Crews aboard Eurostar trains trapped in the channel tunnel on December 18 and 19 should have received better training, according to the independent review published today (February 12).
The review was led by Christopher Garnett, former chief executive of GNER and former commercial director of Eurotunnel, along with Claude Gressier, board member of French Railways (SNCF).
"Crews found the experience very stressful," said Garnett, "and train managers did not have direct contact with Eurostar, making it difficult for staff to advise passengers."
"We recommend a lot more training for train crews, especially in evacuation measures and dealing with passengers.
"Rescue arrangements also need to be speeded up... they need more rescue trains.
"Passengers must not go through this experience again."
The results of the review by the UK and French governments show Eurostar must improve its operations in terms of train reliability, evacuation and rescue, and communication.
A total of five trains were trapped in the channel tunnel. One particular train entered the tunnel at around 22.30 on the evening of December 18, but passengers did not reach their destination until 09.15 the following morning.
"This was the worst train that you could imagine," said Garnett.
It was filled with families returning from Disneyland Paris. When the train broke down inside the tunnel it immediately lost air conditioning, ventilation and all lighting.
"While there were some lights on in the tunnel, people said they couldn't see clearly. There was a rapid rise in temperature and people were getting worried."
Panicked passengers started trying to open the doors to get some air, but the conditions inside the tunnel are extremely hot and humid - the temperature was 25â°C, leaving passengers dehydrated.
At 1.50 a rescue shuttle appeared and started offloading passengers, a process which took around two hours. The shuttle itself had "appalling" conditions, said Garnett, with insufficient toilets for the 670 people onboard, and confusing instructions on how passengers could get food and water.
It departed for Coquelles in France, where there was a further 90 minute wait before passengers eventually departed for England. They reached their destination at 09.15, more than 12 hours since they had originally left.
Despite finding the evacuation had been carried out safely, the report said evacuation and rescue procedures need a major overhaul, with Eurostar criticised for not training its crews in how to deal with passengers during an evacuation.
But "this was taking place against a very difficult weather backdrop," said Garnett.
"I don't think anybody could have imagined we were going to get this number of issues all happening in the same night."
The trains themselves need a number of engineering improvements before next winter, to avoid a repeat of this year's disruptions. They had not undergone sufficient winter weather preparations to withstand these conditions and maintenance procedures need to be revised, said the report.