Passengers abandon train at Lewisham with 3rd rails still live.

[ainsworth74]

2M50 should never have passed L253. For me, that was the most significant decision.

Agreed in reality if 2M50 had not passed L253 then once it became clear that 2M48 wasn't clearing the section anytime soon then 2M50 could have been sent into an alternative platform and terminated and kept the junction clear for other trains to pass. Though I can certainly see why the signaller did what they did! A busy day with lots of disruption which causes pressure/distraction and so you fall back on the habit of authorising trains to follow closely behind each other rather than taking that step back to think "hang on, 2M48 is having difficulty departing so I'll just hang-fire a minute and hold it at L253 rather than L445 to keep my options open".

One thing that struck me, and I don't think it's mentioned by the RAIB report, is the role that perhaps fatigue and break arrangements played on the signaller at this point? According to the report shifts at London Bridge were 12 hours long with shift change at roughly 0645 and 1845 so by the time this is all kicking off from 1730 onwards the signaller has been on duty for around 11 hours. Plus we are told that they returned to the panel at 1730 having been on an hours break (so presumably between around 1630 to 1730). I do wonder if the impact of being on duty for 11 hours and just coming back from a break so still getting "back in the saddle" so to speak perhaps played a role?

 

[ComUtoR]

interesting stuff™

Human factors are important in any incident and the railway is certainly taking learning points from aviation in this respect. If I put on my tinfoil hat with the cynical brim.. I find that the RAIB report(s) almost deliberately miss out important points and certainly ones which the industry refuses to face. If I don my professional cap.. It's because the report(s) are fact based evidence only. They can then be used to raise discussion points for places like this forum, Spark research, internal briefs, new rule creation, new procedures, RED videos, etc etc.

I think that with Human Factors we need to accept they exist first. Something the industry is currently struggling with.

 

[Greg Read]

Had the passengers not jumped ship minutes beofore things moved, much of this would not have happened, had the signalman talked the train behind into the occ section, and there had been an incident, then the Signlaman would have been on the carpet and worse.
Passengers have to take some responsibilty for their actions, if they jump off a train, they surely must know the power will be turned off and nothing else will move for some time ! ??

 

[OneOffDave]

Do you get two aircraft landing at the same platform at the same time ?



Too many cocks cooks...

No, because planes don't land at platforms. But there have been incidences of runway conflicts between landing aircraft

Do you have a source for there being too many people at the Gold level on the day in question? Was there more than one Gold Commander?

 

[OneOffDave]

Had the passengers not jumped ship minutes beofore things moved, much of this would not have happened, had the signalman talked the train behind into the occ section, and there had been an incident, then the Signlaman would have been on the carpet and worse.
Passengers have to take some responsibilty for their actions, if they jump off a train, they surely must know the power will be turned off and nothing else will move for some time ! ??

But at the time they jumped ship, the passengers had no way of knowing how long they were going to be stranded there with no toilets in view of a station. It's important to remember that we are all viewing the passengers' actions with much more situational awareness than any of them had at the time. For all they knew at the time, they could have been left there for another couple of hours. The railway organisations seems to have a real difficulty understanding that the passengers they carry are human beings, not just inert cargo who can be left uninformed for indeterminate lengths of time. 99% of commuters don't know anything about how trains get power and don't care. All they care about is for the TOC to get them to and from work without too many delays. They aren't railway enthusiasts, to them it's a necessary evil they have to endure.

 

[DerekC]

One question I asked myself after reading the report this morning. When signal control is transferred to a ROC do the integrated control centre functions based at Friars Bridge Court go with it, and if so does that make this kind of incident easier to handle effectively?

They can. AIUI Wessex ICC was moved from Waterloo to Basingstoke ROC, and the ensuing problems caused by experienced staff not wanting to move were highlighted in one of last year’s reports into SWR/NR operating problems.

Can somebody clarify this further. It seems to me that separation of signal control from "integrated control" contributes to uncertainty and slow response in this sort of situation. If ROCs put them together then that would be a good thing, although I recognise the difficulty of making the transition.

 

[DerekC]

But at the time they jumped ship, the passengers had no way of knowing how long they were going to be stranded there with no toilets in view of a station. It's important to remember that we are all viewing the passengers' actions with much more situational awareness than any of them had at the time. For all they knew at the time, they could have been left there for another couple of hours. The railway organisations seems to have a real difficulty understanding that the passengers they carry are human beings, not just inert cargo who can be left uninformed for indeterminate lengths of time. 99% of commuters don't know anything about how trains get power and don't care. All they care about is for the TOC to get them to and from work without too many delays. They aren't railway enthusiasts, to them it's a necessary evil they have to endure.

Does GSM-R provide talk-through from integrated control to train PA? I know CSR did because I heard it used a few times many years ago. It seems to me that if somebody in control told the passengers the situation and the actions being taken they might be less likely to egress the train. Of course this can be done via the driver, but it's better to hear from the horse's mouth.

 

[Highlandspring]

Can somebody clarify this further. It seems to me that separation of signal control from "integrated control" contributes to uncertainty and slow response in this sort of situation. If ROCs put them together then that would be a good thing, although I recognise the difficulty of making the transition.

In a ROC the Control function is still seperate from the signalling function. The two may be physically located on the same floor but even then there is usually a partition of some sort and all communication is supposed to be by phone; controllers aren’t allowed on the signaller’s side of the floor and vice versa. Some ROCs place them on different floors.

Does GSM-R provide talk-through from integrated control to train PA?

Yes.

 

[ComUtoR]

The railway organisations seems to have a real difficulty understanding that the passengers they carry are human beings, not just inert cargo who can be left uninformed for indeterminate lengths of time. 99% of commuters don't know anything about how trains get power and don't care. All they care about is for the TOC to get them to and from work without too many delays. They aren't railway enthusiasts, to them it's a necessary evil they have to endure.

They didn't heed the advice posted on the train and effectively ignored it to their risk and irrespective of the railways actions, which are highlighted throughout the report. The passenger egress contributed to the incident. If people are not going to listen to advice given and people are going to egress on to the track then they must accept responsibility for the consequences. The fact remains; passenger egress made it worse.

Does GSM-R provide talk-through from integrated control to train PA?

Yes, and it was mentioned in the report.

 

[OneOffDave]

They didn't heed the advice posted on the train and effectively ignored it to their risk and irrespective of the railways actions, which are highlighted throughout the report. The passenger egress contributed to the incident. If people are not going to listen to advice given and people are going to egress on to the track then they must accept responsibility for the consequences. The fact remains; passenger egress made it worse.

But if it's found that basic signage in the rolling stock doesn't change passenger behaviour then they need to find something that will. The railway industry could learn a lot from the airline industry about human factors and how to alter behaviours. Also it must be recognised by the rail industry that you can't hold people indefinately on trains without access to toilets and water and not expect them to do something about it. What is an acceptable number of people to have to urinate and defecate over themselves/the carriage before they get their finger out an evacuate them?

 

[ComUtoR]

Do you have a source for there being too many people at the Gold level on the day in question? Was there more than one Gold Commander?

Gold Command did nothing. Their actions contributed nothing and their actions were ineffective.

Paragraph 152 from the Lewisham RAIB report.

152 The forecast of cold winter weather that started on Sunday 25 February 2018 resulted in regular EWATs and in Network Rail and Southeastern setting up gold command organisations for the week (paragraphs 53 and 54). These command and control arrangements resulted in the implementation of a set of pre-defined strategies for managing the risk of conductor rail ice accumulation that were described in their respective winter season preparation procedures. These strategies did not together prevent trains from experiencing serious traction current collection difficulties and the consequential effects

TWO, potentially THREE people could have prevented the entire incident taking place. NONE of them were Gold Command. A huge consequence of Gold Command is that we lose Managers on the ground.

Every year we struggle to get Ghost Trains covered or implemented. Staff can't get into work in poor weather, diagrams become non existent and we often work on the fly, getting through to control becomes an absolute joke, huge staff displacement, partridge, pear tree, clusterf... But yeah, great, we have Gold Command to save us.

One of the recommendations (4) from the report highlights what is needed. Get people on the ground to support train crews and passengers.

 

[edwin_m]

They didn't heed the advice posted on the train and effectively ignored it to their risk and irrespective of the railways actions, which are highlighted throughout the report. The passenger egress contributed to the incident. If people are not going to listen to advice given and people are going to egress on to the track then they must accept responsibility for the consequences. The fact remains; passenger egress made it worse.

The problem seems to have been that the passengers had been getting the same message for an hour or so, that someone was trying to do something but the driver didn't have any better information. Most of the passengers would have been regular commuters, probably used to being stuck for long periods with no useful information, and probably think they know enough about the railway that they can evacuate safely with a station a short distance away. Some may have known this would lead to the power being cut off and other trains being stranded, but they probably thought that would happen anyway and they might as well get out sooner rather than later.

One of the lessons could be that when a stranding occurs, the first action should be to start getting trapped but still moveable trains into places where they can be safely evacuated if the need arises, before taking action to resolve the original problem.

 

[ComUtoR]

But if it's found that basic signage in the rolling stock doesn't change passenger behaviour then they need to find something that will.

I agree. Maybe more announcements because that will help.... !!£$!"£%"£

The railway industry could learn a lot from the airline industry about human factors and how to alter behaviours.

They are trying. It's still relativity new.

Also it must be recognised by the rail industry that you can't hold people indefinately on trains without access to toilets and water and not expect them to do something about it.

There is no magic bullet. This was an impossible situation that spiralled out of control. The railway is frustratingly slow at everything. I have no idea how you can suddenly conjuror up toilets from the ether to provide them at the drop of a hat.

 

[ComUtoR]

One of the lessons could be that when a stranding occurs, the first action should be to start getting trapped but still moveable trains into places where they can be safely evacuated if the need arises, before taking action to resolve the original problem.

I asked about maybe running some services wrong road back towards The Cross but there were trains clogged up. The problem with running a metro service is that the second a problem arises everything back up in minutes.

I would agree that action needs to be quicker and much more proactive. I would support any new approach that goes towards that.

 

[OneOffDave]

Gold Command did nothing. Their actions contributed nothing and their actions were ineffective.

Paragraph 152 from the Lewisham RAIB report.


TWO, potentially THREE people could have prevented the entire incident taking place. NONE of them were Gold Command. A huge consequence of Gold Command is that we lose Managers on the ground.

Every year we struggle to get Ghost Trains covered or implemented. Staff can't get into work in poor weather, diagrams become non existent and we often work on the fly, getting through to control becomes an absolute joke, huge staff displacement, partridge, pear tree, clusterf... But yeah, great, we have Gold Command to save us.

One of the recommendations (4) from the report highlights what is needed. Get people on the ground to support train crews and passengers.

You claimed it was too many cooks and then said they did nothing so it doesn't matter how many of them there are. I say we go with your scheme and just have three blokes on the ground as they can sort everything across the network. You obviously don't understand the role of gold command and I suspect no good incident response command and control knowledge. People on the ground is a Silver/Bronze issue and should be being led by them and those managers complaining to Gold if they aren't given enough resource.

 

[OneOffDave]

I agree. Maybe more announcements because that will help.... !!£$!"£%"£

There is no magic bullet. This was an impossible situation that spiralled out of control. The railway is frustratingly slow at everything. I have no idea how you can suddenly conjuror up toilets from the ether to provide them at the drop of a hat.

If you look at the range of methods Network Rail use to change passenger behaviour, they aren't limited to signs and announcements. A range of media both on and off trains are used.

It's fairly straightforward, you don't take toilets to the passengers, you move the passengers from where there aren't any to where there are. I can't think of many other situations where it takes several hours to evacuate people in the centre of built up areas. God knows how they'd manage the need for a fast time evacuation

 

[Taunton]

. You obviously don't understand the role of gold command.

It looks like Gold Command didn't understand it either. They let this happen :

- No de-icing train run on the route since overnight the previous night.
- A near 2-hour gap in services to Blackheath.
- Nevertheless they allowed a train behind the one having great difficulties to run just one block behind where it had no chance of being diverted to another route or detrained at a platform.
- Didn't identify the big issue emerging.
- Didn't cue the signal team to do a Calling On procedure.

 

[SECR263]

As one of the trains was stuck in sight of the station could not the driver had suggested to the Signalman that he be given a permissive move to enter the station. This would have solved a lot of problems by detraining pass and also allowing the train behind which I believe need to move over the junction and away on a different line. As it was an emergency all suggestions should be considered?? Or are drivers not allowed to tell the signalman of a possible move?

 

[hwl]

As one of the trains was stuck in sight of the station could not the driver had suggested to the Signalman that he be given a permissive move to enter the station. This would have solved a lot of problems by detraining pass and also allowing the train behind which I believe need to move over the junction and away on a different line. As it was an emergency all suggestions should be considered?? Or are drivers not allowed to tell the signalman of a possible move?

One of the issues is why the permissive working didn't happen (used so infrequently in the area...)

 

[Robertj21a]

Absolute comedy of errors, but could have had very serious consequences indeed. So many things that should/could have happened, but didn't and, personally, I doubt that many lessons will have been learnt. It will still go wrong all over again if/when similar circumstances arise.

 

[OneOffDave]

It looks like Gold Command didn't understand it either. They let this happen :

- No de-icing train run on the route since overnight the previous night.
- A near 2-hour gap in services to Blackheath.
- Nevertheless they allowed a train behind the one having great difficulties to run just one block behind where it had no chance of being diverted to another route or detrained at a platform.
- Didn't identify the big issue emerging.
- Didn't cue the signal team to do a Calling On procedure.

Oh I forgot that Gold Command control the operation of the railway at an individual train level. Interesting that from reading what's on here , the bronze and silver levels operated perfectly and it was just gold that screwed up.

 

[broadgage]

Reports from neighbours suggest to me that next time this happens, that passengers will escape sooner rather than later. "best to escape BEFORE you wet yourself, rather than after"
Few passengers believe the soothing announcements, and more such announcements seem unlikely to help.

I ask of railway professionals, talking not of generalities but about this particular case "how long is it reasonable to confine passengers in the reported conditions "

My view is that when on board conditions are particular bad, is that evacuation should be considered within 30 minutes, and be mandatory within 60 minutes. If conditions are more benign, with everybody seated, toilets available, and heating or cooling working, then evacuation is far less urgent.
But I repeat that in my view when conditions are similar to those reported at Lewisham, that evacuation should be considered, and planning started within 30 minutes, and be mandatory within 60 minutes.

 

[SamYeager]

My view is that when on board conditions are particular bad, is that evacuation should be considered within 30 minutes, and be mandatory within 60 minutes. If conditions are more benign, with everybody seated, toilets available, and heating or cooling working, then evacuation is far less urgent.
But I repeat that in my view when conditions are similar to those reported at Lewisham, that evacuation should be considered, and planning started within 30 minutes, and be mandatory within 60 minutes.

I believe that evacuation is only considered once a train is classed as "stranded" however neither of the two trains principally involved has been declared as "stranded" prior to the first egress from 2M50 after it had spent more than 60 minutes sitting at a red light. The report doesn't really seem to go too much into why this decision wasn't made earlier.

I note that considerable time was spent by the driver of the first train (2M48?) trying to draw away very slowly from the platform. Obviously with a very large dose of hindsight I do wonder whether this driver should have recognised at an earlier stage that he needed external assistance and made the signaller and others aware of this. This might have focussed minds earlier on declaring trains stranded and considering evacuation.

 

[ainsworth74]

Regarding evacuation to the lineside it's clearly an option that you wish to avoid if at all possible. It requires a lot of staff, it means members of the public traipsing lineside with all of those attendant hazards (particularly on a day like the Lewisham case where there was snow and ice around) along with the impact on train running. But I wonder if that desire to avoid that outcome is, in some ways, making it more likely as those making decisions try and put it off as "this next idea will work and we'll get the train to a platform". But that idea doesn't work. So "well this next idea will work and we'll get the train to a platform". But that idea doesn't work either. Then "aha but this idea will definitely work and we'll have the passengers in a station!". Also doesn't work. "Nono we'll try this and then we'll be okay!". And by then the passengers have been there so long that they lose faith and self-evacuate so even if that final plan would have worked it's all irrelevant now anyway as the job is stopped.

I guess this might be those human factors again as I can understand why you get yourself into that loop when the alternative is difficult and somewhat risky but I do wonder if there needs to be some serious consideration about a hard limit to those loops rather than delaying taking that decision because "this plan will work!"? It seems to me we've had a number of incidents of late that have gone on for a long period of time because, perfectly reasonably, those making the decisions have not wanted to evacuate and so keep trying things that, if they come off, will avoid an evacuation. But they don't come off...

 

[etr221]

Reports from neighbours suggest to me that next time this happens, that passengers will escape sooner rather than later. "best to escape BEFORE you wet yourself, rather than after"
Few passengers believe the soothing announcements, and more such announcements seem unlikely to help.

I ask of railway professionals, talking not of generalities but about this particular case "how long is it reasonable to confine passengers in the reported conditions "

My view is that when on board conditions are particular bad, is that evacuation should be considered within 30 minutes, and be mandatory within 60 minutes. If conditions are more benign, with everybody seated, toilets available, and heating or cooling working, then evacuation is far less urgent.
But I repeat that in my view when conditions are similar to those reported at Lewisham, that evacuation should be considered, and planning started within 30 minutes, and be mandatory within 60 minutes.

Yes, the starting point for handling any similar incident is that passengers WILL, sooner or later, self detrain. How soon will depend on circumstances - it will be sooner for a crowded, toiletless metro train in sight of civilisation with negligible passenger management (read; the driver is busy with other things so no announcements), later on a half empty Inter City in the middle of nowhere with attentive customer care - but it WILL happen An hour seems to be a reasonable first guess for when, so any call from a driver to say 'I'm stopped away from a platform...' should conclude '... and my passengers can be expected to self detrain in less than an hour' (by then the clock is already ticking) - and the railway should start on its procedures - initially designating incident manager to consider the situation, and what the options are, and preparing to get more staff (MOM, passenger care, etc.) on the way to assist.

Getting back to this specific incident, a major contribution to it becoming as serious as it did was that - despite Gold Command being established, and the KRS contingency plan in force (read: a fragile railway) - the service just came to a grinding halt as trains came to red signals without anything much going wrong - apart from 2M48, none of the trains involved actually failed, they just stopped - was that no-one seems to have noticed the service totally falling apart - by 1745 the SE mainline was essentially in a most (if not actually all) lines blocked situation - and done anything in the way of raising or escalating the alarm.

The other thing to say is that, because of the RAIB's role, their report is very narrowly focused on the safety issue (of passengers self detraining), rather than considering the incident as a whole.

 

[OneOffDave]

Regarding evacuation to the lineside it's clearly an option that you wish to avoid if at all possible. It requires a lot of staff, it means members of the public traipsing lineside with all of those attendant hazards (particularly on a day like the Lewisham case where there was snow and ice around) along with the impact on train running. But I wonder if that desire to avoid that outcome is, in some ways, making it more likely as those making decisions try and put it off as "this next idea will work and we'll get the train to a platform". But that idea doesn't work. So "well this next idea will work and we'll get the train to a platform". But that idea doesn't work either. Then "aha but this idea will definitely work and we'll have the passengers in a station!". Also doesn't work. "Nono we'll try this and then we'll be okay!". And by then the passengers have been there so long that they lose faith and self-evacuate so even if that final plan would have worked it's all irrelevant now anyway as the job is stopped.

I guess this might be those human factors again as I can understand why you get yourself into that loop when the alternative is difficult and somewhat risky but I do wonder if there needs to be some serious consideration about a hard limit to those loops rather than delaying taking that decision because "this plan will work!"? It seems to me we've had a number of incidents of late that have gone on for a long period of time because, perfectly reasonably, those making the decisions have not wanted to evacuate and so keep trying things that, if they come off, will avoid an evacuation. But they don't come off...

Very much this. That kind of tunnel vision is very common in incidents and this is where part of your command and control function should be looking at the wider picture and pointing out that now a couple of options have failed that there's a need to address the emergent needs of the people still stuck on the trains. I've seen emergency incidents where you have one 'cell' working on solving the problem while at the same time, there's another 'cell' setting up arrangements for the fallback position (relocation/evacuation/whatever) should the solution fail. If the work of the second cell isn't needed than that's great but if it is, you are already a long way to having everything in place.

 

[farleigh]

Obviously a massive balls up but does anybody get disciplined in these situations?

 

[ainsworth74]

Obviously a massive balls up but does anybody get disciplined in these situations?

For what reason? With the benefit of hindsight it's all very simple to see where it went wrong. With the situation as it was playing out on the ground? Who should be disciplined and for what? It seems to me there's far more mileage in looking at this objectively and seeking ways we can avoid it happening again rather than birching everyone involved.

 

[Mojo]

The other thing to say is that, because of the RAIB's role, their report is very narrowly focused on the safety issue (of passengers self detraining), rather than considering the incident as a whole.

Ought to point that there was an "Independent Report" that was published in August last year and discussed in this thread (posts from #897 onwards), and can be read here: https://newsroom.southeasternrailwa...ent-report-lewisham-network-rail-southeastern, this does take a greater overview of operational matters rather than just from a safety perspective.

 

[farleigh]

For what reason? With the benefit of hindsight it's all very simple to see where it went wrong. With the situation as it was playing out on the ground? Who should be disciplined and for what? It seems to me there's far more mileage in looking at this objectively and seeking ways we can avoid it happening again rather than birching everyone involved.

I asked a simple question as I was interested. You did not answer this. You brought up birching, not me.
Anyway - anyone have a sensible answer?