Recipient

Light Rail Safety and Standards Board

First report 28 Sep 2021•Latest report 28 Sep 2021

Recipient record

Reports, concerns and published responses

Other public bodies · Rail safety body. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 16

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

16stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Light Rail Safety and Standards Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

28 Sep2021
South London
Concerns raised1
1. Risk of under-reporting of incidents
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Monitor developments in anonymous reporting and update documentation accordingly.
  Stated in progress
2. Action
  Publish documentation, developed with CIRAS, explaining anonymous reporting schemes and their benefits.
  Stated planned
3. Action
  Continue recording, monitoring and assessing hazardous events and precursors through the national Tram Accident and Incident Reporting database and National Risk Model.
  Stated in progress
Respondent positions 2
1. Position
  LRSSB cannot require light rail operators to join CIRAS or comply with its guidance because adherence is voluntary and licensing conditions do not apply.
  Unable to act
1. Position
  All seven UK tramways subscribe to a confidential reporting scheme, understood and confirmed to be CIRAS.
  Disputes the concern
AI-generated summary

Dane CHINNERY and 6 others · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

On 9 November 2016, a tram travelling between Lloyd Park Station and Sandilands station derailed and overturned after the driver became disorientated and failed to brake before a tight curve; seven passengers were killed. The substantive concerns included inadequate risk assessment and mitigation, a lack of a just culture discouraging reporting of health and safety concerns, and the risk of under-reporting incidents.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Light Rail Safety and Standards Board; that does not assign responsibility.
PFD Monitor interpretation
Risk of under-reporting of incidents
Wider context from the report
“The risk of under-reporting of incidents ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Monitor developments in anonymous reporting and update documentation accordingly.

Verbatim wording from the response
“2.5 LRSSB will continue to monitor advancements in this area and will update its documentation accordingly.”

Source location
2021-0337-Response-from-Light-Rail-Safety-and-Standards-Board-Anonymous-reporting-CIRAS_Published
Page 3 · response
Published 14 October 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish documentation, developed with CIRAS, explaining anonymous reporting schemes and their benefits.

Verbatim wording from the response
“3.2 In collaboration with CIRAS, LRSSB intends to provide documentation detailing such schemes and their benefits. This documentation is currently in preparatory draft form, but LRSSB expects publication to be before the end of this business year (March 2022).”

Source location
2021-0337-Response-from-Light-Rail-Safety-and-Standards-Board-Anonymous-reporting-CIRAS_Published
Page 3 · response
Published 14 October 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue recording, monitoring and assessing hazardous events and precursors through the national Tram Accident and Incident Reporting database and National Risk Model.

Verbatim wording from the response
“3.3 LRSSB continues to record, monitor, and assess hazardous events and their precursors through the national Tram Accident and Incident Reporting database (TAIR). All networks submit data to this LRSSB database. These inputs are then fed through to the LRSSB National Risk Model which provides outputs that identify potential current and future risk to both the UK sector as a whole or an individual network. Using this data LRSSB can then focus attention on any new technology or process required. LRSSB will, by the production of standard / guidance or by research and development seek to mitigate the chance of the identified event occurring. LRSSB believe that the use of this “live” database and its outputs will aid the sector in preventing future serious incidents.”

Source location
2021-0337-Response-from-Light-Rail-Safety-and-Standards-Board-Auto-Braking_Published
Page 3 · response
Published 14 October 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
LRSSB cannot require light rail operators to join CIRAS or comply with its guidance because adherence is voluntary and licensing conditions do not apply.

Verbatim wording from the response
“1.6 It should be noted, however, that LRSSB is an organisation that requires voluntary adherence to its guidance and best practice. Unlike the heavy rail industry, light rail operators are not required to be licensed under the Railways Act 1993 and there are therefore no licence conditions requiring membership of LRSSB or compliance with its outputs, however, currently, all seven 2nd generation UK tram networks are members of LRSSB and are actively engaged. While some parts of the Railways Act 1993 do apply to light rail and tramways, significant parts of that Act do not. This reflects the historic policy position that Government has taken under which light rail and tramway systems have generally been more associated with highways provisions rather than the more heavily regulated mainline railways.”

Source location
2021-0337-Response-from-Light-Rail-Safety-and-Standards-Board-Anonymous-reporting-CIRAS_Published
Page 2 · response
Published 14 October 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
All seven UK tramways subscribe to a confidential reporting scheme, understood and confirmed to be CIRAS.

Verbatim wording from the response
“2.2 In the Preventing Future Matters report published by HM Senior Coroner, South London, LRSSB was asked to respond on the topic of Anonymous Reporting. The report details how all tramway operators should look at using CIRAS (or a similar anonymous reporting scheme) and whether such schemes are used and if not, why not.”

Source location
2021-0337-Response-from-Light-Rail-Safety-and-Standards-Board-Anonymous-reporting-CIRAS_Published
Page 2 · response
Published 14 October 2021
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Risk of under-reporting of incidents

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 3

Respondent positions 2