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.
A rescue worker at Sandilands on the morning of the crash. The RAIB report seeks to ensure that nothing like this ever happens again
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.
RAIB’s Simon French: ‘far-reaching recommendations’
“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
Click here to downlaod a copy of the full RAIB report in pdf format
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An earlier article in Inside Crodon mentioned that shifts for drivers are changed from late to early, rather than late to mid then early. Did the RAIB investigation discuss the shift pattern as a source of possible driver tiredness?. To me, this seems fundamental.
Shift patterns and managing tiredness of drivers are one thing. A sensible approach but certainly not the solution.
Toughened glass is also an obvious improvement, but again not the solution.
The solution is to prevent any tram from physically derailing, regardless of the condition of the driver. This to me, means 2 things:
1) An automated braking system before bends (as suggested by the report)
2) An effective “Dead mans handle” that slows to halt if the driver begins to lose consciousness. Whatever is currently in place is clearly not fit for purpose
So sad that we had to wait until the loss of lives before such things are considered. So very sad indeed. My thoughts go out to the familes of those that loss their lives and to the survivors of what must have been a life changing incident.
We owe it to them.
Did you read the report, the glass was toughened (para 312), and met the European standards (para 319-331), the problem was the standard did not foresee the need to hold passengers in the tram. While this was a known problem across the transport industry there are escape issues of stronger glass is used. To avoid ejecting passengers will need some type of laminated glass and this was fitted in the windscreens of the tram but is difficult to break (para 60). N.B. Buses and coaches use the same type of glass, whether we want the stronger glass fitted will depend on how quickly we want to get out of a burning bus / coach.
“1) An automated braking system before bends (as suggested by the report)” this is being looked at across the industry but the Urgent safety advice (Appendix F) does not demand this. S37 suggests the development of a system.
As for the Dead mans handle para 401 “In common with most trams and trains in the world, there was no device fitted that was capable of reliably detecting drivers’ loss of awareness.” para 402 to 407 are worth reading.
N.B. The investigation found that only 6 trams worldwide have overturned since 1993 (para 216), Para 219 tells us that between 2012 and 2015, 31 buses or coaches overturned resulting in injuries/fatalities in the Great Britain.
Micro or nano sleep can affect you when not tired. I wrote my wife’s car off many years ago and my only explanantion is that I fell asleep. It was early afternoon, I had just had a walk in fresh air but have no recollection of the 300m or so before braking and swerving to try and avoid the crash.