The Rail Accident Investigation Branch (RAIB) have released their latest report into an incident on one of the UK’s light rail systems with the publication of a report into when a London Tramlink vehicle managed to operate in service with doors open back on 13th April 2013.
The incident occurred on Saturday 13th April 2013 between 1733 and 1738 when 2548, travelling between West Croydon and Beckenham Junction, departed from both Lebanon Road and Sandilands tram stops with all of its doors open on the left-hand side. Some of the doors did close during the journey but one set of doors remained open for the duration, which totalled two minutes and 25 seconds. The incident ended when a controller noticed on CCTV that it had departed from Sandilands with the doors open and arranged for the tram to be stopped.
Following their detailed investigation the RAIB decided that the following were key factors in the incident:
*A fault override switch, which disables safety systems such as the door-traction interlock, has been inadvertently operated by the driver whilst trying to resolve a fault with the tram. [The driver had been trying to resolve a fault with the spring applied brake before arriving at Wellesley Road].
* The driver did not close and check the doors before departing the tram stops partly because he was distracted by dealing with the fault and partly as he believed the tram could not move with its doors open.
* The design of controls and displays in the driving cab contributed to the driver’s inadvertent operation of the fault override switch.
* Breakdowns in communication between the driver and passengers and between the driver and controller mean neither the driver or controller were aware of the problem until the tram left Sandilands.
Eight recommendations have been made by the RAIB:
* Tram Operations Ltd should revise its policy on verbal communications
* Tram Operations Ltd should revise its training modules and procedures on fault handling
* London Tramlink, in conjunction with Tram Operations Ltd, should improve cab displays and labelling in all of its trams
* UK tram operators should conduct an assessment of controls in driving cabs in their current and future fleets to identify those which override safety systems.
* The Office of Rail Regulation should ensure that UK tram operators publish suitable guidance on ergonomics principles for cab interface design and identify where such guidance is to be found in the long term.
* Trams Operations Ltd should take steps to improve the clarity and consistency of passenger controls and displays on its trams.
* London Tramlink should develop and implement a programme to prioritise and expedite the planned upgrade of the radio system to achieve an improvement in signal coverage and strength across the network and reliable operation in adverse weather.
* Tram Operations Ltd should improve its fault reporting processes to ensure that faults are properly logged and tracked to resolution.
The full report can be downloaded from the RAIB website at http://www.raib.gov.uk/cms_resources/140306_R052014_Lebanon_Road.pdf.