The company which manages Croydon’s tram network did not properly understand the operation of their own tramway, according to the official report into the Sandilands derailment in which seven people died last year.
The report by inspectors from the Rail Accident Investigation Branch – RAIB – found that there had been an incident just days before the crash, when a speeding tram came close to coming off the tracks on a bend on the same stretch, but that no action was taken by the management.
The complete breakdown of tram operator FirstGroup’s system of reporting faults and complaints comes in for particular criticism. One transport expert says that the report is “totally damning” of FirstGroup.
The complaints procedure has been deemed so broken that Transport for London has taken it away from FirstGroup and brought it back in-house. A whistle-blower had warned of the perils of driver fatigue on the Croydon tram network in 2014, but no action was taken.
Tom Edwards, BBC London’s transport correspondent, has written today, “This will raise again huge questions about the fragmentation of the transport industry and I’m sure questions about the role of privatisation and companies operating concessions on behalf of public bodies.”
The report has been published some 13 months after the tram tragedy which claimed the lives of seven people and injured 61 other passengers.
The report contains 15 recommendations to ensure safety on the tracks in future, including establishing a national tramways supervisory authority, automatic braking systems to prevent trams from travelling too fast, and driver alertness monitoring.
As Inside Croydon reported on Monday, a key recommendation of the RAIB is that the glass used in tram windows and doors needs to be far stronger. The inspectors found that all of the fatalities at Sandilands on November 9, 2016, were caused by passengers falling out through the breaking glass windows and going underneath the carriage.
The inspectors found action was not taken following a similar speeding incident 10 days before the derailment. On October 31, a passenger raised concerns about a speeding tram which went round a bend near Sandilands. The driver of that tram applied the hazard brake, but the driver did not report it. The RAIB said that tram “came close to coming off the tracks”.
The inspectors also suggest that the driver of fateful tram 2551 may have fallen asleep while at the controls. They found that the 43-year-old driver suffered an episode of disorientation as his tram approached the bend where the tram derailed. They believe he drifted into “microsleep” lasting up to 49 seconds during a stretch of track which contains three tunnels.
Richard Harrington, the lead inspector, said: “The horrific scenes that were inside that tram meant that many people’s memories of exactly what happened were not clear. In terms of how much of the driver’s recollection there is, it is not a lot, but that is not unusual for people that have been involved in serious accidents.”
The report said management were also not aware of previous incidents involving late braking on the approach to Sandilands, some of which was due to a “reluctance of some drivers to report their own mistakes”.
In a statement accompanying the report, the RAIB said that its inspectors “found that the risk of trams overturning on curves was not properly understood by the tramway and so there were insufficient safety measures.
“All of the passengers who were killed, and many of those who were seriously injured, fell through the windows or doors as the tram tipped over.”
Survivors told the inspectors that it was “like being inside a washing machine” when the tram derailed.
Simon French, the chief inspector of rail accidents said: “The RAIB’s report into the accident at Sandilands will stand as the record of the events that led to the tram overturning and the terrible human consequences.
“Our careful analysis of the evidence, and identification of the causal and underlying factors, has enabled us to make a number of far-reaching recommendations. These will have a lasting impact on the way that the tramway industry manages its risk.
“We are recommending action in five main areas. The first is the use of modern technology to intervene when trams approach hazardous features too fast, or when drivers lose awareness of the driving task.
“Tramways need to promote better awareness and management of the risk associated with tramway operations. Work needs to be done to reduce the extent of injuries caused to passengers in serious tram accidents, and to make it easier for them to escape. There need to be improvements to safety management systems, particularly encouraging a culture in which everyone feels able to report their own mistakes. Finally, greater collaboration is needed across the tramway industry on matters relating to safety.
“UK tramways have been aware of our key findings and the focus of our recommendations for many months now. I am very encouraged by the progress that has already been made in addressing the recommendations and the collaborative approach that is being taken.
“It is vital that the right action is taken to stop such a tragic accident from ever happening again.
The RAIB has made 15 recommendations intended to improve safety. They include:
- technology, such as automatic braking and systems to monitor driver alertness
- better understanding the risks associated with tramway operations, particularly when the tramway is not on a road, and the production of guidance on how these risks should be managed
- improving the strength of doors and windows
- improvements to safety management systems, particularly encouraging a culture in which everyone feels able to report their own mistakes
- improvements to the tram operator’s safety management arrangements so as to encourage staff to report their own mistakes and other safety issues
- reviewing how tramways are regulated
- a dedicated safety body for UK tramways
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