THE final report into the Croydon tram crash of November 2016 has said the driver of the tram which overturned at speed, killing seven people, may have been in a momentary ‘microsleep’ which made him ‘lose awareness’. By the time he woke up, he may not have realised in time that his tram was overspeeding dangerously close to the tight curve at Sandilands Junction, where there is a restriction of 20km/h.

The Rail Accident Investigation Branch concluded that the risk of trams overturning on curves had not been ‘properly understood’.

It found that that the driver had probably ‘lost awareness on a section of route on which his workload was low’, and that if he had experienced a brief microsleep it was linked to fatigue.

However, the RAIB has dismissed reports that shift patterns at the Tramlink depot, which is operated by FirstGroup, were the underlying cause of his tiredness. A further factor could have been that the driver regained consciousness as his tram approached Sandilands Junction along a section of track where ‘the infrastructure did not contain sufficiently distinctive features to alert tram drivers that they were approaching the tight curve’.

The crash in the dark, wet morning of 9 November 2016 threw a number of passengers through the windows as the tram overturned at an estimated speed of some 70km/h. Seven people were killed and 61 others hurt, 19 of them seriously.

Chief inspector of rail accidents Simon French said: “We are recommending action in five main areas. The first is the use of modern technology to intervene when trams approach hazardous features too fast, or when drivers lose awareness of the driving task. Tramways need to promote better awareness and management of the risk associated with tramway operations. Work needs to be done to reduce the extent of injuries caused to passengers in serious tram accidents, and to make it easier for them to escape. There need to be improvements to safety management systems, particularly encouraging a culture in which everyone feels able to report their own mistakes. Finally, greater collaboration is needed across the tramway industry on matters relating to safety.

“UK tramways have been aware of our key findings and the focus of our recommendations for many months now. I am very encouraged by the progress that has already been made in addressing the recommendations and the collaborative approach that is being taken.”

London transport commissioner Mike Brown said that TfL would continue to work alongside the RAIB, FirstGroup and the ORR. A separate report into the crash prepared by TfL will be published in early 2018.

He added: “Since the incident we have introduced a wide range of additional safety measures to make sure such a tragedy can never happen again. These include new signage and warning systems for drivers, additional speed restrictions, enhanced speed monitoring and an upgrade of the CCTV recording system.

“An in-cab driver protection device has been trialled and is now fitted to every tram, meaning that any sign of driver distraction or fatigue results in the driver being alerted immediately. Work to install a system to automatically reduce tram speeds if required is also underway.

“We have enhanced the customer complaints process so that all reports are now managed by one dedicated TfL team and any that relate to safety are prioritised for immediate investigation.”

TfL is also working with other British tram operators ‘to ensure that any lessons are learned’.

FirstGroup chief executive Tim O’Toole said: “We are profoundly sorry that such an incident could take place aboard a service we operate and on behalf of everyone at FirstGroup, I would like to reiterate our condolences to the families and friends of those who lost their lives, and all those who were injured and affected.
 
“I would like to thank the Rail Accident Investigation Branch for their thorough report into the incident. We are grateful for their recommendations for improvements to the system in Croydon and tram networks across the UK.

“The RAIB concluded that management of fatigue was not a factor in the incident, nor did a speeding culture contribute to it. Nevertheless, over the past year we have taken a series of actions, working closely with Transport for London on whose behalf we operate the system, to implement additional measures including enhanced speed monitoring and restrictions, improved signage and renewed guidance on fatigue management.”