Report 02/2019: Self-detrainment of passengers onto lines that were still open to traffic and electrically live at Lewisham
Self-detrainment of passengers onto lines that were still open to traffic and electrically live at Lewisham, south-east London, 2 March 2018.
Summary
At 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:
- 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
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.
Recommendations
The RAIB has made five recommendations:
-
Three are directed jointly at Network Rail and Southeastern and concern:
- 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
-
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 RAIB has also identified two learning points. These concern:
- 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
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.
Response to recommendations:
- RAIB will periodically update the status of recommendations as reported to us by the relevant safety authority or public body
- RAIB may add comment, particularly if we have concerns regarding these responses.