Tram overturns in Croydon - 7 killed, 51 injured - 9 Nov 2016

[whole diary]

[grahame]

The tragedy of this event seems to be the age profile of those killed, so young 

Indeed ...

[GBM]

And I suspect, a breath test.

Yes, standard procedure (on the heavy rail network at least) is for a drugs and alcohol screen to be conducted on any individuals involved in an incident of any serious nature.  This would be a urine test rather than breath test though, but if the police are involved and arrest anyone they would no doubt undertake a breath test themselves.

I remember many years ago as a driver I reported a 'near miss' to the signaller involving some trackside workers, a couple of whom were not in a position of safety when I approached.  I later found out that they were all immediately relieved of their duties and the whole team were tested for drugs and alcohol - this sort of zero tolerance approach is part of the reason the railways are so safe.

First bus perform a drugs and alcohol test prior to being accepted.  The company Doctor also performs various medical tests, including urine tests.
Thereafter, random testing for ALL employees (including travel office staff, admin staff, etc, etc).  A company medical every 5 (?) years; annually when over 65.
Also after any serious incident.

[TaplowGreen]

The tragedy of this event seems to be the age profile of those killed, so young 

Indeed ...

.............and that (as is becoming increasingly clear) it was an accident waiting to happen through excessive speeding which appears to have been widely known and acknowledged, and yet nothing was done to prevent it.

[ChrisB]

Pretty well spread - those above aged 19-57

[IndustryInsider]

.............and that (as is becoming increasingly clear) it was an accident waiting to happen through excessive speeding which appears to have been widely known and acknowledged, and yet nothing was done to prevent it.

The good thing is that the RAIB^▸ (Rail Accident Investigation Branch) report will leave no stone unturned in investigating the incident and won't gloss over any factors that may have contributed towards it.  I'll be interested to read it.

[stuving]

.............and that (as is becoming increasingly clear) it was an accident waiting to happen through excessive speeding which appears to have been widely known and acknowledged, and yet nothing was done to prevent it.

That's where I expect the RAIB^▸ (Rail Accident Investigation Branch) will concentrate their comments. There must have been some kind of risk assessment on the network, and this point - fast off-road section followed by slow corner, still off-road - should have rung bells. On the road the driver has to drive by eye, and automatic safety systems don't seem to be at all common for trams anywhere (except tram-trains sharing track with trains). So driver behaviour is critical, as as such needs to be monitored.

Without asking for new or specialised equipment, the operators might do several things:

• Seeking, and listening to, passenger feedback.
• Installing speed monitors at critical sites.
• Sample checks on recordings from ODTR or control room.
• Incognito observers.

I suspect a speed limit like this has a big safety margin, partly because there is no overspeed detection system. That might be consciously by design, or just that is seems a good idea. But drivers may exploit that margin, reasoning that they can go faster because of it.

If you look at it as part of the safety design, it has a specific purpose: it means you can monitor speeds only occasionally and if they are too high remind drivers (as forcefully as you need to) to stick to the limit. In other words, small overspeeding incidents will happen, and are part of the feedback path that prevents dangerous overspeeding. But that path is purely procedural, and someone has to remember to do it, and to keep doing it.

[Chris from Nailsea]

A further update, from the BBC^» (British Broadcasting Corporation - home page):

Croydon falls silent to remember tram crash victims

The people of Croydon fell silent in remembrance of the seven victims of Wednesday's tram crash.

It comes a day after those killed in the accident where named by the British Transport Police (BTP^▸ (British Transport Police)).

They were Donald Collett, 62, from Croydon, Philip Logan, 52, and Robert Huxley, 63, both from New Addington.

Those already named were Mark Smith, Dane Chinnery, Phil Seary and Dorota Rynkiewicz.

Bishop Jonathan Clarke of Croydon Minster read out the names during the cathedral's annual service of remembrance for the fallen in two world wars and in other conflicts.

The tram driver, Alfred Dorris, 42, from Beckenham, south-east London, is currently on bail.  He was arrested after the derailment on suspicion of manslaughter.  Investigations into the crash are continuing.

A spokesman for FirstGroup, which operates the south London tram network for TfL^» (Transport for London - about) said: "We can confirm that Alfred Dorris has worked for us since March 2008. Given the ongoing investigation we don't have anything further to add at this point."


Tributes have been paid to Philip Logan (left), Donald Collett (centre) and Robert Huxley, (right)

[stuving]

There is an ORR^» (Office of Rail and Road formerly Office of Rail Regulation - about) document called GUIDANCE ON TRAMWAYS Railway Safety Publication 2 online. It's from 2006, but still current.

What does it have to say about the dangers of sharp bends, the transition from off- to on-road, and overspeeding? Nothing. Not a word. There is only this very general point:

4 Application of this guidance should provide a sufficient level of safety for approval to be
given by the Inspectorate, provided that it has been demonstrated that the use of the
guidance is wholly applicable to the works, plant or equipment.
5 If this is not the case, then the Inspectorate will wish to be satisfied that due
consideration has been given to ensuring that all intolerable risks have been eliminated
and that all remaining risks have been reduced to be as low as reasonably practicable
(known as ALARP).

It also has this:

Effects on existing works
6 This document does not apply retrospectively to existing works, plant and equipment.
However, new or altered works, plant and equipment might introduce incompatibilities or
inconsistencies with the existing works, plant or equipment. In this case, approval may
only be given if appropriate arrangements have been made to address these safety
implications, which may include modifications to the existing works, plant or equipment.

Behind this is the Railways and Other Transport Systems (Approval of Works, Plant and Equipment)
Regulations 1994 (SI 1994/157) as amended*. And there are several ORR guidance notes to that. And then there is a European level of railway standards, including Common Safety Methods (or which risk assessment is one), which may or may not apply to tramways. I couldn't really say from a quick look if anything does apply to this case.

Note that most of this applies to changes, not existing systems, so Tramlink (opened in 2000) may not have been covered by anything of the kind. While there must have been some safety regulations at the time, it may have been different (and not just by being much, much, shorter).

* No not that one, it's The Railways and Other Guided Transport Systems (Safety) Regulations 2006 (as amended).

[ChrisB]

Metrolink in Manchester is newer, I think - what safety systems are built in to that?

[John R]

Metrolink started in 1992, although for many years the vast majority of its route (Bury - Altrincham) was former BR^▸ (British Rail(ways)) lines with just a small section of on street running.

[grahame]

Metrolink started in 1992, although for many years the vast majority of its route (Bury - Altrincham) was former BR^▸ (British Rail(ways)) lines with just a small section of on street running.

Even the original section, though, ran on a railway alignment with ended in a rather sharp corner (at Victoria Station).  And on the Eccles branch ... much more recent ... Cornbrook to Pomona id virtually dead straight then the line does a sudden right turn at the station.  But I think the Manchester Metro has two modes of tram running - street and off street and I'm not sure how they switch between them; perhaps there are significant differences to the Croydon system, but whether that's the case or not I would suspect there are people in Manchester, Birmingham, Sheffield, Nottingham and Blackpool all taking a very careful look at their own operations to make sure their safety cases are watertight

[grahame]

The Time today carries an article which is critical of the shift system on the Croydon Tramlink - but that article is their copyright / behind a paywall and I'm probably not supposed to share it in public.  Headline is "Tramdrivers left 'in a daze' by erratic shifts". See http://www.firstgreatwestern.info/coffeeshop/index.php?topic=17659.0 for more details if you're a frequent posting member.  I will attempt to resolve what I can and cannot post here in public from The Times and bring further data if I can, or others are welcome to post the same stuff if it's elsewhere in a public place.

[stuving]

Form the Croydon Advertiser:

Former Croydon tram driver claims 'crazy' working conditions mean staff are 'never fully awake'

By CBallinger  |  Posted: November 11, 2016

A former tram driver has criticised the working conditions staff are subjected to and believes "crazy" shift patterns could have contributed to the fatal Croydon crash which has claimed seven lives.

The driver of the tram which overturned on Wednesday morning is alleged to have told a passenger immediately after the derailment that he thought he had blacked out at the controls.

The 42-year-old from Beckenham was arrested on suspicion of manslaughter and released on bail until May. It is understood that establishing if the driver blacked out, or fell asleep, will be a crucial part of the police investigation.

The former driver with six years' experience has told the Croydon Advertiser he understands drivers have fallen asleep while in control of trams in the past and that he "always felt in a bit of a daze" himself.

The man, who asked not to be named, said colleagues would complain to each other about being unable to get into a regular sleeping pattern because of the different shifts they would constantly be working.

He added that the tight left-hand turn where the tram derailed on Wednesday just before Sandilands station is considered a "nasty bend" by drivers.

Speaking to the Advertiser he said: "If you ask me people need to understand the context of what pressures are put on tram drivers before they give this driver a raw deal. [If he did fall asleep] I don't think he is entirely to blame, the working conditions are responsible.

"If he did [fall asleep] he wouldn't be the first and he won't be the last.

"Nobody is ever fully awake, I was always feeling in a bit of a daze, and that is because the way the shifts work doesn't allow the drivers to get a regular sleep pattern.

"When I was a driver we worked seven days on the trot and then got four days off. We'd then work seven days again before getting two days off and then work two days for one day off. It was crazy.

"During all this you could have a week of early starts, at say 3.45am, and then a week of late shifts finishing at 2am. When I was a driver the longest shift was nine hours and the shortest six hours.

"You could never get into a routine of proper sleep.

"At the Therapia Lane tram depot there were three vending machines and the only drink available in one of them was Red Bull - that tells you everything you need to know.

"We would all moan to each other about the shift system and the lack of sleep we were getting."
Former Croydon tram driver claims 'crazy' working conditions mean staff are 'never fully awake'
...

Note the date. The quotes appeared verbatim in yesterday's Sunday Times, before being recycled in today's Times, pretty much verbatim too. So as to being their copyright ...

[TaplowGreen]

BBC^» (British Broadcasting Corporation - home page) 1 London News very interesting tonight, net seems to be closing in on First Group over this incident - God help them if it emerges they knew about the speeding and did nothing (which very much seems to be the case judging by these reports and others)

http://www.bbc.co.uk/news/uk-england-london-37979121

[ChrisB]

From the RAIB^▸ (Rail Accident Investigation Branch)

Summary
1 At about 06:07 hrs on Wednesday 9 November 2016, a tram running between New Addington and Wimbledon derailed and overturned on a curve as it approached Sandilands Junction, in Croydon (figure 1). The tram travelled for a short distance on its side before stopping in the vicinity of the junction.

2 Seven people suffered fatal injuries in the accident. A further 51 people were taken to hospital, with eight of them suffering injuries described by the London Ambulance Service as “serious or life-threatening”.

3 The Rail Accident Investigation Branch’s (RAIB) initial review of the on-tram data recorder (OTDR^▸ (On Train Data Recorder)) shows that the tram was travelling at a speed of approximately 70 km/h (43.5 mph) as it entered the curve, which had a maximum permitted speed of 20 km/h (12.5 mph).

The RAIB’s role and the context of this interim report

4 The RAIB is responsible for conducting independent investigations into railway
and tramway accidents in the UK^▸ (United Kingdom). The purpose of its investigations is to improve
safety by establishing the causes of accidents and making recommendations
to reduce the likelihood of similar occurrences in the future or to mitigate their
consequences.

5 The RAIB is not a prosecuting body; its investigations are focused solely on safety
improvement and do not apportion blame or liability. The police and the Office of
Rail and Road deal with contraventions of the law. None of their statutory duties
are changed by the RAIB investigation.

6 The RAIB’s investigation is running independently of those of the British Transport
Police, the Office of Rail and Road, and the industry. However, all investigating
agencies, and the industry, are co-operating fully with each other.

7 This interim report provides some key information including the RAIB’s findings
from its initial investigation. It builds upon the information already provided
on the RAIB’s website1. A final report will be published on completion of the
investigation. All RAIB investigation reports are available on the RAIB website.

8 At any stage in its investigations the RAIB may also issue urgent safety advice
(see paragraph 32) and make recommendations to such persons as appropriate
in the circumstances

information
People

9 The driver was the only member of staff on the tram. The exact number of passengers is still being established, but is believed to be around 60.

Parties involved

10 The tramway infrastructure is owned and managed by Transport for London through its London Trams subsidiary.

11 Tram Operations Ltd, a subsidiary of First Group, operates the trams.
Key features of the route and accident location

12 The accident occurred at Sandilands Junction on the London Tramlink network in Croydon; the point at which the two easterly legs of the network from Beckenham Junction/Elmers End and New Addington converge (see figure 2).

13 The tram involved in the accident was running between Lloyd Park and Sandilands tram stops on the route from New Addington. After the Lloyd Park tram stop, the route runs in the open for about 900 metres, and then passes through Sandilands tunnels (comprised of three closely spaced tunnels with a total length of 512 metres), before emerging into a cutting approximately 100 metres before the left-hand curve on which the accident occurred. The curve has a radius of approximately 30 metres.

14 The tramway runs in its own dedicated corridor in this location (it does not change to street running until after Sandilands tram stop). The alignment through the tunnels on the approach to the curve is straight, and the track is on a gently falling gradient from the tunnel portal to the curve, before rising again through the junction.

15 The maximum permitted speed for trams approaching the area from Lloyd Park is 80 km/h (50 mph) until the curve near to Sandilands Junction, at which point it drops to 20 km/h (12.5 mph). A reflective board denotes the commencement of the 20 km/h speed restriction; it is located approximately 30 metres before the point where the derailment occurred.

16 Trams, including those in Croydon, generally operate on ‘line-of-sight’ principles, with drivers being required to check that the route ahead is clear. Indicators are provided at locations where conflict can occur, such as junctions and road crossings. There is no requirement for advance warning of speed restrictions (neither is there a requirement for speed control systems to be fitted to trams).
External circumstances

17 At the time of the accident it was dark and raining heavily.

The tram

18 The vehicle involved was tram 2551, one of 24 units (comprising three bogies and two cars joined by an articulation unit) that made up the initial Croydon fleet. It was built by Bombardier Transportation in Austria in 1998.

19 The tram was equipped with forward facing and internal closed circuit television (CCTV^▸ (Closed Circuit Tele Vision)) cameras and an OTDR. The OTDR records key parameters such as the vehicle speed and the driver’s operation of power and brake controls.

20 The OTDR was functioning at the time of the accident, and the evidence obtained is being used in the RAIB’s investigation. However, an initial examination of the tram’s CCTV equipment suggests that it was not working at the time of the accident.

The accident

21 Tram 2551 departed from New Addington at 05:55 hrs, calling at six stops including Lloyd Park. After leaving Lloyd Park it travelled at up to 80 km/h (50 mph)(in accordance with prevailing speed restrictions), as it ran towards its next stop at Sandilands.

22 The tram entered the curve on the approach to Sandilands Junction at a speed of approximately 70 km/h (43.5 mph). As it encountered the curve, it derailed and turned over onto its right side, travelling for approximately 25 metres before it stopped.

Consequences

23 Seven people lost their lives in the accident and 51 were taken to hospital, eight of them suffering from serious injuries.

24 The right side of the tram, which made contact with the ground, was severely damaged.

25 There was some damage to the track and lineside equipment in the vicinity of the accident.

The investigation

26 The RAIB was notified via its telephone incident line at 06:42 hrs, and deployed five inspectors and two support staff to the site of the accident. The first three inspectors arrived on site at 10:02 hrs. The RAIB completed work on site at 09:20 hrs on 12 November 2016.

27 The RAIB has:
l secured relevant physical evidence including the tram;
l moved the tram to a secure location;
l obtained details from the tram’s OTDR;
l carried out a detailed survey of the track and other infrastructure in the area of the accident;
l started gathering evidence from the tram operator;
l started gathering evidence from witnesses; and
l launched an appeal for other witnesses to come forward (www.gov.uk/government/news/raib-witness-appeal).

Initial findings
Track

28 The RAIB has undertaken a survey of the track in the vicinity of the derailment and will be reviewing the findings from the survey in due course. At this stage, no evidence has been found of any track defects, or obstructions on the track, that could have contributed to the derailment.
The tram and its operation

29 Detailed examination of the tram has not yet been possible. However, the RAIB’s initial investigation has not indicated any malfunction of the tram’s braking system.

30 A tram approaching the Sandilands Junction area from Lloyd Park at 80 km/h (50 mph) would need to brake at its full service rate of 1.3 m/s2 approximately 180 metres before the speed restriction board in order to be travelling at 20 km/h (12.5 mph) when the board was reached.

31 Initial analysis of the tram’s OTDR indicates that some braking was applied in the 180 metres before the 20 km/h (12.5 mph) speed restriction board, but this was only sufficient to reduce the tram’s speed from 80 km/h (50 mph) to approximately 70 km/h (43.5 mph) by the time the tram passed the board and entered the curve on which the accident occurred.

Urgent Safety Advice

32 In the light of this accident, the RAIB has issued the following urgent safety advice to Tram Operations Ltd and London Trams:
‘The factors that led to the over-speeding are still under investigation. Until these factors are better understood, and before the junction re-opens to passenger operation, the RAIB advises London Trams and Tram Operations Ltd to jointly take measures to reduce the risk of trams approaching Sandilands Junction from the direction of New Addington at an excessive speed. Options for consideration should include the imposition of a further speed restriction before the start of the existing 20 km/h speed restriction around the curve and/or additional operational signs.’

RAIB’s future action in the investigation

33 During its investigation the RAIB will work in conjunction with other agencies to contact the families of those who lost their lives and those who were injured in the accident. The RAIB will also be contacting any passengers who were on-board the tram when the accident occurred, but who were not injured.

34 The RAIB’s ongoing investigation will include consideration of:
l the sequence of events before and during the accident;
l events following the accident, including the emergency response and how passengers evacuated from the tram;
l the way in which the tram was being driven and any influencing factors;
l the design, configuration and condition of the infrastructure on this section of the route, including signage;
l the tram’s behaviour during the derailment and how people sustained their injuries;
l any previous over-speeding incidents at Sandilands Junction; and
l any relevant underlying management factors.

35 The RAIB’s investigation report will include recommendations to reduce the likelihood and/or consequence of similar events occurring in the future.