Ice on the Conductor Rail

Locations: Hastings and , Ramsgate and Ashford, and and Rochester to

12th February 2016 Network Rail / Southeastern / GTR

/ 1 Ice on the Conductor Rail (12/02/2016)

AGENDA Introductions Incident Data Incident Summary Service Recovery Profile Specific Objectives of the Review Review of Learning Points Review of Actions

/ 2

Incident Summary

th  On Friday 12 February significant disruption to Southeastern services occurred on a number of lines of route as result of ice on the conductor rail.

 Services from start-up and throughout the morning peak resulted in a number of trains being stranded at/or between stations owing to difficulties drawing power from the 3rd rail.

 Lines worst affected were those between:  Hastings and Tonbridge  Ramsgate and Ashford  Dover and Faversham  Rochester to Swanley.

 MPV anti-ice circuits had been run the evening before and again overnight on the majority of routes (the only exceptions being those under engineering possession) along with the Snow & Ice Treatment Train. However a band of freezing rain that swept across the county at around 03.00 resulted in an additional layer of ice forming.

 Some disruption was also experienced in Sussex to GTR services as a result of overnight ice on the Conductor Rail but to a much lesser extent than on .

 Reactionary delay from Kent incidents did affect GTR services in Sussex lines of route around Crystal Palace

/ 6

Specific Objectives of the Review

 The effectiveness of the anti-ice chemical relative to the weather conditions experienced during the early hours of Friday 12th February and identify options for potential future improvements/solutions  The effectiveness of Conductor Rail heating where fitted.  The accuracy of the weather forecast provide by MetDesk and identification of any future improvements if applicable  The planning and delivery of the MPV and SITT circuits including the timing of these and the selected flow rate of anti-ice application (litres per minute)  The communication and dissemination of information from the KICC to NWR and Southeastern Senior Leaders and On-call Managers and the Media Relations teams  The Southeastern Winter stock strengthening plan and the allocation of Class 375/8 units with anti-ice capability  Service recovery and Train Crew management and the interface between the KICC and AFC (High Speed Control)  Incident management and the deployment of Response staff to trapped trains  The management of passenger and staff welfare and any safety issues identified  Trigger levels for EWAT conferences and the robustness of the Southeast Winter Management plan  Lessons learnt and post incident mitigation introduced

/ 7 Headline findings

Control & Service Recovery  The KICC team became overwhelmed very quickly and gold command was not set up  The magnitude of the issue was not immediately recognised  It was the equivalent to having “6 to 7 fatalities at once”  The morning focus was rightly on getting people into London and then shifted to being in place for the PM peak – the question which should have been asked was “at what point do we accept normal recovery is impossible and more drastic action is needed?”  The incident was largely resolved by 9-10am so we should have been in a suitable place by 4pm to be ready for the evening peak – however, we didn’t have a plan in place to recover from this scale of incident/s. Resilience and treatment strategy  Conrail heating was in place and performed as expected but not adequate for freezing rain  Icing is a relatively rare occurrence with the last similar incident in 2010  Mitigations have since been put in place (e.g. increasing the flow) but these are only likely to minimise the impact of another event, the risk of this happening again still exists  There is a high likelihood that the anti-ice treatment was ineffective in terms of resilience to effects of freezing rain – however, this needs to be independently tested and verified  The weather forecast accuracy was not good enough – neither rain nor freezing temperatures had been forecast.  Although it is questionable whether an improved forecast would have materially changed our actions or recovery on the day

/ 8 Key Findings: Control & Service Recovery

 The lack of preparedness and mitigation plans for an incident of this magnitude highlighted a deficiency in our service recovery framework  MAIN ACTION: to form a cross-organisational group to jointly develop plans for service recovery – in particular for major incidents of this magnitude. The purpose of this group will be to:  Identify and implement processes for optimal service recovery solutions for major route wide perturbation and how this is instigated  to include ‘red button’ or ‘nuclear’ option to cancel ALL services for a period of time after the am peak to allow robust recovery of the pm peak  Review existing Train Crew diagrams to allow rapid implementation of shuttle services between key points where parts of the network are closed  Identify ‘best practice’ incident management and service recovery elsewhere in the business and including TfL and options to implement on South East route  Review resource levels and structure at the KICC  are we sufficiently resourced to manage major unplanned events?  Identify a solution for service management & recovery communications between KICC and Ashford (High Speed)  Agree a joint comms strategy for major incidents

/ 9 Key Findings: Resilience and Treatment Strategy

 There remains uncertainty around our ability to forecast freezing rain and the effectiveness of existing treatment strategies to mitigate against this  ACTION: to form a working group to review and better understand the impact of existing plans and opportunities to further improve these:  Conduct independent laboratory tests on existing 3rd rail anti-ice products and effectiveness in relation to ‘freezing rain’  Arrange for testing of interaction between Kilfrost anti-ice applied by MPV and Magic Ice applied by Class 375/8 units  Work with MetDesk to identify how we can improve accuracy of forecast risk and understand the likely frequency of these type of events based on historical data, modelling and intelligence based real time forecasting  Review the Winter Management Plan and include specific actions and mitigation around freezing rain risk, EWAT process and Ghost train circuits  Review MPV circuits and timings (for example: Kent has 3 night and 2 day circuits, Sussex 4 night circuits – is the latter more effective)  Identify alternative engineering solutions (primarily train based) such as “sleet brushes” and feasibility/operability on 3rd rail area  Evaluate de-icing (versus anti-icing) benefits and options and optimal solutions if this is the most effective way of managing the risk

/ 10