By Ian Simpkins, Chief Editor
UPDATED WITH INTERNAL MEMO FROM FIRST CAPITAL CONNECT.
An incident in which a train lost power and became stuck for three hours, with 476 passengers experiencing ‘intolerable conditions’ has been described as an astonishing story of unpreparedness and confusion by London Travelwatch.
The report, which was issued by the Rail Accident Investigations Branch (RAIB) of the Department for Transport (DfT), criticised First Capital Connect (FCC) claiming it was unprepared and had poor communication.
The train lost power shortly before arriving at St Pancras International station when a piece of foliage fell on the pantograph. This is the part of the train which connects with the overhead power supply. The driver then was able to regain power to the front half of the train and it was decided to continue the train in service to Kentish Town where the passengers would have been detrained and the service cancelled.
After leaving St Pancras, power was once again lost and subsequently became stuck with no power supply for three hours.
When a train looses power non vital systems are turned off and only vital systems remain on battery power for a limited period of time. This is why the Air Conditioning and Toilets became inoperative. After 40 minutes the battery power for the public address system also ran out of juice and as such the driver was unable to communicate with them. Passengers then decided to open doors to get extra ventilation into the already unbearable conditions inside the train.
FCC was further criticised for the way staff considered that the only way of rectifying the problem was to send a rescue train to the scene.
The report also states that the train moved with at least two doors open and passengers on the track after the driver overrode safety alarms.
The summary of the 65 page report is as follows and statements from both FCC and Network Rail are towards the bottom of this article:
Immediate cause
The driver moved train 1W95 when it was not safe to do so, with passengers standing in the vicinity of one or more sets of open doors
Causal factors
The causal factors were:
- a. Despite the problems experienced on train 1W95 at St. Pancras, FCC allowed it to continue to Kentish Town with passengers on board, despite the risk that the train might fail.
- b. Foliage had become lodged around the rear pantograph of train 1W95 while the pantograph was not in use, which caused electrical tripping after the train left Farringdon with the pantograph raised and the subsequent immobilisation of the train at Dock Junction
- c. FCC gave only limited consideration to a range of possible strategies for rescuing train 1W95 and its passengers and at an early stage focused solely on the use of an assisting train for moving train 1W95 and its passengers to Kentish Town.
- d. The arrival of the train provided to assist train 1W95 into Kentish Town was affected by a series of delays.
- e. The conditions for passengers within train 1W95 became increasingly uncomfortable as time wore on. In an attempt to make conditions more tolerable, some passengers opened doors and, later, some alighted from the train.
- f. Only limited information was provided to the passengers on train 1W95 during the first 45 minutes of the incident and no information was provided after that time.
- g. The driver of train 1W95 moved the train with some doors open because he had been informed that train doors were closed and his in-cab display could not be relied upon to establish the exact status of doors because it had been affected by the loss of power.
- h. FCC’s policy for handling incidents involving stranded trains was not applied.
Summary of conclusions
Underlying factors
The underlying factors were:
- a. The driver of train 1W95 was not given adequate support during the incident, which affected his ability to manage the conditions on board the train.
- b. FCC had not briefed its policy on stranded trains to all key staff prior to the incident.
- c. FCC’s competence management regime did not equip staff involved in the incident with the skills to perform some of the necessary key tasks.
- d. Between 2009 and 2011, FCC had investigated a number of incidents involving trains becoming stranded for extended periods of time, but had not implemented measures to improve its handling of such incidents.
- e. Relevant safety lessons had been identified in performance-focused reviews on a number of occasions before the incident at Kentish Town on 26 May 2011, but no action had been taken.
- f. FCC’s management had not identified or addressed deficiencies in the processes for emergency preparedness prior to the incident.
Factors affecting the consequences of the incident
- A factor that possibly affected the consequences of this incident was the availability and use of information from social networking sites by passengers as an input to their decisions to self-evacuate from the train.
FCC’s managing director Neal Lawson publicly said:
This quick and decisive action means we have already made 10 separate changes to the way we operate to address the findings, The report recognises this and makes only one further recommendation specific to ourselves – and our work to close this out is now substantially complete. This incident was a difficult and testing time for everyone involved for which we would once again like to apologise. It is important that we have learned from it along with the rest of the rail industry.
FCC’s internal information, which we have been Emailed by a ‘concerned employee’ states:
The Rail Accident Investigation Branch (RAIB) today published a report into last year’s evacuation of train 1W95 that became stranded for almost three hours between St Pancras International and Kentish Town.
This incident was a difficult and testing time for all the customers and colleagues affected and it is right that we apologise for not handling it as well as we should have. It is important that we have learned from it along with the rest of the rail industry and we must ensure that such an event does not happen again.
FCC welcomes the report which confirms many of the findings from our own internal investigation and that of an independent enquiry by an external consultant that we commissioned the day after the incident took place.
The quick and decisive action that we took in reaction to the incident means we have already made 10 separate changes to the way we operate to address the findings. The report recognises this and makes only one further recommendation specific to FCC – and our work to close this out is now substantially complete.
The actions we have already completed
The 10 actions we have already completed are (in summary):
- Reviewed our competence assessment, training and briefing regime to prepare drivers for such incidents.
- Put in new equipment on our class 377/5 trains, including emergency door screens that allow the doors to be opened for increased ventilation but prevent passengers from alighting. We have also briefed drivers on a technique to obtain additional power for the PA system.
- Changed our on-call instructions.
- Put in place an audit trail for briefing documents, traction notices and updated procedures.
- Created with Network Rail a specific Thameslink ‘core’ route response and communication document.
- Reviewed procedures for reviews of serious incidents and introduced a way of tracking what is done to ensure outcomes are identified, reviewed, monitored and completed.
- Introduced enhancements and put in additional resources to give drivers of stranded trains more technical support.
- Introduced enhancements and additional resources to provide customer service support to FCC controllers dealing with stranded trains.
- Reviewed our disruption management policy and emergency response procedures – drivers are now not permitted to enter the centre of London with trains that are vulnerable to break down with passengers on board.
- FCC has redrafted its policy on dealing with stranded trains and the controlled evacuation of passengers with five significant changes.
Further actions
The further recommendation made by the RAIB specific to FCC is that we should review our management processes to examine why we were unable to identify and address deficiencies in emergency preparedness prior to the incident. We are addressing this by mapping the way changing one standard can affect another. This is now being validated before being briefed out to the business.
The RAIB makes two further recommendations for the rail industry as a whole: one is that train operating companies, the Rail Safety Standards Board and Network Rail agree a process for dealing with such emergencies. The other is that the industry should better manage safety outputs raised during Network Rail’s Serious Performance Incident Reviews. We have already acted on both these recommendations.
Neal Lawson, Managing Director
A Network Rail spokesman said:
The recommendations set out by RAIB are entirely sensible and have already been acted upon as part of a wide-ranging review of our procedures for dealing with incidents such as this.
