Investigators conclude tram operators failed to understand risk of vehicle overturning and to take enough safety measures

This article is more than 2 years old

This article is more than 2 years old

Investigators have said they believe the Croydon tram crash was caused by the driver briefly falling asleep before speeding through a sharp bend, but tram operators had failed to properly understand the risks and put enough safety measures in place.



Inspectors said new measures were needed across Britain’s tram networks, including technology to monitor drivers’ alertness and automatically reduce speeds before dangerous junctions.

Seven passengers were killed and 61 injured, 19 seriously, when the south London Tramlink tram came off the rails on 9 November last year. It was travelling at 73km/h (45mph) in a 20km/h zone.

Simon French, the chief inspector at the Rail Accident Investigation Branch, said he was “surprised and concerned” by tram operators’ lack of understanding of the risk of a vehicle overturning.



“It appears there was a gap here. It had been dismissed or thought not to be credible,” he said.



The RAIB found that even at a speed of 49km/h, the tram would have overturned. During the investigation, nine other drivers told inspectors they had needed to brake heavily before the junction at Sandilands where the crash occurred. However, the RAIB said drivers had been reluctant to report incidents or near misses to managers at FirstGroup’s Tram Operations Ltd, fearing disciplinary measures.

Another speeding tram had come close to overturning on the same junction nine days before, inspectors said.

French said more safeguards were needed on a “public transport system that is heavily reliant on the continued focus of the staff in a high-risk area”.

The RAIB said a dedicated safety body for trams should be set up to combat an “inadequate understanding of risk” across the UK’s eight urban tramways.

Facebook Twitter Pinterest The tram derailed near the Sandilands stop in Croydon. Photograph: RAIB/PA

The final report into the accident said the driver could have fallen into a “microsleep” during a 49-second period when the tram was passing through three consecutive tunnels in the hours of darkness.



Inspectors said it was possible a “sleep debt” accumulated by the driver, who was regularly sleeping less than six hours before waking up at 3.20am to go to work, could have made him fatigued.

The driver, Alfred Dorris, 43, from south-east London, told RAIB inspectors he had no recollection of the moments before the crash. Dorris was arrested by British Transport Police on suspicion of manslaughter and bailed. On Thursday, police said they were preparing a report for the Crown Prosecution Service.



Richard Harrington, the RAIB’s lead inspector, said it was not unusual for people involved in serious incidents to have little recollection of events. “The horrific scenes that were inside that tram meant that many people’s memories of exactly what happened were not clear,” he said.

The tram, a morning service from New Addington to Wimbledon, was travelling in darkness and heavy rain when it overturned just after 6am. Passengers, who were thrown across and around the vehicle, described it as “like being in a washing machine”.

The report said a substantial number of the survivors had suffered shock and emotional trauma. After the windows and doors smashed on impact, passengers fell through the openings and were crushed as the tram slid to a stop, about 27 metres (89ft) from where it derailed.

All the passengers who died and most of the seriously injured were thrown through the windows, which led the RAIB to call for the use of tougher glass and doors in vehicles. Survivors waited about nine minutes before emergency services were able to assist injured people in leaving the tram.

Sarah Jones, the MP for Croydon Central, said the findings were “quite shocking”, adding: “There were missed opportunities to prevent this tragedy and safety improvements are needed across the network.”



Transport for London said it had already introduced additional safety measures since the crash, including new signs, speed restrictions and infrared eyeball monitors to alert tram drivers if they show signs of falling asleep.

Facebook Twitter Pinterest Sarah Jones, the MP for Croydon Central, said the findings were ‘quite shocking’. Photograph: ITN

The drivers’ union Aslef said the device would not have prevented the Croydon crash, but trams needed the same standards of construction and automatic braking as trains.



Finn Brennan, the union’s organiser on Tramlink, said: “Tram Operations Ltd should be dealing with the underlying causes of fatigue among staff and developing a fair culture that supports, rather than blames, staff.”

FirstGroup said 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 said the company had nevertheless implemented measures including enhanced speed monitoring and renewed guidance on fatigue management.

But solicitors representing victims of the crash said the company’s failure to investigate previous complaints was “inexcusable”.



Trevor Sterling, a partner at Moore Blatch, said the report showed “a systemic failing within Tram Operations Ltd, which meant an accident of this type was inevitable”.



“Had apparent issues been adequately addressed before and appropriate steps taken, this catastrophe could potentially have been avoided,” he said.

The passengers who died in the crash were Dane Chinnery, 19; Philip Seary, 57; Dorota Rynkiewicz, 35; Philip Logan, 52; and Robert Huxley, 63, all from New Addington; and Mark Smith, 35, and Donald Collett, 62, from Croydon.

Apart from London, there are tram and light rail operations in Blackpool, Manchester, Birmingham, Nottingham, Sheffield, Tyne and Wear, and Edinburgh.

