An investigation into the four-hour stranding of train passengers in snow says the companies involved caused a “loss of dignity” to passengers and “did not do enough.”

The incident saw passengers across nine trains left in “unacceptable conditions” – some without light or heating – during the extreme cold and snow into the evening of March 2.

Some passengers were forced to urinate on themselves, according to the Network Rail South East Route and Southeastern report, with many taking matters into their own hands and walking along the tracks.

The incident left some passengers with minor injuries.

“The rail industry 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,” according to the report.

But the self-evacuation was “understandable” due to  “significant levels of discomfort” and “loss of dignity.”

“Although passenger self-evacuation was understandable in the circumstances, self-evacuation of trains is not normally recommended by the rail industry, especially on third rail lines where there is a risk of electrocution,” the report continued.

A lack of information between the companies and “the need to shift mind-set away from railway operating considerations to meeting the needs of stranded passengers” were the two largest factors, according to the report.

Network Rail South East Route and Southeastern staff also did not follow their own procedures around stranded passengers.

“This was not a conscious decision by the teams from either organisation but unfortunately the result of a lack of situational awareness at the KICC [the joint control centre for the two companies],” according to the report.

Recommendations for the companies included additional infrastructure to stop the build-up of ice on the conductor rail.

The report also included a recommendation staff test arrangements for extreme weather and passenger stranding through emergency simulation exercises.