Flawed inquest into tram crash is ‘Hillsborough repeating itself’

A former Transport for London board member has written to the Attorney General to call for a second inquest into the causes of the 2016 tram crash at Sandilands. This follows the conclusion of the long-delayed inquest at Croydon Town Hall in  July, in which the jury delivered a verdict of “accidental deaths” for the seven people killed in what was the worst tram disaster in Britain in a century.

Michael Liebreich: supporting tram crash victims’ families in calls for new inquest

“This is Hillsborough repeating itself,” Michael Liebreich has told Rail magazine.

“It took 25 years for those families to get the original inquest verdict quashed. This must not happen again.”

In common with the experience of Liverpool families who campaigned for years for a fresh inquiry into the deaths of 97 football fans at an FA Cup semi-final in Sheffield in 1989, the families of the victims of the Sandilands tram crash say that the conduct of their inquest to be completely unsatisfactory.

They believe that the Coroner, Sarah Ormond-Walshe, was wrong when she stopped their legal team from cross-examining any officials from TfL or their contractors, First Group, and their operating company, Tram Operations Ltd.

The families now have an influential supporter in Liebreich, who chaired TfL’s safety audit panel between 2016 and 2018 when he was a board member.

As Inside Croydon has reported previously, Liebreich has accused TfL of a continuing cover-up over tram driver fatigue, with two adverse reports on the topic having been withheld from the Rail Accident Investigation Branch while it was working on its report into the Sandilands crash.

Now specialist magazine Rail, in its latest edition, has published a column by respected transport journalist Christian Wolmar which raises several further questions over the evidence-lite Coroner’s inquest and the TfL cover-up.

According to Wolmar’s report, Liebreich has written to the RAIB asking it to re-open its report to better include the findings from the two fatigue reviews.

Liebreich has also raised numerous additional flaws and omissions in the RAIB report.

There is mounting concern that the Coroner did not consider swathes of important evidence about the 2016 Sandilands tram crash, according to Wolmar’s latest column in Rail magazine

RAIB did not consider the fact that six drivers had been sacked for falling asleep prior to the Sandilands disaster. “Given that the response by management to an admission of falling asleep was to sack the person concerned, Liebreich reckons that many such incidents went unreported,” Wolmar reports, not unreasonably.

The RAIB report also failed to include the fact that the Croydon tram driver, Alfred Dorris, had been taking medication for high blood pressure, a diuretic, which may have resulted in disturbing his sleep.

Leibreich’s letter to the Attorney General in support of the victims’ families demand for a fresh inquest, said: “RAIB did not so much as look at the Operating Agreement between First Group and TfL – yet this was the contract which governed their relationship, divided up safety responsibilities and lay at the core of the safety culture at the time of the crash.”

Christian Wolmar: ‘The Sandilands accident needs a thorough investigation’

Liebreich and others have raised concerns that operators have effectively prioritised running to their timetable over passenger and staff safety. “It seems that they were running a tram system like a bus operation, and London’s record on bus safety is appalling,” Leibreich said.

Leibreich also questioned the all-too-cosy relationships between senior figures at TfL and the operators – “there was a revolving door between the two”, he said – naming Leon Daniels, TfL’s managing director of surface transport at the time of the accident, who was a former director of TOL. John Rymer, the managing director of TOL, was a former colleague of Daniels.

“None of this was considered by RAIB,” Leibreich said.

Wolmar writes, “The Sandilands accident needs a thorough investigation which sadly so far neither the RAIB nor the inquest process has delivered.”

Read more: Lawyer’s plea: ‘Save tram victims’ families further heartache’

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3 Responses to Flawed inquest into tram crash is ‘Hillsborough repeating itself’

  1. moyagordon says:

    So sad for the families to be in this situation, having to fight for a thorough investigation into the deaths of their loved ones. Who wouldn’t want to look into an accident of this nature as thoroughly as possible, to avoid it happening again. A second inquest must go ahead.

  2. d9015 says:

    Coming late to this, I’d note some detail that immediately sprung to mind when the crash happened in 2016, and relevance to :
    – the 2008 fatal crash, between a tram & a bus in Croydon, not considered as a tram crash by RAIB, but with published notes, by far the best detail compared to any unpublished reports (as mandated by Section 39 RTA1988) from Croydon Council, or the inquest report, on the bus passenger ejected through the upper deck window. The RAIB notes highlighted the risk of using toughened glass side windows on buses and trams – a key factor in many of the Sandilands deaths in 2016
    – the 1969 Morpeth rail crash – where a driver ‘lost’ locational awareness & entered a 40mph curve at 80mph. Note here that the locomotive remained on the track & the train could have in theory taken the curve at 90mph on track in perfect condition, with the load of newspapers properly secured in the leading carriage, allbeit with ‘severe discomfort’ for those on the train. Minor track ‘weaknesses’ and the movement of over a ton of newspapers triggered the crash
    – one of the reasons that the locomotive remained on the rails at Morpeth was that railway tracks are more accurately set up & maintained than tram tracks. Transition curves and canted (banked) track ‘eases’ the forces as the train enters a curve rather than the violent lurches and much tighter curves found on a tram system

    – the change from ROTS to ROGS in 2006 in which the ORR’s & RAIB’s roles in regulation and crash investigation were curtailed and ‘weakened’. Guided busways were no longer monitored and crashes reported as if they were a tramway, and tram systems delegated the work of writing and monitoring their operational safety systems with ORR checking them
    – in the period leading up to the Sandilands crash I’d noted 8 matching busway derailments with an identical causal factor, the locational awareness of the driver. On the clear busway drivers could travel at up to 56 mph (90 Km/h) with hands off the steering. At ‘flares’ where routes diverged or joined a normal road drivers had to slow to 30mph and steer the bus through, and this was not happening, at one location twice in 6 months. A system using trackside beacon and engine/brake controls on the bus triggered if the speed was not reduced on approach to the restriction – a feature available for modern bus & truck engines through their electronic control systems
    – there was also work done in 2008 to review and understand the derailment dynamics for trams, with their different tyre profiles from heavy rail vehicles. Dynamic modelling for the RAIB investigation has dismissed the flange-climb possibilities, although my gut feeling from 50 years of working in engineering & transport is that there is something in there that might be hidden & relevant as a trigger to the sequence. Just don’t have enough detail to figure out what it might be

  3. Nigel Harris says:

    RAIB Report states, 49 percent of drivers surveyed brake at the second tunnel gap. This requires 9 percent g brake selection when taking the gradient into consideration. This is rather aggressive for the time of year, regarding leaves. So where do the other 51 percent brake? Why this polarised braking mentality?

    The safe braking point would be about 4 percent g, from the start of the tunnels. All for the sake of around 7 seconds longer . One second for each victim.

    Competence management spend too much time being vindictive, and not enough time being logical. RSSB state 6 percent g as good defensive braking, in normal conditions of rail adhesion. The second tunnel gap is not a safe braking point.

    The second tunnel gap braking point requires 9 percent g braking. This considers 2 seconds freewheel and the falling gradient. November leaf fall, how can competence management allow this as a safe braking point.

    Where do the other 51 percent of drivers brake? Why this polarised braking mentality?

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