diverted into another platform. Having made this decision the signalling staff still had the option of applying a Rule Book regulation known as emergency permissive working. This procedure would have allowed train 2M50 to pass the stop signal and enter the platform once train 2M48 had moved far enough clear. However, the first passenger left train 2M50 before signalling staff decided to implement this regulation. It is likely that the delay in making this decision arose because the train was not declared as stranded in a timely manner, and inadequate management of the disruption caused by the adverse weather.Because the emerging situation at Lewisham was not recognised as a serious incident sufficiently quickly, key decisions were not made to define and implement plans to manage the circumstances. Other factors included informal communication using inappropriate channels, poor presentation of key operational information and ill- defined incident management processes.RecommendationsThe RAIB has made five recommendations: Newsdate: 25 March 2019 unlike many locations in Kent, the conductor rails in most of south-east London are not heated the last application of anti-icing fluid was about 19 hours before the incident, and it is likely to have ceased to be effective due to the implementation of a special timetable, and previous train delays, no train had operated over the affected route for 90 minutes – if trains had run during this period they would have removed ice from the conductor rail and helped prevent it accumulating a near-by mobile operations manager, who was trained and equipped to de-ice the conductor rail, was not alerted for 40 minutes. 190325_R022019_Lewisham SummaryAt about 18:41 hrs on 2 March 2018, a passenger got out of Southeastern train 2M50 and went onto the track near Lewisham station when it was unsafe to do so. Adjacent lines were still open to traffic and the electric third rail traction power system was live. By the time that this had occurred the train had been held at a signal outside the station for over an hour because the train in front, 2M48, was having difficulty drawing power and being able to move forward due to ice accumulation on the conductor rail. Train 2M50 stopped across a key junction and caused the train that was following it, 2S54, to block another junction. This resulted in a further seven trains being unable to move.The electric traction power was turned off in the immediate vicinity within about three minutes of the driver informing the signaller that a passenger was on the track. However, while the electrical control operator was finalising the isolation three passengers also got off train 2S54 and crossed lines that may have been live at the time. Around a further 30 passengers exited train 2M50 of their own accord and went onto the track; a few possibly did this when the lines were still live. Within 45 minutes passengers had got off at least two other trains. The uncontrolled nature of the detrainments delayed traction power reinstatement and resulted in trains being stranded for around four and a half hours. Emergency services attended and helped with incident management and recovery. Although no-one was seriously injured, conditions on all of the stranded trains became very difficult for passengers and staff.The RAIB’s investigation has focused on the safety learning relating to the initial unsafe passenger detrainments. While incident and recovery management actions are broadly described, they were not the subject of detailed examination by the RAIB.The initial detrainment occurred because of the time the train had been held at the signal. Passengers were getting increasingly uncomfortable in crowded carriages with no toilet facilities. Ultimately the motivation of passengers to leave the train outweighed the effectiveness of encouragements to stay on board.The accumulation of ice on the conductor rail, which prevented train 2M48 from drawing power, is a known problem that the railway industry seeks to mitigate with a range of measures. In this instance weather forecasts had warned Network Rail and Southeastern that there was a high risk of ice forming on the conductor rail and they had implemented arrangements to manage this. These arrangements proved ineffective for the following reasons: PDF, 2.93MB, 69 pages the management of conductor rail ice risk the process for the timely identification and management of train stranding events the visibility and communication of information to and within railway control centres. Three are directed jointly at Network Rail and Southeastern and concern: The RAIB has also identified two learning points. These concern: The implementation of safety learning identified in this report would have greatly reduced the impact of the incident on other trains that became stranded, and the wider service disruption that occurred as a result.Simon French, Chief Inspector of Rail Accidents said:“To be stuck on a train that is not moving can be an unpleasant experience. Add to this a crowded commuter service, limited information and no toilet facilities, and the result is a situation that none of us would want to be part of.“Our investigation has focused on the circumstances which led some passengers to get out of the trains and walk along the tracks which were still open to traffic, in proximity to a live conductor rail. We have considered what could have been done to prevent a relatively minor event involving one train escalating to involve numerous other trains and thousands of passengers. Our investigation highlights the importance of decisive action in the early stages of an incident involving a stranded train.“Our major cities are reliant on rail services to convey many millions of passengers on a daily basis, relieving pressure on road networks that are already congested. Achieving this herculean task requires a high frequency of train services and rolling stock that is capable of conveying large numbers of people. Generally, the rail network is able to meet this challenge. However, on such high density routes, serious delays can themselves be a safety issue because on-board conditions can deteriorate rapidly and frustration and discomfort can lead to people taking matters into their own hands, putting themselves at risk of being struck by a train or electrocution.“Professionalism in railway operations includes the ability to anticipate how a situation may develop. Today, signallers and operations controllers oversee large areas of the rail network which means that they have the role of front-line managers for incidents like this. It is important that the training they are given equips them for this role. When conditions outside are challenging, and things are not going entirely smoothly, thinking in a more precautionary manner about the possible consequences of a particular move may pay dividends. In this case, bringing a train close up behind another that was having trouble moving forward blocked a set of junctions in a way that soon trapped eight trains. Furthermore, prompt application of existing emergency working procedures, which had been designed for just this situation, could have unjammed the railway and got trains on the move, and people safely on the way to their destinations.“We are recommending that the railway industry takes action that will minimise the risk of trains becoming stranded in icy weather. However, since the effects of the British weather can never be entirely overcome, and given the range of other factors that can disrupt the operation of the railway system, our other recommendations relate to the need for better management of the consequences of a stranded train, so that the railway remains in control of events and people are not put at risk.“As the railway continues to create signalling centres covering huge geographical areas, and embraces more and more digital technology, its ability to manage operating incidents in an efficient manner should be significantly enhanced. However, I fear that this opportunity will be lost unless the railway develops an overarching ‘control and command’ strategy. Such a strategy could define the ways in which system designers and railway system managers should jointly address the need for efficient incident management on the modern railway. It should include good practice and high level principles governing the design and subsequent operation of large control and command facilities, such as signalling centres and operational control rooms.”Notes to editors The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions. RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report. For media enquiries, please call 01932 440015. the timely application of emergency signalling rules, such as emergency permissive working, and of training and opportunities to apply such infrequently-used regulations signallers and staff in railway control centres following appropriate protocols when using voice communications.