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

[deltic]

Depressing reading - it would appear that if one decision early on had been different then the mass stranding would not have happened. Competent rail staff on board was only effective when they could actually get through the train.

 

[Surreytraveller]

The disclaimer at the beginning of the report says it all, though. They take no responsibility if anyone takes on board what is written in the report.

 

[Taunton]

Why did NR and the operator commission a separate report, which they have got out ahead of the official one?

The report was paid for by these two - and it shows. Toadying to those who paid for the report, self-justifications from the first paragraphs, glossing over of the key issues, real welfare of passengers problems airbrushed down to a few bullet points at the end of Section 7. And all blah'd out to the media in advance of the official report, which they presumably hope it will be mistaken for.

I just hope the RAIB take them to task for doing this. And if Arthur D Little had any professional integrity they would have declined the work.

 

[deltic]

Why did NR and the operator commission a separate report, which they have got out ahead of the official one?

The report was paid for by these two - and it shows. Toadying to those who paid for the report, self-justifications from the first paragraphs, glossing over of the key issues, real welfare of passengers problems airbrushed down to a few bullet points at the end of Section 7. And all blah'd out to the media in advance of the official report, which they presumably hope it will be mistaken for.

I just hope the RAIB take them to task for doing this. And if Arthur D Little had any professional integrity they would have declined the work.

I didnt see any toadying, it was damning of Network Rail and the TOC and the welfare of passengers was highlighted

 

[deltic]

The disclaimer at the beginning of the report says it all, though. They take no responsibility if anyone takes on board what is written in the report.

Its a standard disclaimer - the report is prepared for Network Rail and Southeastern. If anyone else uses it for decision making then that is at their own risk.

 

[Surreytraveller]

I like the bit about staff at Lewisham ensuring people tapped out their Oystercards. All that would do is cause them to be charged for two incomplete journeys instead of one!

 

[Mag_seven]

Why did NR and the operator commission a separate report, which they have got out ahead of the official one?

I don't see the need for separate reports either although it will be interesting to see if there are any differences!

 

[John Bray]

I think the report covers passenger welfare well (though the idea that passengers could not handle a toilet without a powered door or flush is daft, they should be designed to degrade to a gravity disposal solution). With hindsight clearly the fault was inflexible signallers not allowing allowing the front of 2M50 to creep into Lewisham station while the rear 2M48 was still on the platform, with 2S54 closing up. That would have allowed 2 trains to optionally evacuate (were there inter-set doors?), and clear the route for 6 trains on the main line, just leaving 2S54 to deal with.

Its confirmed that the first trackside evacuation after 62 minutes dleay, which sounds entirely justified to me.

 

[etr221]

Having read through the report, the thing that strikes me is the slowness in recognising that there was an incident occurring, and that (because of where it was) this was rapidly going to become serious; and then to quickly establish effective control (something that - substantially - people were playing catch up on all evening)

But two questions I wonder about (not really specific to the incident, but perhaps brought to light by it):
a) does the railway have any system for designating areas as 'critical', where any incident will have major side effects?
b) has any review been made of the robustness (hence validity) of the (South Eastern) Emergency Timetable?

 

[TPO]

I didnt see any toadying, it was damning of Network Rail and the TOC and the welfare of passengers was highlighted

Indeed, and I note that the main author (Mike Sowden) is a very experenced railway operator. I remember him from his days at Network Rail in the Thames Valley, he's a tip-top bloke and not at all the toadying type. The disclaimer is a standard paragraph (usually to keep the consultants' indemnity insurer happy).

TPO

 

[Tom Quinne]

I think the report covers passenger welfare well (though the idea that passengers could not handle a toilet without a powered door or flush is daft, they should be designed to degrade to a gravity disposal solution). With hindsight clearly the fault was inflexible signallers not allowing allowing the front of 2M50 to creep into Lewisham station while the rear 2M48 was still on the platform, with 2S54 closing up. That would have allowed 2 trains to optionally evacuate (were there inter-set doors?), and clear the route for 6 trains on the main line, just leaving 2S54 to deal with.

Its confirmed that the first trackside evacuation after 62 minutes dleay, which sounds entirely justified to me.

Inflexible signaller....hmmm are you a Signaller ?

We can’t just get drivers to creep or otherwise without authority for control, I think you’ll find it’s then who fudge decisions, even when NWR Control say yes, often TOC Control day no.

 

[SamYeager]

Inflexible signaller....hmmm are you a Signaller ?

We can’t just get drivers to creep or otherwise without authority for control, I think you’ll find it’s then who fudge decisions, even when NWR Control say yes, often TOC Control day no.

Rules is rules! However perhaps it might have helped if the signaller had raised the possibility that it would be possible if EPW was authorised although I realise that's with the benefit of hindsight. More generally perhaps there needs to be a greater willingness to consider making greater use of the flexibilities available when the weather conditions are particularly inclement, perhaps tied to the official weather status declared? I am aware that proposal has its own significant dangers if used too readily.

 

[talltim]

But what else could be done? It's stuck, in foul weather on congested infrastructure, so there's little chance of anything turning up to give it a push. As for getting pax off, this was I presume a DOO train? A small team of people are required to safely evacuate a loaded train, the Driver can't do it on his own. Indeed Driver and Guard is still pushing it for a controlled situation. Station staff are usually not PTS, and they certainly won't have been trained for a lineside evacuation, so despite their proximity in this case, they're not much good. So you're looking at NR staff, on-call managers, BTP etc, and of course they're all already running around like the proverbial chickens. So, what can you do really?!

You have guards and you PTS train your station staff...

 

[etr221]

Inflexible signaller....hmmm are you a Signaller ?
We can’t just get drivers to creep or otherwise without authority for control, I think you’ll find it’s then who fudge decisions, even when NWR Control say yes, often TOC Control day no.

Rules is rules! However perhaps it might have helped if the signaller had raised the possibility that it would be possible if EPW was authorised although I realise that's with the benefit of hindsight. More generally perhaps there needs to be a greater willingness to consider making greater use of the flexibilities available when the weather conditions are particularly inclement, perhaps tied to the official weather status declared? I am aware that proposal has its own significant dangers if used too readily.

While I fully agree that trains can't just be instructed to pass signals at danger, and that rules are rules, the fact is that it was rigid adherence to them - without apparently considering, let alone implementing, emergency procedures such as EPW (emergency permissive working) until too late - that caused the situation to develop as it did, into a major incident. And it should be noted that the weather conditions - after causing the initial stall of 2M48 - played no part in this.

As has been said above, when a train has become stranded (stationary away from a platform for a significant time) then passenger self evacuation is a matter of when, not if, and the railway needs to work on that basis - because once passengers start self evacuating then the railway has lost control. So when a train has been stopped (away from platform) for more than five or ten minutes then an incident should be being declared, with managers/controllers thinking about how they can resolve the situation - by implementing emergency procedures (epw, Thunderbird, whatever) or preparing for a controlled evacuation (or both).

Given that the incident essentially commenced at 1735-1740 (when 2M48 was barely managing to get going, and 2M50 came to halt at the signal behind it), this would have meant an incident proclamation by 1750; but as it was this - and any involvement of managers/controllers - doesn't seem to have happened until 1816 (during which time train after train was becoming stranded), with nothing seeming to actually have been done before the passengers on 2M50 started self evacuating at 1840, an hour after their train came to a stand just outside Lewisham station.

 

[Tom Quinne]

EPW is a very useful tool, but to get it authorised it quite difficult as is everything that isn’t the norm.

A Signaller can’t self authorise, and control are often adverse to making decisions without passing it up the chain which all takes time, even when a plan I formulated by party a, party b can’t put the block on it.

Fear not though lessons with be learnt....

 

[Surreytraveller]

It is all very well saying the signaller should have used EPW, but the signaller would have been working under an extreme workload, as would the driver of the train and control. People being flexible during high workload situations in the past haa caused train crashes and killed people. Sitting in an armchair and suggesting they should have done this or that with the benefit of hindsight is a lot different than being fatigued working under extreme pressure dealing with multiple incidents at the same time with dozens of people shouting at you, or trying to talk to you, or asking you to make several contradictory decisions about different things all at the same time.

 

[AngusH]

Why are there dozens of people shouting at signallers in the first place?

Perhaps the first step would be look at signaller's workloads and the flow of communications to see if the system could be rearranged.

 

[etr221]

It is all very well saying the signaller should have used EPW, but the signaller would have been working under an extreme workload, as would the driver of the train and control. People being flexible during high workload situations in the past haa caused train crashes and killed people. Sitting in an armchair and suggesting they should have done this or that with the benefit of hindsight is a lot different than being fatigued working under extreme pressure dealing with multiple incidents at the same time with dozens of people shouting at you, or trying to talk to you, or asking you to make several contradictory decisions about different things all at the same time.

I wouldn't disagree - as the proverb has it, judge no man until you have walked a mile in his moccasins. And a criticism I would make of the 'independant report' is that it does no more than hint at what (and how much) else the South Eastern control (TOC and NR) were having to deal with at the time.

But - when it comes down to it - the reason there was a major incident that evening was that, however justifiably, a much less severe one had been allowed to get out of hand.

And I will also observe - getting back to the criticism of passengers self detraining - when the first of them did so, it was - from my reading of the report - after an hour in which essentially nothing had actually been done to get them on their way.

 

[Bikeman78]

It is all very well saying the signaller should have used EPW, but the signaller would have been working under an extreme workload, as would the driver of the train and control. People being flexible during high workload situations in the past haa caused train crashes and killed people. Sitting in an armchair and suggesting they should have done this or that with the benefit of hindsight is a lot different than being fatigued working under extreme pressure dealing with multiple incidents at the same time with dozens of people shouting at you, or trying to talk to you, or asking you to make several contradictory decisions about different things all at the same time.

Hopefully one lesson to be learned is don't send anything off the down fast onto the Tanners Hill line unless it can clear the junction.

 

[bramling]

Why are there dozens of people shouting at signallers in the first place?

Perhaps the first step would be look at signaller's workloads and the flow of communications to see if the system could be rearranged.

I suspect any review would lead back to the current situation - namely that the railway isn't really staffed to cope smoothly on the rare occasions when things are really bad.

How many extra staff we are all prepared to pay to sit around 98% of the time is a matter for debate.

 

[AngusH]

I suspect any review would lead back to the current situation - namely that the railway isn't really staffed to cope smoothly on the rare occasions when things are really bad.

How many extra staff we are all prepared to pay to sit around 98% of the time is a matter for debate.

98% is a week a year.... I think we need to pay if it's really that bad.

I'm guessing you didn't quite mean that literally.

The problem I have is if some poor person is facing this level of workload and makes a critical error and someone dies. Then that person will undoubtably get blamed: "Oh they were negligent, they should have done a more professional job. They didn't meet the standard expected of them. Lets send them to jail!"

If the system is failing in this way, I always feel deeply unhappy when this blame game happens and I'd prefer it not happen in the first place. So either the system needs improvement or if it is already absolutely as good as it can be made then we need to pay for those extra staff.

 

[philthetube]

On the underground their is a SOO. (Senior operating official), whos job is to look at situations which require movements which do not comply with the rune book. They have to look at situations and make decisions, logging what is decided and what they have considered before making the decision, what can go wrong etc. Is there a similar position on NR?

 

[Tio Terry]

98% is a week a year.... I think we need to pay if it's really that bad.

I'm guessing you didn't quite mean that literally.

The problem I have is if some poor person is facing this level of workload and makes a critical error and someone dies. Then that person will undoubtably get blamed: "Oh they were negligent, they should have done a more professional job. They didn't meet the standard expected of them. Lets send them to jail!"

If the system is failing in this way, I always feel deeply unhappy when this blame game happens and I'd prefer it not happen in the first place. So either the system needs improvement or if it is already absolutely as good as it can be made then we need to pay for those extra staff.

Think you've got your numbers back to front. 98% is roundly 51 weeks of doing nothing and one week of doing something a year!

 

[bramling]

98% is a week a year.... I think we need to pay if it's really that bad.

I'm guessing you didn't quite mean that literally.

The problem I have is if some poor person is facing this level of workload and makes a critical error and someone dies. Then that person will undoubtably get blamed: "Oh they were negligent, they should have done a more professional job. They didn't meet the standard expected of them. Lets send them to jail!"

If the system is failing in this way, I always feel deeply unhappy when this blame game happens and I'd prefer it not happen in the first place. So either the system needs improvement or if it is already absolutely as good as it can be made then we need to pay for those extra staff.

I didn’t mean the 98% literally, however you could say that we get adverse weather for a week or two per year in one form or another, generally strong winds or ice/snow. The last few winters before this one were pretty mild and many parts of the country didn’t get much if any snow at all.

The rest of your post is unfortunately a fairly accurate reflection of how I see things - staff are simply expected to take “it all kicking off” in their stride, and then get criticised when the inevitable happens. The mainline railway also has a big weakness in that station staff are generally not operationally trained in the same way that LU staff are, so there isn’t really the option of using station staff to either help get things moving or as a last resort assist with evacuations.

The lack of snow for several years may well have led to a bit of complacency / loss of experience this year too. The challenges thrown up by ice/snow require every person to be at the top of their game, as one weak link in a chain can cause the railway to grind to a halt very quickly - a multiplier effect kicks in which is exactly what happened at Lewisham.

 

[bramling]

On the underground their is a SOO. (Senior operating official), whos job is to look at situations which require movements which do not comply with the rune book. They have to look at situations and make decisions, logging what is decided and what they have considered before making the decision, what can go wrong etc. Is there a similar position on NR?

Only really the shift managers in TOC or joint controls.

The mainline simply doesn’t have the control structure that LU does. The fragmentation between TOC and NR doesn’t help, and nor does the divide between TOC controls and NR signallers.

I think it’s too early to say whether the ROC concept will help - getting everyone in one building certainly isn’t a bad thing, but it still doesn’t fully address the issue of fragmentation - and the transient nature of franchises probably hasn’t helped, although to be fair the Kent control function is one which has led a comparatively stable life.

 

[etr221]

Talking about having 'spare' resources (additional, or additionally qualified, staff, etc.) either the the railway has to have the procedures and resources available to expeditiously handle incidents, or it has to be prepared to say that the sort of thing that happened on 2nd March was not a failure, but the expected and intended (as per plan and preparartion) result (including passengers stuck for hours in bad conditions on stranded trains).

If you're not prepared to pay the price of succeeding, you'll have to pay that of failure...

 

[bramling]

Talking about having 'spare' resources (additional, or additionally qualified, staff, etc.) either the the railway has to have the procedures and resources available to expeditiously handle incidents, or it has to be prepared to say that the sort of thing that happened on 2nd March was not a failure, but the expected and intended (as per plan and preparartion) result (including passengers stuck for hours in bad conditions on stranded trains).

Absolutely nail hit on head. Now find someone in the industry (either NR, TOC or DFT) with the relevant decision-making power who is prepared to state that on the record!

Instead we have the usual fudge - predictable mess-up happens, conveniently find something an overworkloaded member of staff has omitted to do (which due to the said overworking is pretty much inevitable), put out a few briefings for the future, and sit back and wait for the next mess-up.

To be fair, there is no right or wrong answer to the original question, and it's a wider issue in the sense that we're all stakeholders as farepayers / taxpayers -- do we want fares to rise to pay for resources that won't be used most of the time? How many simultaneous incidents do we need to have resources available to handle?

Perhaps the solution is to have as much flexibility in the industry as possible - so during times of extreme need there is a pool of people who can be relatively readily diverted off their less critical normal work. We already see this with TOC revenue staff often assisting with events crowd management. Unfortunately the fragmented nature of the industry works against such flexibility, as TOC staff generally don't get involved with incident response which seems to have become a NR responsibility. Again, LU is a little better in this respect due to being one railway -- but they're suffering too from loss of expertise and not wanting to take time & expense training / maintaining skills that aren't used that often.

 

[SamYeager]

More generally perhaps there needs to be a greater willingness to consider making greater use of the flexibilities available when the weather conditions are particularly inclement, perhaps tied to the official weather status declared? I am aware that proposal has its own significant dangers if used too readily.

Perhaps the solution is to have as much flexibility in the industry as possible - so during times of extreme need there is a pool of people who can be relatively readily diverted off their less critical normal work. We already see this with TOC revenue staff often assisting with events crowd management.

I think we're talking about two facets of the same thing which is the potential need for additional flexibility from the railway industry in times of severe weather disruption. I fully accept that there is a danger that this additional flexibility might result in tragic accidents unless well managed. However I don't think that it is unreasonable for the travelling public to expect the railway industry to plan for and put in the required safeguards to be able to manage such flexibility in clearly defined circumstances and with clear and well documented instructions. I specifically use the term "railway industry" as I believe that this is something that both TOCs, multiple TOCs in some instances, and NR need to plan together.

 

[carriageline]

With hindsight clearly the fault was inflexible signallers not allowing allowing the front of 2M50 to creep into Lewisham station while the rear 2M48 was still on the platform, with 2S54 closing up.

Speaking from personal experience, most incidents that bare any resemblance to the start of this one, are normally resolved within 5-15 minutes. Things like EPW are “last resort” things, hence the term emergency. Signallers will normally use their experience and estimate that this incident will last 5-10 minutes longer, and thus it’s easiee to get the incident resolved, than ‘waste’ time putting EPW into use.

Inflexible signaller....hmmm are you a Signaller ?

We can’t just get drivers to creep or otherwise without authority for control, I think you’ll find it’s then who fudge decisions, even when NWR Control say yes, often TOC Control day no.

Thankfully SSMS at my place can authorise it. And this incident has certainly highlighted and reminded us of that

Hopefully one lesson to be learned is don't send anything off the down fast onto the Tanners Hill line unless it can clear the junction.

Would never work. You can’t operate a railway off the worst possible scenarios, otherwise everything runs a lot more restrictively. Plus, every driver is different. One day you will get an 8 car behind that signal, the next a 6 car will hang back

On the underground their is a SOO. (Senior operating official), whos job is to look at situations which require movements which do not comply with the rune book. They have to look at situations and make decisions, logging what is decided and what they have considered before making the decision, what can go wrong etc. Is there a similar position on NR?

NR now have “Incident Officers” which do exactly as you say, and act as gold command during incidents. It’s helpful when an incident occurs at 3AM and most senior management (apart from on calls) are no where near, and not immediately aware.

 

[etr221]

Speaking from personal experience, most incidents that bare any resemblance to the start of this one, are normally resolved within 5-15 minutes. Things like EPW are “last resort” things, hence the term emergency. Signallers will normally use their experience and estimate that this incident will last 5-10 minutes longer, and thus it’s easiee to get the incident resolved, than ‘waste’ time putting EPW into use.

I'm sure you're right, that most such situations are quickly (5-15 minutes) resolved through normal action. The problem is when they aren't: repeated 'just another 10 minutes' quickly mounts up, and, if and as information to passengers, will lead to a loss of trust by them in 'the railway', and them making their own arrangements, as they did on March 2nd. There has to be a point (15 minutes?) at which - even, perhaps especially, if things have just come to standstill, as they had - an incident is declared, and the alternative course(s) of action are considered, and set in motion - bearing in mind that the 'golden hour' to deal with the situation is by then probably only 45 minutes. And if 'normal actions' clear the situation quickly, good, the alternative can be stood down, but by then there should be an expectation that they won't.