Summary
At 18:46 hrs on Tuesday 7 November 2017, a London Overground service from Dalston Junction to Battersea Park, operated by Arriva Rail London, came to a stand shortly before reaching Peckham Rye station. A faulty component on the train had caused the brakes to apply, and the driver was unable to release them. There were about 450 passengers on the train.
The train driver spoke over the railway radio system to the service controller, train technicians, and the signaller. Following these conversations he began, with the assistance of a member of staff from Peckham Rye station, to evacuate the passengers from the train via the door at the right-hand side of the driver’s cab at the front of the train. This involved passengers climbing down vertical steps to ground level, very close to the live electric conductor rail (third rail) and walking along the side of the line for about 30 metres to Peckham Rye station.
Soon afterwards, an operations manager from Govia Thameslink Rail, which manages Peckham Rye station, contacted the member of station staff and realised where they were and what was happening. The operations manager immediately instructed the driver to stop the evacuation, and requested that he contact the signaller and his company’s controller for further instructions. The driver, after further advice from control room based train technicians, isolated various train safety systems, and found that he was eventually able to release the brakes and move the train forward into Peckham Rye station, arriving at about 19:44 hrs. It was then possible for all the remaining passengers to leave the train normally, and it proceeded, empty, to the depot at New Cross Gate. No-one was hurt in the incident.
The incident occurred because the driver initiated the detrainment of passengers without the traction current being switched off. He did this because he was given instructions by control room staff who had misunderstood the actual location of the stranded train. The train driver and the signaller did not reach a clear understanding about the actions that were required to safely detrain the passengers. The delay caused unrest among the passengers on the train and contributed to stress and task overload of the driver, which affected his decision making. The driver’s experience and skills did not enable him to cope with these demands, and Network Rail did not effectively implement its own procedures for managing an incident involving a stranded train.
Underlying factors were that Arriva Rail London strategic command and Network Rail signalling staff were not adequately prepared to manage the incident, and the railway industry standards and procedures relating to stranded trains place little emphasis on the need for practical training for those involved. The RAIB also observed that there were a number of deficiencies in the training and briefing of staff and in the ARL control room arrangements.
Recommendations
The RAIB has made three recommendations, directed to Arriva Rail London and Network Rail, intended to improve the response of the railway industry to train failures and other abnormal events, and has identified three learning points relating to the importance of following the correct procedures when preparing to evacuate passengers from trains, ensuring that communications are properly understood, and passing on the details of incidents promptly and effectively.
Simon French, Chief Inspector of Rail Accidents said:
“Minor technical faults on trains are a daily reality on the railways, but sometimes these minor events, if not identified and dealt with promptly, can quickly develop into a potential safety incident. On this occasion misunderstandings and confusion resulted in passengers being told to leave the safety of a train, climb down vertical steps above a live electric rail, and walk in darkness along an overgrown path to a station. About eighty people went through this before the evacuation was stopped, and it is very fortunate that no-one was hurt.
“When dealing with this type of incident, a train driver has many tasks to perform, and as we all know stress can sometimes affect our ability to function properly. Unfortunately, over recent years there have been a number of incidents on the railway in which train drivers have not been adequately supported when managing a difficult situation in unfamiliar circumstances. It is essential that on these occasions the signaller, train driver, any other involved staff (whether on the train or on the ground) and the various control rooms all work together to coordinate their activities to ensure the needs of passengers are recognised, and the train driver is supported to ensure that the incident is effectively and efficiently resolved.
“Following previous incidents, the railway industry has put in place policies for managing incidents in which trains become stranded. This incident has shown that when things go wrong, these policies may not be effective. One reason for this is that the people who have to put the necessary arrangements into operation do not get the opportunity to practise the procedures. We are recommending that, both locally and nationally, the incident management arrangements should be reviewed, and processes put in place to exercise them regularly. It’s not enough to have a plan – it must work when it is needed, and if it has never been practised the chances are it won’t work.”
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.
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Newsdate: 9 October 2018
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