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The Rail Accident Investigation Branch (RAIB) found the risk of trams overturning on curves was “not properly understood” on the tramway and there were insufficient safety measures, according to its report into the Croydon tram crash last year
(Image: a tram heading for Sandilands station)
The finding come in the RAIB’s report into the overturning of a tram at Sandilands junction, Croydon, on 9 November 2016.
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.
Simon French, 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.
“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.”
French said there was recommended action in five main areas:
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.
French continued: “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.”
Sarah Jones, the MP for Croydon Central, Sarah Jones, described the report as “quite shocking” and also said there “were missed opportunities” to stop the incident.
One of the lawyers for the victims of the incident, Trever Sterling from Moore Blatch, said the report revealed a “systematic failing” within the Tram Operations firm, which meant an incident was “inevitable”.
Summaryn of the RAIB report
On the morning of 9 November 2016, tram 2551 reached the maximum permitted speed of 80 km/h as it entered the first of three closely spaced tunnels, which together extended for about 500 metres. When leaving the tunnels, the tram should have been reducing speed significantly as it was approaching the sharp curve round to Sandilands junction, where there is a 20 km/h limit. This was marked by a speed limit sign at the start of the curve. On the day of the accident, the tram was travelling at 73 kilometres per hour when it reached this sign.
The excessive speed caused the tram to overturn as it passed through the curve. Passengers were thrown around inside the tram and the tram slid along the ground on its side. Of the 69 passengers involved in this tragic accident, seven died and 61 were injured, 19 seriously.
Investigation methods included:
obtaining data from the tram’s onboard recorder and the tramway’s signalling system
conducting tests on the tram’s safety systems
using computer modelling to understand the minimum speed that would overturn a tram on the curve at Sandilands
reviewing the design of the infrastructure
reviewing the tramway’s safety and risk management systems
interviews with people and organisations involved
surveying tram drivers to understand how trams were being driven on that route
The RAIB’s investigation concluded that it is probable that the driver temporarily lost awareness on a section of route on which his workload was low. The investigation has found that a possible explanation for this loss of awareness was that the driver had a microsleep, and that this was linked to fatigue. Although it is possible that the driver was fatigued due to insufficient sleep there is no evidence that this was the result of the shift pattern that he was required to work.
It is also possible that, as he regained awareness, the driver became confused about his location and direction of travel through the tunnels. The infrastructure did not contain sufficiently distinctive features to alert tram drivers that they were approaching the tight curve.
The investigation found that:
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
Recommendations
The RAIB has made 15 recommendations intended to improve safety. 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 concluded: “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.”
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Croydon tram accident: Risk of overturning on curves “not properly understood”The Rail Accident Investigation Branch (RAIB) found the risk of trams overturning on curves was "not properly understood" by the tramway and there were insufficient safety measures, according to its report into the Croydon tram crash last year.
James Evison
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I still wonder why no one has picked up on braking points. The second tunnel gap requires 9 percent g braking equivalent with consideration to the falling gradient. The exit from the tunnel will surely be a low adhesion zone especially in November when wet.
Around 50 percent of other tram drivers don’t brake at the second tunnel gap. Why this polarised braking strategy? I would brake from 500 m using basic calculation of about 6 percent g, and 2 seconds retarding force build up. The time lost is just is about 5 seconds. The error safety margin is substantial with the extended braking point.
What sort of competence supervisory management exists within the rail industry? Most occupations require a combination of theory and practice. The rail industry is all about driveability.
I drove trains for 21 years, I only ever met one competence manager that actually understood the units of deceleration.
I still wonder why no one has picked up on braking points. The second tunnel gap requires 9 percent g braking equivalent with consideration to the falling gradient. The exit from the tunnel will surely be a low adhesion zone especially in November when wet.
Around 50 percent of other tram drivers don’t brake at the second tunnel gap. Why this polarised braking strategy? I would brake from 500 m using basic calculation of about 6 percent g, and 2 seconds retarding force build up. The time lost is just is about 5 seconds. The error safety margin is substantial with the extended braking point.
What sort of competence supervisory management exists within the rail industry? Most occupations require a combination of theory and practice. The rail industry is all about driveability.
I drove trains for 21 years, I only ever met one competence manager that actually understood the units of deceleration.
What ever happened to basic physics?