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RAIB: Croydon tram driver had ‘lost awareness’ before fatal derailment

The driver of the fatal Sandilands junction tram accident in Croydon, London, had “lost awareness” before the carriage he was controlling derailed, killing seven people, the latest interim report from the Rail Accident Investigation Bureau has reported.

The late application of the brake and the absence of emergency braking going towards the tight left hand turn suggested that the driver, Alfred Dorris, the only member of staff on board, had lost awareness before the accident, although the RAIB is investigating other factors that may have played a part.

The report also indicated that the tram had been travelling at 46mph, faster than the 43.5mph that was initially thought before the accident occurred in a 13mph zone near the Sandilands stop in Croydon.

The findings also described how the victims were “ejected” out of the tram’s smashed windows, saying: “Of the seven passengers who died, one was found inside the tram; two were found partially inside the tram; three were found underneath the tram; and another was found on the track close to the tram.”

The new report also found that the number of passengers on board the tram was actually around 70, rather than the 60 that was initially suggested in the RAIB’s first interim report published on 16 November 2016.

Commenting on the report, London’s transport commissioner Mike Brown said: “Our thoughts remain with all those affected by the tragic tram derailment and we continue to do all we can to offer our support.

“We continue to work with the RAIB and will take on board all recommendations from this and other investigations, including our own, that are underway.”

Brown also reassured the public that the TfL Sarah Hope phone line will remain available for those affected by the accident to provide counselling and support for the public.

Since the accident, the RAIB has issued urgent safety advice to Tram Operations Ltd and London Trams advising drivers to take measures to reduce the risk of trams approaching the Sandilands junction from New Addington. London Trams has also installed chevron warning signs on the curve and on other similar tight bends on the network as a precaution.

Other tram operators across the UK were also advised to introduce intermediate stepped speed restrictions in situations on the approach to curves, all operators who this was relevant to responded and introduced the speed restriction.

Looking to the future of the investigation, the RAIB said it will continue to investigate the sequence of events leading up to and during the incident, as well as the emergency response and the way the tram was driven leading up to its derailment.

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John Gilbert   20/02/2017 at 21:37

Yes, but what the blazes is meant by "lost awareness?" Did he black out or lose consciousness? If so why not say so. In any case it is to be hoped that this result will prove that there was absolutely nothing wrong either with the tram or the concept of the tram/light rail system!!

Andrew Gwilt   21/02/2017 at 00:08

Very frightening to hear about the tram accident that claimed 7 people but also very frightening that the tram was travelling at 46mph (74.03 kmph) as it approached the bend/corner and it derailed as it went too fast. I think that the driver mislead the signs to slow down as the track do curve at that location close to Sandilands tram stop, East of Croydon Town Centre as one line (Routes 1, 2 and 4) turns left towards Beckenham Junction and Elmers End from Therapia Lane and West Croydon station and the other line (Route 3) turns right towards New Addington from Theraipa Lane and Wimbledon/West Croydon after after the tram stop.Or was it after he missed the tram stop and the tram derailed.

Tothehills   21/02/2017 at 09:21

What I find concerning in all of this is that it appears the trams were not designed for crash worthiness. Since the 1967 Hither Green crash modern rolling stock has been designed to remain integral in the event of a crash; i.e. the windows do not come out causing the rolling stock to run-over its passengers. It seems the tram manufacturers need to relearn this lesson - the equivalent crash in a modern train may have injured passengers but would have been unlikely to have killed any of them/

James Palma   21/02/2017 at 13:33

As a former Croydon Tram driver for 5 1/2 years, just some things I hope people will find useful. 1) Drivers know the network inside out, where speed restrictions are, where curves are, when to brake early, when to brake late, how the trams behave in all different weathers etc. Additional signage is a nonsense just to pretend something is being done to appease people. In reality signage is irrelevant, for the reasons above, and speed restrictions are only any assistance where drivers are in a position to heed those speed restrictions, which it seems this driver was not! 2) when I drove the trams I would do 8-9 rounders (trips) from East Croydon to New Addington per day, working 5-6 day weeks, sometimes with 3 or 4 days on the same route or duty. So 36 times in any 4 day period. That is without over time, when I could do an additional 3-4 rounders. now times that by 5 years. I have an idea where I am going. 3) That was as one driver, doing one duty. Consider the timetable, how many trams and drivers make one movement over that curve in any one day for the last 18 years. I am sure a statistician would be able to work out the odds of an accident such as this happening again. 4) Now, losing awareness can be for any number of reasons. The timetable for that route was, if I remember rightly, first tram off shed at 430am. the driver signing in 30 minutes before to: read late notices, get instructions and the keys, prep the tram etc. The driver also has to get out of bed and get ready to go to work and get to work so they could be getting up at 230am. So they could naturally be tired. I suggest, any driver that has been through that tunnel and has not fallen asleep or dozed or just phased out for a seconds without realizing it, is not telling the whole truth. It is well documented on the tube and other railway networks. 5) this is just an example, NOT a presumption of what MAY have happened 6) With regard to the design of the trams, I think you will find they are designed to be crash worthy. All the weight is in the bottom (the frames, bogies etc.) there is also a very substantial frame forming parts of the body to minimize the effects of side on collisions etc. Buses and trams are designed to lean for some considerable distance before toppling. For example, I have seen the after effects of a tram hitting a bus at 50mph (the trams top speed). The bus was written off, the tram is still in service. Even trams have collided at low speed (20kph), as documented in the RAIB New Addington collision. so they are safe. 7) This is one sad incident, not a daily occurrence, so I suggest people really should think with their brains and not with their knees as knee jerk reactions cost money that could be better spent elsewhere.

Dorian Baker   21/02/2017 at 14:32

Although the RAIB first report said the curve is "about 30m radius", I looked at digital map data which shows just 20m radius. I have no data on installed track cant but the group of switches to the west will have nil cant. Very tight curve and nil cant is the exact recipe for a derailment + overturning. A fairly simple per way scheme could deliver 40m radius and 150mm cant within the TfL ownership boundary and make the whole junction infinitely safer with no loss of time messing up the working time-table

John Grant   21/02/2017 at 17:45

Agree that chevrons are a nonsense. Ideally there should be something like TPWS, or at least an audible warning in the cab at the point where the brakes ought to be applied.

Stuart B   21/02/2017 at 20:30

The death toll in this accident and the claim of loss of awareness by a supposedly experienced driver demands that something different be done to prevent similar tragedies in the future. I would suggest that centreline lighting, similar to that used on airport runways, might be used in situations like this. On runways at major airports, lights are installed at uniform intervals along the entire runway centreline to provide a continuous lighting reference from end to end. The first light is positioned 75 ft/25 m from the landing end and they continue every 50 ft/15 m to a point 75 ft/25 m from the far end of the runway. When viewed from the near (landing/takeoff) end of the runway, the centreline lights are all white for most of its length. When 3000 ft/900 m remain, however, red lights begin to alternate with the white lights for the next 2000 ft/600 m. For the last 1000 ft/300 m of the runway, the centreline lights are all red. An illustration may be found at Why not install similar warning lights on the ground between the tracks on the approach to a sharp bend, or indeed any feature that demands a significant drop in speed? They can be mounted flush with the surface, as is done on runways, to minimise interference with cars or pedestrians. If lights would cost too much, flush-mounted retroflectors could be used instead. We're all familiar with the "cat's eyes" that are used to indicate the centre of a roadway, so why not consider their use here?

John Grant   21/02/2017 at 20:38

Lights will only work if the driver has his eyes open, which seems not to be the case here.

Jerry Alderson   22/02/2017 at 16:43

What James Palma has written is very useful. I support his use of statistics to show that there is a very low chance of this happening again and that there should not be a kneejerk reaction. I do wonder, however, whether a cost-effective solution could be introduced on new trams. A passive balise in the track showing the maximum speed is the easy bit (you see them at statinos to inform the train how long the platform is and on which side, for example). Putting a detector in the bottom of the tram (both ends) and wiring it to the speedometer and an alarm (or the brakes) is the expensive bit. I also agree that the trams are crashworthy when they are upright. Obviously the problem here was that they fell over. News reports have not revealed how the seven passengers died (probably far too gruesome) but, like Tothehills, my assumption was that the windows came out "causing the rolling stock to run-over its passengers" and perhaps decapitating them. Nasty!

Mod   22/02/2017 at 21:43

Andrew, the article states that the driver lost awareness, however the reasons for this have not been disclosed. Again we must ask you to not speculate.

Mark Hare   23/02/2017 at 11:32

@Andrew Gwilt you clearly have no idea what you're talking about. I'm sure the driver did not 'misread the signs' approaching the curve - he would have been well aware of the features of the route and where to brake. And anyone who can't understand how a driver 'loses awareness' - have you never been driving your car over a familiar route and gone into 'autopilot' mode? Have you never been performing a menial task and lost concentration, had a daydream or been thinking about something else? Humans are not machines and sadly they make mistakes, that's a fact of life. Anyone who claims they never make a mistake is a liar.

Andrew Gwilt   23/02/2017 at 18:31

@Mod. Oh I'm sorry for speculating on this. But I was only making my opinions ok. How about you keep your own opinions to yourself and shut it ok. Idiot.

Andrew Gwilt   23/02/2017 at 18:35

@Mod. And another reason why you think I'm speculating just rubbish. You think I was making my comments up. Oh please just shut up and keep your opinions to yourself ok. Rant over.

Andrew Gwilt   23/02/2017 at 21:40

Well thanks for clarifying it that I was mostly wrong on what I commented. @Mark Hare. Sarcastic Idiot

Mark Hare   24/02/2017 at 12:48

Very good Andrew. I notice you seem to comment a lot on here with your 'opinions' but don't seem to possess the knowledge to back those opinions up. Feel free to voice your opinions whenever you like but be aware that there are many railway professionals on here who will call you out if you post uninformed views.

Mod   25/02/2017 at 08:12

Andrew, I'm the site moderator, you don't tell me what to do here. People have been killed so it is very disrespectful to claim that you know why the accident happened, and especially to start lashing out at other commenters. At some point we have to draw a line and this might be that point.

Andrew Gwilt   07/03/2017 at 17:43

Fine I rest my case. You guys have won. I apologise.

Ray Newell   25/04/2017 at 09:10

Please could a driver or similar expert tell me how a driver knows when to commence braking in the tunnel when the tunnel exit is difficult to see (such as at night or in poor visibility). Is it based upon the lights that appear to be present in the tunnel? Is it possible that in reduced visibility the necessary cues would be obscured? I would be interested to know if anyone thinks the absence of a cue to commence braking could be a factor in this accident.

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