This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
I am Miss Sarah Ormond-Walshe, HM Senior Coroner, South London jurisdiction
An investigation was opened on 21st November 2016 and inquests completed on 22nd July 2021. Conclusion of Accident was made for all the deceased.
Circumstances of the death
A jury found: In the early morning of 9th November 2016 the deceased was a passenger on the Tram 2551 travelling between Lloyd Park Station and Sandilands station. The tram driver became disorientated, which caused loss of awareness in his surroundings, probably due to a micro-sleep. As a result of which the driver failed to brake in time and drove the tram towards a tight curve at excessive speed. The tram left the rails and overturned onto its right side, as a result of which the deceased was ejected from the tram and killed.
The Conclusion the jury found was: Accident, adding a narrative.
TOL 1. The risk assessment process failed to sufficiently identify the risk of the tram overturning and crashing at the tight Sandilands curve at high speed with the probability of fatalities. 2. TOL identified the importance of line of sight driving and route knowledge but failed to identify additional measures to mitigate risk. 3. The lack of a 'just culture' discouraged drivers from reporting health and safety concerns. The driver The driver lost awareness and became disorientated ahead of the Sandilands curve probably due to a micro-sleep. Following this the driver failed to hit the braking point by which time the tram was travelling too fast to negotiate the Sandilands curve. The result was a high speed derailment, the tram over-turning and 7 fatalities.
Coroner’s concerns
The risk of under-reporting of incidents
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised1
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 An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7
Action
Monitor developments in anonymous reporting and update documentation accordingly.
Stated byLight Rail Safety and Standards BoardStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
Action
Publish documentation, developed with CIRAS, explaining anonymous reporting schemes and their benefits.
Stated byLight Rail Safety and Standards BoardStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
Action
Continue recording, monitoring and assessing hazardous events and precursors through the national Tram Accident and Incident Reporting database and National Risk Model.
Stated byLight Rail Safety and Standards BoardStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
Action
Facilitate staff feedback through union representatives by allocating weekly time for union duties and holding regular management meetings with representatives.
Stated byTram Operations LtdStated completedThe respondent said that this action was complete when they made their response on 14 October 2021.
Action
Maintain membership of CIRAS and provide staff with confidential reporting access through prominently displayed contact details.
Stated byTram Operations LtdStated completedThe respondent said that this action was complete when they made their response on 14 October 2021.
Action
Provide internal reporting resources through staff suggestion boxes, including weekly checks, regular emptying, written responses and appropriate follow-up.
Stated byTram Operations LtdStated completedThe respondent said that this action was complete when they made their response on 14 October 2021.
Action
Enable direct staff reporting to senior management through an open-door policy and active encouragement of self-reporting.
Stated byTram Operations LtdStated completedThe respondent said that this action was complete when they made their response on 14 October 2021.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2
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.
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.33
1
Engage with tram operators and, where appropriate, the LRSSB on passenger safety issues reported by users.
Stated byTransport FocusStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
2
Assess and communicate relevant updates from light-rail networks through LRSSB’s sector communication channels.
Stated byLight Rail Safety and Standards BoardStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
3
Consult TfL and London Trams to establish remedial action taken or reasonably available to address passenger ejection through tram doors.
Stated byLight Rail Safety and Standards BoardStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
4
Assess proposed tram-door changes against the holistic risk profile, including effects on driver inattention and speed-management controls.
Stated byLight Rail Safety and Standards BoardStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
5
Review the provenance and relevance of standards concerning tram-saloon door security and crashworthiness, including the RAIB technical recommendations.
Stated byLight Rail Safety and Standards BoardStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
6
Continue participating in European and British Standards Institution working groups to influence the design and manufacture of future light-rail fleets.
Stated byLight Rail Safety and Standards BoardStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
7
Continue developing the reference library of light rail safety standards and guidance.
Stated byLight Rail Safety and Standards BoardStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
8
Disseminate CIRAS committee information, reports and analytics to the light rail sector through the Light Rail Heads of Safety Group.
Stated byLight Rail Safety and Standards BoardStated completedThe respondent said that this action was complete when they made their response on 14 October 2021.
9
Use the London Trams Safety Risk Model to assess risk before and after safety systems and measures are fitted.
Stated byTransport for LondonStated completedThe respondent said that this action was complete when they made their response on 14 October 2021.
10
Ensure future London Tram fleet procurements meet applicable LRSSB guidance and incorporate learning from the existing-fleet door-strengthening work into door-mechanism specifications.
Stated byTransport for LondonStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
11
Determine the appropriate way forward for existing-fleet door improvements, including funding requirements and implementation timelines, after receiving the technical report.
Stated byTransport for LondonStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
12
Complete an engineering study assessing whether the CR4000 fleet’s existing door mechanisms can be strengthened and how any identified solution could be rolled out.
Stated byTransport for LondonStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
13
Operate the procured, developed and installed Physical Prevention of Overspeed System at identified high-risk locations to automatically brake overspeeding trams to a controlled stop.
Stated byTransport for LondonStated completedThe respondent said that this action was complete when they made their response on 14 October 2021.
14
Review recently issued LRSSB guidance and determine whether further work is needed on the existing fleet to comply with it.
Stated byTransport for LondonStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
15
Review the published guidance after 12 months and monitor its implementation and supplementary network safety measures.
Stated byLight Rail Safety and Standards BoardStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
16
Continue monitoring advancements in automatic braking, driver inattention detection and speed management.
Stated byLight Rail Safety and Standards BoardStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
17
Continue developing the light rail safety and standards reference library.
Stated byLight Rail Safety and Standards BoardStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
18
Use risk-model outputs to identify required technologies or processes and seek to mitigate identified events through standards, guidance or research and development.
Stated byLight Rail Safety and Standards BoardStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
19
Publish guidance on detecting driver inattention and managing tram speed.
Stated byLight Rail Safety and Standards BoardStated completedThe respondent said that this action was complete when they made their response on 14 October 2021.
20
Commission and undertake research and development trials of obstacle detection and avoidance systems for light rail vehicles.
Stated byLight Rail Safety and Standards BoardStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
21
Continue monitoring LRSSB’s progress on tram-door standards and work with LRSSB and the sector as standards decisions develop.
Stated byDepartment for TransportStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
22
Consult passenger groups, system operators and stakeholders on coordinating a nationwide process for passengers to raise tram safety concerns.
Stated byDepartment for TransportStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
23
Agree a nationwide solution with Transport Focus, LRSSB and other stakeholders for raising passenger safety concerns in 2022.
Stated byDepartment for TransportStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
24
Continue working with UK Tram, LRSSB, system operators and stakeholders to address concerns raised in the Prevention of Future Deaths reports.
Stated byDepartment for TransportStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
25
Conduct a collaborative engineering assessment of in-service CR4000 doors, including detailed physical assessment and failure analyses, to identify strengthening options.
Stated byAlstom Engineering And Services LimitedStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
26
Consult approved door suppliers and relevant stakeholders on the feasibility of improved future door designs.
Stated byAlstom Engineering And Services LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
27
Establish and communicate recommendations for applicable improvements to existing CR4000 fleets.
Stated byAlstom Engineering And Services LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
28
Engage relevant authorities and standards bodies to review UK light-rail door regulation and, if necessary, recommend revisions.
Stated byAlstom Engineering And Services LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
29
Assemble an international multidisciplinary team to investigate feasible changes to current and future tram-door designs.
Stated byAlstom Engineering And Services LimitedStated completedThe respondent said that this action was complete when they made their response on 14 October 2021.
30
Share recommendations for current in-service CR4000 doors with vehicle owners.
Stated byAlstom Engineering And Services LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
31
Present the findings of the door-strengthening and feasibility studies to the Senior Coroner, including the industry perspective and regulatory recommendations.
Stated byAlstom Engineering And Services LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
32
Continue discussions with IFE on strengthening current doors and developing future door-design standards.
Stated byAlstom Engineering And Services LimitedStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2021.
33
Review future tram-door designs and establish recommendations for applicable improvements to new-build and future fleets.
Stated byAlstom Engineering And Services LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 October 2021.
Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.9
1
Transport Focus lacks the remit and resources to initiate a bespoke tram passenger safety group.
Stated byTransport FocusUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
2
London TravelWatch is not a dedicated passenger safety group and therefore cannot serve as a model for the proposed national group.
Stated byTransport FocusDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
3
The amount of responsive work LRSSB can undertake depends directly on its Department for Transport funding settlement, which is not guaranteed beyond August 2022.
Existing driver-inattention and speed-management guidance and implementation should significantly reduce the risk of a similar occurrence.
Stated byLight Rail Safety and Standards BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
5
Individual tram networks are responsible for developing and finalising system-specific driver-inattention and speed-monitoring risk controls.
Stated byLight Rail Safety and Standards BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
6
The centrally funded national passenger safety group and automatic braking issues were not addressed to tram operators, so no commentary is provided.
Stated byTram Operations LtdOutside remitThe respondent said that this matter was outside its role or authority.
7
The operator does not own the trams or have authority to implement tram-door adaptations.
Stated byTram Operations LtdUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
8
London Trams, together with tram manufacturers, holds the ultimate decision on adapting Croydon Tramlink tram doors.
Stated byTram Operations LtdRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
9
Relevant authorities and regulators are responsible for establishing or specifying safety standards; recommendations may be adopted or mandated by them.
Stated byAlstom Engineering And Services LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Pin
Get email alerts
Request correction
Information checked against the published report and official responses