An investigation into the Croydon Tram crash last year, which killed seven people and injured 61, has found there were 'insufficient safety measures' on the tramway and a lack of understanding of potential dangers.
The Rail Accident Investigation Branch (RAIB) has made 15 recommendations, which it hopes will have 'a lasting impact on the way that the tramway industry manages its risk', including a review of how tramways are regulated and the creation of a dedicated safety body.
The RAIB's accident report found:
- there was no mechanism to monitor driver alertness or to automatically apply the brakes when the tram was travelling too fast
- there was inadequate signage to remind drivers when to start braking or to warn that they were approaching the sharp curve
- the windows broke when people fell against them, so many passengers were thrown from the tram causing fatal or serious injuries.
The issue of driver fatigue was raised after the incident as it emerged tram drivers had raised concerns about the dangers of their shift patterns.
The report concluded that the shift pattern followed by the driver should not have caused an increased risk of fatigue on the morning of the accident, 'above the general fatigue risk factor of very early starts, but that it is possible his sleep pattern could have led to a sleep debt, a situation which can result in microsleeps'.
It stated it was 'possible that a microsleep was a factor in the driver’s loss of awareness on the morning of the accident'.
It also found that Tram Operations Ltd (TOL), which is the operator of the trams and is owned by First Group, did not always manage the risk of tram driver fatigue 'in line with published industry practice'.
On the morning of 9 November 2016, tram 2551 overturned as it reached a curve due to 'excessive speed', the RAIB found.
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.
The tram reached the maximum permitted speed of 80 km/h as it entered the first of three closely spaced tunnels. On leaving these it 'should have been reducing speed significantly' to make the 20kmh limit for the sharp curve round to Sandilands junction.
On the day of the accident, the tram was travelling at 73kmh as it entered the curve.
RAIB recommendation areas 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
Simon French, chief inspector of rail accidents said: '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 needs 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.'
Transport for London chief, Mike Brown, said TfL will also be publishing its own investigation report in the new year.
'Since the incident we have introduced a wide range of additional safety measures to make sure such a tragedy can never happen again.'
- new signage and warning systems for drivers
- additional speed restrictions
- enhanced speed monitoring
- an upgrade of the CCTV recording system
- an in-cab driver protection device fitted to every tram, meaning that any sign of driver distraction or fatigue results in the driver being alerted immediately.
He added: 'Work to install a system to automatically reduce tram speeds if required is also underway.
'We have enhanced the customer complaints process so that all reports are now managed by one dedicated TfL team and any that relate to safety are prioritised for immediate investigation. And the TfL Sarah Hope line remains available to all those affected and continues to provide help with counselling and other support to anyone who needs it.
'We also continue to work with the wider tram industry to ensure that lessons are learned from this incident and that we introduce any further measures that could improve the safety of trams across the UK.'
FirstGroup told media it was 'profoundly sorry that such an incident could take place aboard a service we operate'.
Tim O’Toole, the chief executive, said: 'The RAIB concluded that management of fatigue was not a factor in the incident, nor did a speeding culture contribute to it.'
He added the company had implemented measures, including enhanced speed monitoring and renewed guidance on fatigue management.