Time has come for real answers over the Croydon tram crash

Long-lasting tragedy: after an inquest and an Old Baily trial, families of the victims say that they have been denied justice

Yesterday’s acquittal of the driver of the Croydon tram which overturned on a tight bend at Sandilands in November 2016, killing seven people, is welcome, says transport expert CHRISTIAN WOLMAR

Of course, some of those bereaved by the Croydon tram crash may be disappointed by yesterday’s Old Bailey verdict, for not getting what they felt was justice. But, in fact, it would have been a far greater injustice had driver Alfred Dorris been convicted

There has, historically, been a tendency for individuals to be blamed for causing rail accidents, but for the most part such disasters have been the result of systemic and organisational failings, rather than the fault of a single individual.

Even the most cursory investigation of the Croydon crash will show that this was certainly the case at Sandilands. It was the prosecution in the Dorris trial who told the court at the Old Bailey that the operator had created “an accident waiting to happen”.

Of course, driver Dorris made a mistake, but the circumstances leading up to that fateful day reveal a catalogue of, at times, wilful mismanagement and inadequate responses to warnings which made such an accident almost inevitable. If it had not been Dorris, it would have been another driver.

Put quite simply, the tram system was unsafe and that should have long been apparent to its managers and others responsible for its safety.

First, the issue of driver tiredness caused by onerous shift systems was not properly considered by the tram operator, TOL, a subsidiary of FirstGroup. There were reports of at least half a dozen drivers falling asleep at the controls. But as the response to this by the company was to sack those involved, there may have been countless other incidents. TOL failed to address the issue, despite the clear evidence of frequent incidents of driver tiredness.

Secondly, there was the track layout and its obvious risks.

The accident occurred at a 90-degree bend which had a speed limit of just 12mph but was preceded by a long stretch with three tunnels where the limit was 50mph. Concerns about this section of track had long been expressed and yet lighting in the tunnels was in a poor condition, warning signs had been removed and other safety features not introduced.

There had been numerous previous examples of speeding on this stretch of track including one just 10 days before the disaster, which was never properly investigated.

However, because legally a tram system does not require the same safety features as a railway, there was no warning device to alert drivers to speeding, as there would have been in a similar situation on a railway line.

All this was compounded by a wholly inadequate investigation held by the Railway Accident Investigation Board which deliberately seems to have downplayed any suggestion that tiredness caused by the shift pattern could have contributed to the accident.

This inadequate investigation had wider consequences, because the coroner in the subsequent inquest refused to allow witnesses to cover any issues which she felt had already been looked at by the RAIB. This meant that the inquest failed to consider a wide range of contributory factors and its jury was limited to findings of “accidental killing” or “unlawful killing”.

The latter would have implied it was the driver’s fault and therefore, after an astonishing nine days of deliberation, the jury at the inquest returned a verdict of “accidental killing”, which inevitably left the bereaved dissatisfied.

Moreover, the investigations and reporting were coloured by the fact that the accident was caused by a derailment when, in fact, had the tram derailed, it probably would not have overturned, which is what caused the deaths and injuries.

This is an important distinction in learning the lessons from the disaster.

There were, too, attempts to cover up investigations after the accident with Transport for London, for example, failing to submit to the original RAIB inquiry a vital safety audit about fatigue management. Subsequently, the RAIB had to issue an addendum in relation to fatigue. Yet it still did not fully reopen its investigations into what was clearly a contributory cause of the accident.

This undermining of the proper process suggests a wider culture within Transport for London over its lack of proper oversight of TOL. There was also something of a revolving door for staff between TfL and TOL which subsequent investigations did not look into.

The acquittal, together with the failings of the investigations, mean that the bereaved are left with a feeling that the whole process has been unsatisfactory, leaving them with a deep sense of injustice.

Both Transport for London and TOL have pleaded guilty to similar charges, with a sentencing hearing expected next month.

But in truth, they have never really responded properly to what was a totally avoidable tragedy. A further, independent investigation should be undertaken. As the headlines of the various articles about this accident suggest, there are still numerous “unanswered questions” about this disaster. There should not be.

Read more: Flawed inquest into tram crash is ‘Hillsborough repeating itself’
Read more: Lawyer’s plea: ‘Save tram victims’ families further heartache’
Read more: TfL ‘scandal putting passengers at risk’ over driver fatigue

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11 Responses to Time has come for real answers over the Croydon tram crash

  1. Sarah Bird says:

    An erudite post. There needs to be accountability from TFL and TOL for all those affected by this terrible incident , people died , many were injured and left traumatized . Given the generous pay increases and huge bonuses very recently announced for TFL ,at what level are they justified ? The tram driver was held to account at the Old Bailey and in my view was correctly acquitted ,he is also a victim . TFL and TOL have pleaded guilty and should be held accountable .

  2. David Wickens says:

    The tight bend, close to 90 degrees, could have been made shallower at the design stage. However that would have required the acquisition of more land and compensation to the land owners. I expect that the designers operators etc considered that, due to the proximity of the tram stop, trams would have been travelling slowly and a tight bend was therefore no hindrance. In hindsight there is a very real risk (certainty?) that, for whatever reason, trams would sometimes exceed the safe speed limit.

    • Ian Kierans says:

      The cost of the compulsory purchases was never an issue. There was plenty of money to fuel purchases and along some of the routes more land and property was purchased than was required and later sold off at auction with I believe first refusal to original owners. Right from the outset it should have had a permanent speed limit. First and TfL are fully aware of the errors that were made. It should have come out in the first investigation. It did later on.
      The decent into the curve is manageable and safe at restricted speeds even allowing for the see saw effect of many people on one side.

      • David Wickens says:

        It’s a bit academic now but money was clearly an issue for the cost of the scheme as a whole, if not (as you suggest) the compulsory purchase budget. For example, that is why the New Addington link was terminated short of Central Parade.

        • Ian Kierans says:

          Money in public transport investment is always an issue.

          Planning and implementing transport developments are major projects and cost a lot of money from passengers and taxpayers – of which the non passenger taxpayer obviously pays the least especially after Boris pissed away the taxpayer subsidy for that Railway all on its lonesome in 2016. They have a multitude of complexities with issues conflicting regularly. The teams that do these projects are highly skilled and experienced and have proven delivery records. When a decision is made to go or to stop, cost is a factor but the delivery need/benefit is always a higher priority

          Therefore buying a bit of land or a few houses in perspective of a Billion Pound project delivering transport and enabling future municipal planning is frankly a simple decision.

          Does it fit the criteria and priorities? Will it add value?

          Yes/ No?
          The cost is not a major factor as something of less value/benefit will be cancelled and money re-purposed.

          You may want to consider if those houses you mentioned had been bought or the land and those harsh areas ameliorated so there was less gradient – would the soil conditions have allowed it, would subsidence have been a factor, bomb damage etc.
          There are a range of factors to consider in that area.

          I am very sure that the Engineering and business project teams considered all that and a lot more.

          Mistakes occur – but there is no evidence as yet of that.

          The line was inspected and the safety standards met for opening, ergo that was not a factor then and there is still little evidence today to support the view that land/house purchase would have been of benefit. That may change but again no evidence as yet.

          What I do know is that many have travelled that route many times since it was built and there was no speeding at the beginning that was noticable and commented on and it was a smooth ride.

          Yet in 2015 and 2016 I noticed and commented on a marked ride difference that even I, having worked on National Rail and London Underground operationally and in other roles including on the ELL and JLE projects for three decades was quite concerned about and stopped using that route past Sandilands.

          So what changed and who changed it?

          I do not believe it was the driver and never have, as it was more than one driver that regularly went at that speed.

          It was also not because of the cost of a house or a parcel of land as that would be ranging towards incompetence and again there is no evidence yet of such.

          This was due to operational decisions and operational strategies of which there is a lot of evidence.

          The answers as to where costs were cut and why along with their impacts lies in the investigations and TfL and First submissions.

          The questions now really should be (especially for the families)- did those decisions impact on safety and were processes dispensed with that made the route unsafe and by whom and why

          Crucially – was the guiding mind (s) aware or should have been aware that the safety margins could be impacted by their directives and risks were now a lot higher and were these risks noted on the Corporate risk register and notified?
          I would be interested to know if any speeding incident was ever notified to the Inspectorate? Consider that even near misses should be notified

          Did no one at Tram Link think of making a RIDDOR report? An unstable tram moving at a greater sped than the track/route can safely tolerate is a dangerous occurance and should be reported by the operator.
          I would find it hard to believe First did not receive passanger reports on occurances and would be unaware of those events.
          but maybe that will come out in the wash also.

  3. Nigel Harris says:

    The second tunnel gap braking point requires 9 percent g braking. This considers the gradient and brake force build time. Defensive driving with expected good levels of adhesion is 6 percent g braking. Why did competence management allow this braking point to become common practice?

    • Ian Kierans says:

      Operational running to time.

      • Nigel Harris says:

        6 percent g is operational running to time for rail, as stated within RSSB adhesion document. 9 percent g is aggessive, especially during leaf fall. It will be interesting to see what RAIB have to say re Salisbury.

  4. Ian Kierans says:

    Christian raise a number of observational questions. It is good that First and TfL have not sought to cover issues up and are taking a more cultural LUL approach to incidents that cost lives with an emphasis on truth and future prevention. This gives no succor to those who have lost lives and their families.

    Having worked in environments governed by Her (now His) Majesty’s Railway Inspectorate within the Office of Road and Rail. you become used to safety prevention culture and nearly always put in place processes that errs on the side of caution.
    So I was surprised at how the investigations went.

    The issues that have transpired (which Christian covers well) suggests that some reviews of process, practice and decisions are overdue at both Coroners Courts and the RAIB.

    once again though we should remember those who died and the difficulty their families face.

  5. Richard Dargan says:

    It does seem a bit much that the driver of the tram has had to go through an Old Bailey trial while more senior people personally are not called to account for what they have done. Maybe the directors of companies should be designated as ‘responsible corporate officers’ who are accountable for what the company does, and have to account for their actions to a jury. There is something similar to this in case law in America.

    • Ian Kierans says:

      Applicable laws for Directors are the Insolvency Act 1986, the Company Directors’ Disqualification Act 1986, the Health and Safety at Work etc Act 1974 and the Corporate Manslaughter and Corporate Homicide Act 2007, Companies Act 2006 all Equality and Employment law along with fiduciary laws and all criminal laws. This does not excluded civil legislation either. Usually the Company Secretary would be the responsible corporate officer or General Council but they will advise the board of Directors who will be held accountable. In many ways this is better than the American laws, but there are disbenefits also. It can be more difficult here to take on a company and obtain justice.

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