The RAIB have issued a warning to the UK tram industry following the publication of their latest report into an incident which saw a tram driver on Manchester Metrolink fail to stop at Deansgate-Castlefield and then proceeded to pass through a stop signal. With another tram given the right of way it was only the actions of the driver on that other tram which prevented a collision from occurring.
The incident happened during the evening rush hour of 17th May 2019 at approximately 1719 and saw a tram passing through the centre platform at Deansgate-Castlefield without stopping and then failing to stop at the signal at the end of the platform which hadn’t given him right of way. For those familiar with the stop, in its last redesign two platforms are generally used for services into Manchester City Centre (although the centre platform can also be used for terminating services from the city centre) with departure then signalled. In this case the outer platform had the right of way but when the driver of that tram saw that the other vehicle had not stopped as directed he was able to stop and avoid a collision.
The RAIB report concluded that the driver of the tram which should have stopped (both at the stop and signal) suffered from a temporary loss of awareness. Although there remains some doubt as to why he had this loss of awareness the RAIB “considers that it was either the result of a medical event or the driver losing focus on the driving task”. There is no evidence for the reasons for his loss of awareness and his medical record does not confirm whether this was a cause.
Probably the biggest concern in the report is that the same driver had been involved in three similar signals passed at danger incidents. Despite these, and the fact that he had received two final written warnings, no significant action was taken against the driver. The RAIB have suggested that different action taken by KeolisAmeyMetrolink (KAM) may have resulted in a different outcome in this incident. The 62 year old had been driving since October 2017 but despite the previous incidents was still driving without any significant action taken and the report goes into detail about what did happen following each of these incidents.
The report also mentions that none of Thales, Transport for Greater Manchester or KeolisAmey Metrolink adequately considered the hazard of a driver losing awareness when the new layout at Deansgate-Castlefield was originally risk assessed. However, they do acknowledge that KeolisAmey Metrolink did identify the loss of awareness as a part of general risk assessment of tram driving tasks. The RAIB didn’t consider that the associated risks of lack of awareness were effectively controlled. The concern here is that the Sandilands accident on London Tramlink was also caused by a loss awareness and the RAIB had expected recommendations from that report to have been adequately dealt with on Metrolink.
As a result of the incident the RAIB have made several recommendations to ensure similar incident don’t happen again. The first asks KAM to review, update and re-implement its strategy for managing the risk of trams passing signals at danger or stop whilst others relate to a review of driver medical fitness requirements and that the risk of fatigue by drivers should be adequately addressed. KAM have said that they are working to ensure all recommendations are met and that they are considering the driver’s future, who is not currently driving trams, in light of the report.
Simon French, Chief Inspector of Rail Accidents, said: “This alarming incident reinforces the need for the tramway industry to continue to pursue implementation of the important recommendations that RAIB made in the report on the Sandilands junction disaster of 2016. Trams are driven in accordance with the ‘line of sight’ principle, and safe operation is heavily reliant on drivers remaining focused on the driving task at all times. It is important that drivers’ fitness and performance are carefully managed, and systems are in place to detect that a driver has lost awareness. It is therefore encouraging to learn that there is a lot being done in the tramway industry at present to develop, test and evaluate improved systems for the detection of drivers’ loss of awareness. In our investigation into this incident it was disappointing to find that management processes and action plans, intended to address previous safety incidents in which the tram driver had been involved, had not been carried out or were not fully implemented. The integrity of any safety management system relies on conscientious and intelligent application of the procedures that form part of it. If managers don’t do this, the safety of the tramway is at risk.”