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RAIB reveals what should be done to make trams safer after crash – latest updates

RAIB reveals what should be done to make trams safer after crash – latest updates
Aug 04, 2017 Shaking Hands 0 comments
This post was first published by Croydon Advertiser on 03/08/2017.

RAIB reveals what should be done to make trams safer after crash – latest updates

Investigators looking into what caused the Sandilands tram crash that claimed seven lives in November have issued an update into their inquiry and have revealed what should be done to make trams safer and prevent a repeat of the distaster.

The Rail Accident Investigation Branch (RAIB) released the update on Thursday, August 3, and we will be bringing you live coverage.

Seven people died and 51 were injured when tram 2551 travelling from New Addington towards Sandilands tram stop derailed as it entered a bend shortly before the station at 6.07am on November 9.

One previous interim report issued by the RAIB revealed the tram was travelling at 46mph as it hit the 13mph limit bend when it derailed.

The body is also looking at whether the severity of injuries and number of fatalities was made worse by the type of glass used in the tram windows.

An Advertiser investigation in the weeks after the crash suggested the type of glass used in the trams exacerbated the number of injuries and fatalities.

The RAIB is one of three bodies in investigating the crash. British Transport Police are looking at the criminal investigation, while the Office of Rail and Road are looking into health and safety.

We’ll be bringing you on the the RAIB update in our liveblog below.

  Good morning by Tom Matthews

Welcome to our live coverage. We will be bringing you the latest on the RAIB’s investigation as soon as the report is released this morning.

  RAIB update released by Tom Matthews

The RAIB has released its draft recommendations about what tram operators should do. They are as follows:


  RAIB has ‘analysed more evidence’ by Tom Matthews


The RAIB says that the basic explanation of events remains unchanged from its second report in February, which you can read about here.

But they say they have “gathered and analysed considerably more evidence” since that report was published, which has allowed them to put together the recommendations.

The RAIB has written to Transport for London, and Tram Operations Limited (which runs the Tramlink system on behalf of TfL) as well as UKTram, the country’s industry body, to formally confirm the recommendations.

“We did this so they can start to consider what action to take in response, prior to the publication of our final report. The letter has been copied to other UK tram operators and the safety authority”.

As well as the four recommendations below (which we’ll be taking a more in-depth look at shortly), the RAIB also says it’s investigation into how Tram Operations Ltd manages driver fatigue risk may also result in an extra recommendation.

There have been several high profile incidents of drivers appearing to be asleep at the controls, including one shocking example where a driver seemed to be sleeping in George Street Croydon, while passengers tried to wake him up.

A BBC report also found four drivers admitted to falling asleep in trams.


The RAIB’s final report, which is now being written, will also highlight “the importance of ensuring the availability of in-tram CCTV systems”.

As the Advertiser reported back in November, investigators discovered shortly after the disaster that CCTV on board the tram was not working at the time

It has also been revealed that none of the trams have CCTV cameras pointing at the driver.


Here’s what the RAIB has to say about the draft recommendations so far.

A statement said: “This list is not exhaustive, but includes some of the important safety issues that are likely to take time to implement, making early consideration vital. Other areas within the scope of our investigation, such as consideration of underlying safety management and regulatory factors, may also give rise to recommendations. We are encouraged to learn that some tramway organisations have already started work in a number of these areas.”

  When will the final report be published?

The final report of the RAIB’s investigation is now being written. Those named in the report, almost certain to include TfL and TOL, the operating company, will be consulted on the contents before it is published.

The RAIB says: “We are aiming to publish the report in under a year from the date of the accident. However, the publication date remains subject to a number of factors, some of which are outside our direct control.”

  Could trams have automatic speed controls? 

Let’s look at each of the key draft recommendations in a little more depth.

The first recommendation says that UK tram companies should look at “active tram protection” to prevent serious accidents due to speeding at “high risk locations”.

That would appear to include automatic speed restrictions so that trams would slow themselves down at certain locations.

The RAIB’s previous report found the tram was travelling at 46mph in a 13mph zone as it hit the bend. The report also said the driver “lost awareness”.

The second recommendation says there should be research into methods that would detect whether drivers are paying attention, and then “intervene” should the driver not be paying attention.

This ties into how we reported in June that Transport for London was looking to install systems to accomplish both of those things on the Tramlink network.

TfL has opened a tender for bidders to design an automatic vehicle speed monitoring device (AVSM), which could automatically control the tram speed at certain locations, and a driver vigilance device (DVD), which would mean the driver would have to respond to an alert within a certain time period to make sure they are constantly paying attention.

The trams are currently fitted with a “dead man’s handle” that applies the brake if a driver takes their hand from the speed control, but some drivers have reported that it was not working, or could be disabled.

  Safer windows? 

The third recommendation says there should be “improved containment of passengers by tram windows and doors”.

This refers to the fact that when the tram overturned, the glass used in the windows shattered, causing passengers to be thrown from the tram, and in some cases then become trapped underneath.

An Advertiser investigation found that the number of casualties could have been made worse by the fact trams don’t have to use the same laminated safety glass that trains do.

Other than the driver’s front windshield, the glass in tram windows is not laminated safety glass, but instead is ‘shatterable’ safety glass – the type that breaks into small pieces to avoid dangerous shards.

But the problem with shatterable safety glass is that in the event of a derailment, the vehicle loses its structural integrity and passengers can be thrown from inside – causing serious injury or death.

One survivor, Rui De Sa, told the Advertiser: “The only thing that could have avoided these deaths is if the windows didn’t break.”

After several derailments, the heavy rail industry brought in regulations to make sure trains – but not trams, which have the same road safety standards as buses – have laminated windows that stay in place even when broken, thanks to a plastic seal.

So it seems like the RAIB is saying such regulations should also apply to trams. TfL has said in the past that the tram windows meet the appropriate safety standards.

  New safety organisation

The fourth key recommendation says that there should be an industry body that will allow “more effective cooperation between UK tramway owners [such as TfL] and operators [such as TOL] on matters related to safety performance and the development of common standards”.

At the moment, all the country’s tram operators are represented by industry body UKTram, which doesn’t specifically have a role in enforcing cooperation on safety between the owners of tram networks and the companies who run them.

UKTram, largely operates as a meeting and lobbying group for the industry, but does run a “Guidance, Standards, Safety & Assurance Group”.

Here, the RAIB seems to be saying that a body like the Rail Safety and Standards Board (RSSB), which sets safety standards for heavy rail, should be set up for tram companies.

The way the recommendation is worded also seems to suggest the particular issue that arises out of one body that owns the network (like TfL) and then gets a company to run that network for them (TOL), and whether such bodies are sharing information about safety performance effectively. As the Advertiser reported this week, since the crash, TfL says it is “informed” about incidents when drivers have breached the speed limit on the network.

  FirstGroup statment

A statement on behalf of FirstGroup (Tram Operations Ltd’s parent company), has been released after this latest report update.

FirstGroup chief executive, Tim O’Toole, said: “Our thoughts, first and foremost, remain with everyone who was involved in the tragic incident, and we continue to work closely with Transport for London and others to assist those who have been affected.

“We thank the Rail Accident Investigation Branch for their latest update and we will continue to provide full support to their ongoing investigation, paying particular attention to their findings as they emerge.

“Since the incident, additional speed restrictions and associated signage were introduced on the network and we are carrying out enhanced speed monitoring. We follow the industry approach with respect to driver support and welfare including monitoring for alertness and potential fatigue, and will work with TfL to introduce an in-cab alert system.”

  New driver vigilance system 

In response to the recommendations, TfL has said this morning a new driver “vigilance” system is already being trialed. The new system should be in place by the autumn, and it seems it will address one of the key points raised by the RAIB today.

According to Mike Brown, London’s transport commissioner, “any sign” that the driver is distracted or fatigued will result in an immediate alert.

He said in a statement: “Our thoughts remain with all those affected by the tragic tram derailment and we continue to do all we can to offer our support.

“Since the incident we have introduced a number of additional safety measures to the tram network, including additional speed restrictions, enhanced speed monitoring, new signage for drivers and an upgrade of the CCTV recording system.

“An in-cab vigilance system is being trialed and should be fitted to all trams by the autumn. Any sign of driver distraction or fatigue will result in the driver being alerted immediately. Work on an alert system for monitoring and managing tram speed is underway.

“We continue to work with the wider tram industry on these improvements and will consider any further measures that could be introduced to improve safety. We also continue to work with the Rail Accident Investigation Branch (RAIB) and will take on board all recommendations from this and the other investigations that are underway.

“The TfL Sarah Hope line remains available to all those affected and continues to provide help with counselling and other support.”

  MP seeks ‘robust’ recommendations

Croydon Central MP Sarah Jones has said her thoughts remain the families of the victims of the crash. “I am here for them through this process,” she said in a statement.

Mrs Jones has also said she will be “watching closely” for the final report, and hopes to see “robust” recommendations, particularly around window quality and how TOL manages the risk of driver fatigue.

Her statement in full –

  What has happened since the crash?

It’s now nearly nine months since the disaster at Sandilands, and an awful lot has happened since the tragedy. In May our reporter Samantha Booth looked at what has happened since the disaster. You can read her full piece here, that will shed some light on everything that has changed since.

  What about the other investigations?

Both British Transport Police (BTP) and the Office of Rail and Road (ORR) continue to investigate the crash alongside the RAIB. BTP are looking at the criminal side of the investigation, while the ORR is looking at potential health and safety breaches.

It is not yet clear when those investigations will be concluded. The driver of the tram, Alfred Dorris, was arrested on suspicion of manslaughter shortly after the crash and remains on bail.

  New vigilance system 

Here’s more on the news that Transport for London is trialling a new system to keep drivers “vigilant“. The new system alerts drivers should they be distracted or become fatigued.

  Recap of the key points in the report

To recap the four main areas in the RAIB’s final report which are likely to be made to tram operators in the UK are:Here is a full round-up of all the draft recommendations made in the latest RAIB report – and what it could mean.

  • Improved containment of passengers by tram windows and doors.
  • Provision of active tram protection to prevent serious accidents due to excessive speed at high risk locations.
  • Research into active means of detecting the attention state of drivers and intervening the event of inattention.
  • Better industry coordination between operators and owners.