An independent report into an incident which saw commuters stranded in trains during the winter snow - and saw many force open doors and walk along the tracks - has been fiercely critical of train and rail operators.

It said the rail industry "did not do enough to manage the incident in a manner that put the needs of stranded passengers first" or ensure "the well-being of passengers" which led to "many passengers experiencing unacceptable conditions".

It follows an incident on March 2 this year when nine services - some heading into north Kent - found themselves stranded just outside Lewisham station in south London due to snow and freezing rain which made rails and platforms treacherous.

Train operator Southeastern and rail infrastructure firm Network Rail, which commissioned the report, described the conditions as "unacceptable and regrettable".

The report, by consultants Arthur D Little and Southwood Rail Consulting, explains: "Passengers on the nine stranded trains experienced significant levels of discomfort - initially many were standing due to crowding and then as the incident progressed, lower levels of interior train lighting and loss of heating were experienced.

"Many passengers understandably complained about the lack of toilet provision - forcing a number of passengers to relieve themselves in their clothes causing loss of dignity.

"These factors, combined with the proximity of several of the stranded trains to stations and ineffective communication with passengers, led them to self-evacuate to the track."

In some cases the over-crowded trains were just 50 metres from the Lewisham platform.

It added: "The first few passengers that self-evacuated acted as an encouragement to others to follow."

All power to the tracks had to shut down amid fears of electrocution on the live rail by those fleeing the services.

In its findings, the report said: "The rail industy did not do enough to manage the incident in a manner that put the needs of stranded passengers first, ensuring the well-being of passengers, and this led to many passengers experiencing

unacceptable conditions.

"The Network Rail signalling team in the London Bridge Area Signalling Centre did not recognise the significance of the emerging incident and react quickly enough to prevent escalation

"The rail industy did not do enough to manage the incident in a manner that put the needs of stranded passengers first."

"The rail industry command and control arrangements as implemented were inadequate for the type and scale of the incident encountered.

"The communications during the incident, covering many dimensions and parties, were inadequate to support the effective management of the incident.

"The existing rail industry procedures relating to management of stranded passengers were not fully followed although they are not developed for an incident of this nature."

Ambulance crews reported treating four passengers for minor injuries at the scene of the chaos.

The independent report is separate from others being undertaken by the Rail Accident Investigation Branch and the Office of Rail Regulation, and is designed to establish the facts, determine the causes and make recommendations without apportioning blame.

Among its recommendations are:

• Strengthening the train-service decision making including use of the existing conductor rail weather forecast, pre-service and in-service triggers during periods of known severe weather.
• Additional infrastructure and rolling stock measures to help prevent the build-up of ice on the conductor rail.
• Additional and reinforced measures to support decision-making and communication with passengers during stranding incidents to prevent passenger self-evacuation
• Strengthening how rail industry staff in control, signalling and driving functions can by their actions prevent potential stranding incidents, and respond rapidly to them to prevent further escalation.
• Review and update processes and procedures for managing incidents involving stranded passengers, particularly focusing on passenger welfare, incidents involving multiple trains and ensuring that all procedures are compatible within the route and with national guidance.
• Strengthening command and control arrangements for management of incidents and testing of these arrangements through both table-top and real-life exercises involving stranded passengers/trains.

The rail firms have pledged to implement all the recommendations and say new training for 3,500 staff will now take place.

Network Rail is also investigating expanding the installation of conductor rail heating to include key locations, like Lewisham, which although not prone to freezing could potentially benefit from heating in extreme weather events. A trial of a more effective anti-icer on our fleet of snow and ice treatment trains will also be carried out. In addition, Southeastern is exploring the use of ice-breaker shoes on some passenger trains.

Both firms say they are working with specialist consultants on planning and preparation for severe weather.

Southeastern is also examining engineering changes to extend train battery life, meaning train communications systems and lighting could stay on longer if the third rail power system is unavailable as well as improving communications.

In a joint statement, David Statham, managing director of Southeastern, and John Halsall, Network Rail’s south east route managing director, said: “Winter weather conditions in 2018 were the most challenging we’ve seen in the south east for more than a decade. Unfortunately this led to a very serious incident in Lewisham, and we’re determined to learn from what happened.

“We sincerely apologise to passengers for what was an unpleasant and distressing experience. Our staff worked exceptionally hard in extremely difficult circumstances, but the number of trains involved in this incident made it difficult to co-ordinate a response.

"We sincerely apologise to passengers for what was an unpleasant and distressing experience."

“Both Southeastern and Network Rail are taking steps to minimise the possibility of this happening again. We are improving our management of extreme weather, examining ways to keep the power on when conductor rails fail and updating our procedures for communicating with passengers in an emergency.

“We would like to emphasise that the safest option for passengers is to remain on board and await help, even in the exceptionally unusual scenario of a train getting stuck between stations.”