Report into major disruption on the 26th May 2011
This is an initial report into First Capital Connect’s (FCC’s) management of the events on the evening of 26 May.
The investigation was commissioned by FCC’s Managing Director, Neal Lawson, and was conducted by Ben Harding of Atkins.
The incident, involving the 16.30 FCC service from Brighton to Bedford, was caused by a branch becoming entangled with the pantograph. Hundreds of passengers were stuck on a train outside Kentish Town Station for three hours and thousands of customers experienced serious delays throughout the evening.
The events on the evening of 26 May led to around 800 people being trapped on a stationary train for over three hours. Many thousands more had their journeys extended as many trains were cancelled to all FCC destinations on the Thameslink route. After a lengthy delay, a number of train doors were opened by customers, and a small number of customers actually left the train, putting themselves in danger.
FCC asked me to look at what happened and to provide an independent view of what they could do to improve things for customers if incidents like this occur in the future. This is one of five separate investigations that are currently ongoing into this particular incident. Nevertheless I have made ten recommendations that I believe FCC should progress as soon as is practicable. These cover technical issues relating to the train and its recovery, and FCC’s approach to incident management.
My discussions with FCC’s senior management, and in particular the Managing Director, Neal Lawson, have been positive. I believe FCC has recognised the shortcomings these events have revealed, accept the need for improvement, and are committed to ‘making it happen’.
Recommendations - Ben Harding, Atkins
My key recommendations are that:
- Investigations, including the internal technical investigation, should continue and make appropriate recommendations.
- FCC should examine the Network Rail, Rail Accident Investigation Branch and Office of Rail Regulation reports as soon as they are available, and identify whether any of the FCC actions arising from this report need to be changed, or new ones adopted.
- FCC should critically review its ‘on call’ process, and all other processes relevant to incident management, including the disruption management processes, and the use of Kentish Town as the preferred location for getting passengers off the train. This review should include establishing how to ensure that appropriate levels of customer service are provided to all affected customers throughout any incident, and that there is appropriate strategic leadership. It should also recognise the possibility of customers opening doors for ventilation, and getting off the train themselves.
- FCC should consider how the resources in its three Controls (West Hampstead, King’s Cross and Croydon) can be combined in events such as these to avoid conflicting instructions being given and improve the information given to customers.
- FCC should continue to work with NR to ensure that there is absolute clarity of roles and responsibilities during incidents, and effective liaison.
- FCC should review the availability of all relevant resources for all incidents, and ensure that that this is known by all relevant FCC and Network Rail staff. In addition FCC should ensure there is a process to ensure that such resources are regularly checked to confirm they are in place and serviceable.
- FCC should review and update its briefings to drivers (and other staff) for incidents in particular ensuring that drivers are aware of the importance of keeping customers informed, and the process for opening train doors on 377s during prolonged delays.
- FCC should establish whether the possibility of drivers using the PA on 377s after the 90 minute electrical close down is a practicable option, and – if so – include it in their briefing to drivers.
- FCC should consider running a number of ‘real time’ table top exercises to test its ability to manage such incidents.
- FCC should expedite the procurement of emergency door screens, equip each 377 unit with at least four (one per carriage) and brief drivers, and other relevant staff, in their use. It should also consider whether such equipment should be provided for other FCC train types.
First Capital Connect response
First Capital Connect welcomes Ben Harding’s independent report. We have agreed to implement the recommendations immediately and have already put in place a number of improvements from our separate internal investigation.
- Improving and streamlining the way relief trains are joined to failed trains
- Establishing a ‘Core Communications working group’ to look at communications within the core area (Blackfriars to St Pancras where most major incidents occur). This will improve the flow of information from control centre to station manager/driver to the customer.
- Setting up a ‘mobile hotline’ in control centres so key staff (drivers/fitters/station managers) can get the information they need from controllers quickly.
- Reviewing the on-call structure to ensure senior management cover in the evening peaks.
- Adding emergency door screens to trains.
Neal Lawson, Managing Director of First Capital Connect, said: “This incident was not handled as well as we could or should have and, once again, I would like to apologise to all those affected. We are very grateful to Ben for highlighting areas where we could improve and are implementing his recommendations so that customers can have confidence that we will do better in future.
“We need to raise our game during major disruption ensuring that each incident is handled professionally and consistently to the highest possible standard – every operational decision has to be based around what is best for the customer.”