11.09.18
Sandilands: Lessons for the mainline
Source: RTM Aug/Sept 2018
The tragic Croydon crash of 2016 provided many lessons for the UK tramways. But the mainline railway would be wrong to assume many of these lessons don’t apply to them too, says Simon French, chief inspector of rail accidents at the RAIB.
Readers will be familiar with the tram accident at Sandilands in November 2016. The tram approached a tight radius, left-hand bend at around three-and-a-half times the permitted speed of 20 km/h. It overturned and travelled around 30m on its right-hand side before stopping. In the space of three seconds, a normal commute to work turned into a horrific tragedy that affected many people, and will do so for years to come.
Around half the 69 passengers were ejected or partially ejected through broken windows or doors. Seven people were killed, 19 suffered serious injuries, and 43 sustained minor injuries. Many people suffered psychological harm.
The driver had applied insufficient braking. The most likely cause was a temporary loss of awareness at a time of low workload – no driver actions were required on the long straight approach to the accident site. The driver may have had a micro-sleep through being fatigued. He may have become disorientated about the tram’s location and/or direction of travel.
Safety relied heavily on driver vigilance and route knowledge. The risk from excessive speed and overturning was not recognised by the operator and owner at Croydon, nor by the tramway industry and the regulator.
The safety learning for the UK’s tramways is contained in RAIB’s report into the accident, published in December 2017. However, there are lessons in the Sandilands accident for the mainline railway as well, five of which we explore here.
Look beyond recent, local experience when assessing risk
‘I can’t remember it happening’ does not mean ‘it will never happen.’ Low-frequency, high-consequence accidents, by definition, are unlikely to occur on a given system over anything other than long timeframes. Organisations must look globally and over long timeframes to gather sufficient data and understanding of such accidents when assessing risk. Sharing accident and precursor incident data within the railway industry is vital, as is maintaining a long corporate memory.
Risk management should not only be focused on assessing changes
Risk needs to be understood and managed continuously, not just when organisations make changes. Thorough, periodic, first-principles reviews of the risk arising from organisations’ everyday operational hazards should be undertaken. Undertaking risk assessments only when changes occur can lead to current hazards being overlooked.
Use technology to monitor the alertness of train drivers, intervening when necessary
Over the years, the railway has moved from straightforward hold-down “deadman’s handles” to more sophisticated, but still control movement-based, vigilance devices. But technology (optical, infrared and biometric systems) continues to advance. Solutions will get better and cheaper. Applying emergent technologies to the railway has not always been easy, but industry should start to consider such devices for the safety-critical train driver’s role.
Review fatigue management systems against current good practice
The Sandilands accident and other events the RAIB has investigated highlight the importance of fatigue management, particularly away from work. Risk associated with non-work activity is clearly difficult for industry to control; lifestyle guidance and facilitating the reporting of fatigue can help.
Learning from experience and the need for a ‘just culture’
At Sandilands there were a number of previous unreported overspeed approaches to the curve – clues that the hazard existed. How do organisations encourage people to self-report such precursor events? You can only expect people to report their own mistakes when they are not penalised for doing so. And that is why a just culture can enhance safety.
Although there are similarities and differences between mainline and tramway operations, it is always wise to ‘look over the fence’ to learn from each other. It would be unfortunate were the mainline sector to dismiss the Sandilands learning as ‘not for us.’ It is for this reason the RAIB has been working with the RSSB to help disseminate the learning within the UK heavy rail sector.
Top image: Steve Parsons, PA Images
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