The Rail Accident Investigation Branch have released their full report into the tragic derailment at Sandilands on 9th November 2016. Although it has not been possible to prove for definite why it happened the main cause of the incident has been given as the driver losing awareness and it is thought that this was because of fatigue. The report concludes by giving 15 recommendations in improving safety on tramways in the UK.
On 9th November 2016 at CR4000 2551 derailed on the sharp curve at Sandilands junction having failed to reduce speed sufficiently. The tram had reached the maximum permitted speed of 80kmh as it entered the first tunnel at Sandilands and should have reduced speed as it left the tunnels on the approach to the curve at Sandilands junction, which had a 20kmh limit. However, the tram was travelling at 73kmh when it reduced the speed limit sign. This high speed caused the tram to overturn as it passed through the curve and saw passengers thrown around inside the tram and the tram slid along the ground on its side. Tragically seven people died as a result with 61 injured, 19 seriously.
The investigation concluded that it was probable that the driver temporarily lost awareness on a section of route on which his workload was low (on the approach to the tunnels). A possible explanation of this was that the driver had a microsleep and this was linked to fatigue (although it is impossible to prove this either way). It is possible that this was due to insufficient sleep although there is no evidence that this was as a result of the shift pattern that he was required to work.
The investigation also found:
* as the driver regained awareness he was possibly confused about his location and direction of travel through the tunnels
* the infrastructure didn’t contain sufficiently distinctive features to alert tram drivers they were approaching the tight curve
* there was no mechanism to monitor driver alertness or to automatically apply the brakes when the tram was travelling too fast
* there was inadequate signage to remind drivers when to start braking or to warn that they were approaching the sharp curve
* the windows broke when people fell against them, so many passengers were thrown the tram causing fatal or serious injuries
The report also shows that there have been a number of other overspeed incidents at this location, the most recent of which was said to be on 31st October 2016 – less than two weeks before the derailment. This was reported to Tram Operations Limited but was not fully investigated until after the derailment. Some tram drivers had also experienced occasions when they had to apply hazard braking at this location but they did not report this to managers because of the perceived attitude of some managers and they feared the consequences if they did.
The 15 recommendations made as a result of the investigation are:
* ORR should work with the UK tram industry to develop a body to enable more effective UK-wide cooperation on matters related to safety, and the development of common standards and good practice guidance
* UK tram operators, owners and infrastructure managers should jointly conduct a systematic review of operational risks and control measures associated with the design, maintenance and operation of tramways.
* UK tram operators, owners and infrastructure managers should work together to review, develop and provide a programme for installing suitable measures to automatically reduce tram speeds if they approach higher risk locations at speeds which could result in derailment or overturning.
* UK tram operators, owners and infrastructure managers should work together to research and evaluate systems capable of reliably detecting driver attention state and initiating appropriate automatic responses if a low level of alertness is identified. Such responses might include an alarm to alert the tram driver and/or the application of the tram brakes. The research and evaluation should include considering use of in-cab CCTV to facilitate the investigation of incidents. If found to be effective, a time-bound plan should be developed for such devices to be introduced onto UK tramways.
* UK tram operators, owners and infrastructure managers, in consultation with the DfT, should work together to review signage, lighting and other visual information cues available on segregated and off-street areas based on an understanding of the information required by drivers on the approach to high risk locations such as tight curves.
* UK tram operators and owners should, in consultation with appropriate tram manufacturers and other European tramways, review existing research and, if necessary, undertake further research to identify means of improving the passenger containment provided by tram windows and doors.
* UK tram operators and owners should install (or modify existing) emergency lighting so that the lighting cannot be unintentionally switched off or disconnected during an emergency
* UK tram operators and owners should review options for enabling the rapid evacuation of a tram which is lying on its side after an accident.
* The Office of Rail and Road should carry out a review of the regulatory framework for tramways and its long-term strategy for supervision of the sector. This should be informed by a new assessment of the risk associated with tramway operations (allowing for low frequency/high consequence events of the type witnessed at Sandilands junction) and consideration of the most effective means by which supervision can contribute to continuous improvement in passenger safety
* Tram Operations Limited and London Trams should commission an independent review of its process for assessing risk associated with the operation of trams (eg collision, derailment and overturning of trams).
* Tram Operations Limited, drawing on expertise from elsewhere in the FirstGroup organisation, should review and, where necessary, improve the management of fatigue risk affecting its tram drivers with reference to ORR’s good practice guidance.
* Tram Operations Limited, drawing on expertise from elsewhere in the FirstGroup organisation, should review and, where necessary, improve the management of fatigue risk affecting its tram drivers with reference to ORR’s good practice guidance.
* Tram Operations Limited and London Trams should, in conjunction with TfL, improve processes, and where necessary, equipment used for following up both public and employee comments which indicate a possible safety risk.
* London Trams, in consultation with Tram Operations Limited, should review and, where necessary, improve its processes for inspecting and maintaining on-tram CCTV equipment to greatly reduce the likelihood of recorded images being unavailable for accident and incident investigation
* Lonndon Trams, in consultation with Tram Operations Limited should review and, where necessary, revise existing tram maintenance and testing documentation to take account of experienced gained, and modifications made, since the trams were brought into service and review and, where necessary, revise the processes for ensuring that these documents are kept up-to-date in future.
Simon French, Chief Inspector of Rail Accidents, said: “The RAIB’s report into the accident at Sandilands will stand as the record of the events that led to the tram overturning and the terrible human consequences. Our careful analysis of the evidence, and identification of the causal and underlying factors, has enabled us to make a number of far-reaching recommendations. These will have a lasting impact on the way that the tramway industry manages its risk. 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. It is vital that the right action is taken to stop such a tragic accident from ever happening again.”
Mike Brown MVO, London’s Transport Commissioner, commented: “Our thoughts remain with those who lost their lives or were injured in the tragedy at Sandilands, and we continue to do all we can to support everyone affected. We welcome this report from the Rail Accident Investigation Branch and will continue to work alongside them, the Office of Rail and Road and First Group, who operate the tram network, to ensure all of the recommendations outlined are met. We will also be publishing our own investigation report in the new year. 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. And the TfL Sarah Hope line remains available to all those affected and continues to provide help with counselling and other support to anyone who needs it. We also continue to work with the wider tram industry to ensure that lessons are learned from this incident and that we introduce any further measures that could improve the safety of trams across the UK.’
* The full investigation report – which goes into detail on all aspects of the derailment, its causes, how the investigation was undertaken and the recommendations coming out – can be downloaded from the RAIB website.