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Sandilands Tram Crash - An Accident

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transportphoto

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An inquest has found that the 2016 tram crash which killed seven was an accident, the BBC reports:
A tram crash which killed seven people in Croydon was an accident, an inquest jury has found.
More than 50 people were injured when the tram tipped over and spun off the tracks near Sandilands tram stop in south London in November 2016.
The tram was travelling three times faster than a speed restriction.
The inquest jury at Croydon Town Hall reached its verdict after more than nine days of deliberations.
The crash resulted in the deaths of Dane Chinnery, 19, Philip Logan, 52, Philip Seary, 57, Dorota Rynkiewicz, 35, and Robert Huxley, 63, all from New Addington, and Mark Smith, 35, and Donald Collett, 62, from Croydon.
Family members of the victims sat in the public gallery to hear the verdict.
The foreman of the jury said: "The tram driver became disorientated, which caused loss of awareness in his surroundings, probably due to a lack of sleep.
"As a result of which, the driver failed to brake in time and drove his tram towards a tight curve at excessive speed.
"The tram left the rails and overturned on to its right side, as a result of which the deceased [were] ejected from the tram and killed."
Source: Croydon tram crash: Passengers accidentally killed, jury concludes https://www.bbc.co.uk/news/uk-england-london-57721493
 
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GodAtum

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I agree it was a corporate accident, for which the company should be liable.
 

LNW-GW Joint

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The report in the Guardian is a little more nuanced:
Croydon tram crash deaths were accidental, inquest rules | Rail transport | The Guardian
Ormond-Walshe directed the jury at Croydon town hall that it could deliver a verdict of unlawful killing or accidental death, although any verdict of unlawful killing would depend on finding gross negligence by the driver, Alfred Dorris. She said that the evidence was far below the threshold of corporate manslaughter.
...
Ormond-Walshe admitted one witness who had not spoken to investigators. Jim Snowden, a former chief engineer on the network, told the inquest he had raised safety concerns eight years earlier about the stretch of track where the crash occurred, particularly the lack of warning signs.
In a written report from 2008, he had said that there were “long stretches of segregated track and isolated alignments where there are few visual clues as to location during the hours of darkness, there is potential for the driver to lose awareness of the distance to approaching hazards and it may become appropriate to consider the provision of advanced signage as a reminder.”
One of two locations he cited on the network were the Sandilands tunnel immediately before the bend.
Dorris, the driver of the tram, was not called to give evidence at the inquest, having been ruled medically unfit.
 

Applepie356

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Still can’t believe the Tram driver was never prosecuted for death by dangerous driving.

And now this incident being classed as an accident is just a slap in the face to the relatives of the deceased and the survivors of the crash.
I suspect it was done to minimise any potential payout TFL would have to do.
 

edwin_m

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Still can’t believe the Tram driver was never prosecuted for death by dangerous driving.

And now this incident being classed as an accident is just a slap in the face to the relatives of the deceased and the survivors of the crash.
I suspect it was done to minimise any potential payout TFL would have to do.
If there is a suggestion that the driver wasn't provided with reasonable means of alerting them to the hazard, then a prosecution of the driver would most likely fail.

The coroner and the inquest jury are independent of TfL, so it's highly unlikely that the payout or otherwise would have influenced the verdict.
 

AlterEgo

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If there is a suggestion that the driver wasn't provided with reasonable means of alerting them to the hazard, then a prosecution of the driver would most likely fail.
The driver either fell asleep briefly or was distracted, or had a medical episode. He had ample warning of the hazard by using his eyes, which unfortunately may have been closed. The RAIB found it likely he had a "microsleep".

It's not clear why the driver isn't being prosecuted because evidence of any defence he gave to the police hasn't been made public, but mark my words he is a lucky boy, not only to survive, but also to evade the force of the law.

I sympathise with the families of the deceased who are obviously disappointed nobody will be held accountable for their dead relatives.
 

Tomnick

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He had ample warning of the hazard by using his eyes...
It was dark, and raining heavily, and the hazard was almost immediately beyond the exit from a relatively well-lit tunnel, marked only by a small sign and with rails presumably visible beyond the junction carrying on straight ahead on the same alignment. I wouldn't call that ample warning of the hazard, nor did the RAIB.
 

notadriver

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I would have expected to at least have encountered a permanent AWS magnet on heavy rail or have multiple warning signage of a sharp bend on a road. None were present at the time.
 

Ianno87

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It was dark, and raining heavily, and the hazard was almost immediately beyond the exit from a relatively well-lit tunnel, marked only by a small sign and with rails presumably visible beyond the junction carrying on straight ahead on the same alignment. I wouldn't call that ample warning of the hazard, nor did the RAIB.

I would have expected to at least have encountered a permanent AWS magnet on heavy rail or have multiple warning signage of a sharp bend on a road. None were present at the time.

Signage is present now, plus chevrons, plus a speed restriction on approach.
 

WatcherZero

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It does sound like a bit of a white wash. Neither TfL or the Driver testified to the inquest and the families requested a list of key witnesses to testify and have their statements cross examined (managers involved) was refused by the judge.
 

bassmike

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Ideal solution would be speed controlled points with any speeding tram being sent straight on into the presently disused tunnel just beyond the danger point.
 

Tomnick

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Ideal solution would be speed controlled points with any speeding tram being sent straight on into the presently disused tunnel just beyond the danger point.
Carrying on straight ahead would put a "runaway" tram with anything coming around the curve in the outbound direction, and almost immediately onto the double track formation curving away and continuing along the same alignment.
 

bramling

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Still can’t believe the Tram driver was never prosecuted for death by dangerous driving.

And now this incident being classed as an accident is just a slap in the face to the relatives of the deceased and the survivors of the crash.
I suspect it was done to minimise any potential payout TFL would have to do.

My views are mixed on this. I can’t see a prosecution of the driver being justified when there was clearly an unforeseen hole in the safety armour. It does seem that this potential risk was never envisaged.

Prosecuting the operator would be a can of worms, as firstly the decisions will have gone back many years, whilst secondly a number of peer systems in the UK were designed in exactly the same way, so Croydon was completely as per its peers.

This simply leaves some questions over fatigue management, which I do think seem to have been whitewashed over.

I can see how this would be upsetting for the relatives. At the end of the day this incident did happen on TfL’s watch, and there should have been some display of accountability, perhaps a symbolic resignation, this doesn’t seem to have happened.
 

Falcon1200

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It was dark, and raining heavily, and the hazard was almost immediately beyond the exit from a relatively well-lit tunnel, marked only by a small sign and with rails presumably visible beyond the junction carrying on straight ahead on the same alignment. I wouldn't call that ample warning of the hazard, nor did the RAIB.

Presumably however this wasn't the first time the driver had ever been over the route ? Do tram drivers get route-trained and assessed in the same way as train drivers ?

Certainly a terrible accident, and understandable why the families of those feel so aggrieved. Perhaps this particular set of circumstances had not occurred before on a UK tram system, and was not therefore perceived as a serious risk ? At least action has been taken to prevent a repeat (which is of course the story of most if not all railway accidents).
 

edwin_m

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Certainly a terrible accident, and understandable why the families of those feel so aggrieved. Perhaps this particular set of circumstances had not occurred before on a UK tram system, and was not therefore perceived as a serious risk ? At least action has been taken to prevent a repeat (which is of course the story of most if not all railway accidents).
It's mentioned above that Jim Snowdon, who was the manager of the Tramtrack Croydon concession at the time of construction and opening, gave evidence of having raised the issue. And it was certainly anticipated for the similar situation on Metrolink where a chevron sign was added where the Oldham line makes a sharp turn to diverge off the former railway at Werneth.
 

Taunton

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I've never subscribed to the "families have a right to ..." attitude, which commonly seems to be driven by lawyers in the background. Nor am I ever impressed by the "prosecute the driver" approach either, other than deliberate acts.

The operator however should surely have identified the cumulative design issues here. In fact, I'm surprised it took so long from system startup for this to happen.

Everyone has their own ideas. I would have put in an approach-controlled red light that changed only with a speed reduction. And the same coming the other way, from Addiscombe, into the comparable curve.

I'm always struck by the seemingly excessive procedures on the DLR when the auto driving fails and it's being operated manually from the front. Walking speed only, flashing lights operating, not moved an inch without longwinded radio messages back and forth, etc. Meanwhile a few miles down the road we have another TfL operation here with quite comparable vehicles operated at 50mph in the dark wholly on operator line of sight.
 

507 001

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I've never subscribed to the "families have a right to ..." attitude, which commonly seems to be driven by lawyers in the background. Nor am I ever impressed by the "prosecute the driver" approach either, other than deliberate acts.

The operator however should surely have identified the cumulative design issues here. In fact, I'm surprised it took so long from system startup for this to happen.

Everyone has their own ideas. I would have put in an approach-controlled red light that changed only with a speed reduction. And the same coming the other way, from Addiscombe, into the comparable curve.

I'm always struck by the seemingly excessive procedures on the DLR when the auto driving fails and it's being operated manually from the front. Walking speed only, flashing lights operating, not moved an inch without longwinded radio messages back and forth, etc. Meanwhile a few miles down the road we have another TfL operation here with quite comparable vehicles operated at 50mph in the dark wholly on operator line of sight.

There will have been an approach controlled signal protecting the junction, however it’s useless if there’s nothing to physically stop the vehicle if it SPADs said signal at speed.
 

Fishplate84

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I do wonder whether any of these tram drivers actually drive a car on the road. I mean, the poor signage, sheer amount of random external actions of those around them, huge range of conditions must overwhelm their capabilities to make it to the supermarket.

This was so obviously a system, process or human failure and in no way an 'accident'. With all the technology about today it should be impossible to enter a turn at 3x the safe speed. The sooner some automated speed limiters are introduced to remove this responsibility from the driver the better.
 

davetheguard

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I do wonder whether any of these tram drivers actually drive a car on the road. I mean, the poor signage, sheer amount of random external actions of those around them, huge range of conditions must overwhelm their capabilities to make it to the supermarket.

This was so obviously a system, process or human failure and in no way an 'accident'. With all the technology about today it should be impossible to enter a turn at 3x the safe speed. The sooner some automated speed limiters are introduced to remove this responsibility from the driver the better.

And will you be applying these "automated speed limiters" to every car and vehicle on the road too? I'm sorry, but I do wish we would stop having double standards on safety that make an already safer system (rail) even more safe, but continue to allow far lower standards on a more dangerous form of transport (road).
 

61653 HTAFC

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I do wonder whether any of these tram drivers actually drive a car on the road. I mean, the poor signage, sheer amount of random external actions of those around them, huge range of conditions must overwhelm their capabilities to make it to the supermarket.

This was so obviously a system, process or human failure and in no way an 'accident'. With all the technology about today it should be impossible to enter a turn at 3x the safe speed. The sooner some automated speed limiters are introduced to remove this responsibility from the driver the better.
I assume that tram drivers will need at least a full car licence (if not a PSV licence) as they drive on the road. AIUI most train drivers have driving licences but it isn't a requirement.

Upthread someone suggested that the driver is lucky... to have survived sure, and to have not been made the sole scapegoat for failures beyond his control, I guess... but I certainly wouldn't want to be in his shoes right now.
 

Falcon1200

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It's mentioned above that Jim Snowdon, who was the manager of the Tramtrack Croydon concession at the time of construction and opening, gave evidence of having raised the issue. And it was certainly anticipated for the similar situation on Metrolink where a chevron sign was added where the Oldham line makes a sharp turn to diverge off the former railway at Werneth.

Thanks, have to wonder then why these concerns were not acted on ?
 

railfan249

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Does tramlink not have speed control magnets akin to a Moorgate system? I’m perplexed as to why for such a massive speed restriction one wasn’t put in place.
 

Ianno87

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Prosecuting the operator would be a can of worms, as firstly the decisions will have gone back many years, whilst secondly a number of peer systems in the UK were designed in exactly the same way, so Croydon was completely as per its peers.

Presumably Croydon was designed in line with whatever light rail standards applied at the time, which would be it's "defence".

Though I can't think of many other examples of fast straight leading straight into such a sharp bend on other systems (without another feature such as a station stop breaking it up).

Only other one is the bend into Oldham Town centre near the former Werneth station, which has had chevron signage etc ever since its installation in ~2014, and is a gradual drop down of speed on approach.
 

edwin_m

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Though I can't think of many other examples of fast straight leading straight into such a sharp bend on other systems (without another feature such as a station stop breaking it up).

Only other one is the bend into Oldham Town centre near the former Werneth station, which has had chevron signage etc ever since its installation in ~2014, and is a gradual drop down of speed on approach.
That's the one I referred to above. It was identified as a specific issue by the operator's people in one of the safety workshops, and the chevrons agreed as a mitigation. There are probably progressive speed restrictions on the approach as well.

Here's something similar at Nottingham - the end of the long straight run up (or on this part just alongside) the former Great Central where it takes a sharp left to dodge over onto the former Wilford Toll Bridge. In order there are:
  • "Curve" warning sign (black on white diamond per other tramway signs)
  • Progressive speed reduction. There is almost certainly no reason why the track immediately beyond the sign is unsafe at maximum speed - this sign is to ensure that the tram is braking for the more severe restriction beyond. The Croydon report noted that a standard tramway sign for a low speed restriction isn't easily visible at braking distance from maximum speed.
  • Standard highway sign warning of bend - not sure how effective this would be as tram drivers normally ignore highway signs - plus tramway standard sign giving safe speed for curve.
  • Chevrons at the curve itself - these are probably more evident to a driver approaching on the far track than from the camera viewpoint.

I don't know if any or all of these were present at opening. I would expect to find similar measures at the exit from the railway section near Wilkinson Street.IMG_0107.JPG
 

Ianno87

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That's the one I referred to above. It was identified as a specific issue by the operator's people in one of the safety workshops, and the chevrons agreed as a mitigation. There are probably progressive speed restrictions on the approach as well.

Here's something similar at Nottingham - the end of the long straight run up the former Great Central where it takes a sharp left to dodge over onto the former Wilford Toll Bridge. In order there are:
  • "Curve" warning sign (black on white diamond per other tramway signs)
  • Progressive speed reduction. There is almost certainly no reason why the track immediately beyond the sign is unsafe at maximum speed - this sign is to ensure that the tram is braking for the more severe restriction beyond. The Croydon report noted that a standard tramway sign for a low speed restriction isn't easily visible at braking distance from maximum speed.
  • Standard highway sign warning of bend - not sure how effective this would be as tram drivers normally ignore highway signs - plus tramway standard sign giving safe speed for curve.
  • Chevrons at the curve itself - these are probably more evident to a driver approaching on the far track than from the camera viewpoint.

I don't know if any or all of these were present at opening. I would expect to find similar measures at the exit from the railway section near Wilkinson Street.View attachment 100124

Oldham's was definitely there on opening.

Both it and Nottingham are of course much more recent installations than Croydon.
 

edwin_m

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Oldham's was definitely there on opening.
Indeed - the workshop where it was agreed was well before completion of the line. An added hazard here was that the tramway originally continued straight on through Werneth station and the tunnels, before being re-routed into the town centre, so it's conceivable that a driver could momentarily forget that the route had changed.
 

notadriver

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I do wonder whether any of these tram drivers actually drive a car on the road. I mean, the poor signage, sheer amount of random external actions of those around them, huge range of conditions must overwhelm their capabilities to make it to the supermarket.

This was so obviously a system, process or human failure and in no way an 'accident'. With all the technology about today it should be impossible to enter a turn at 3x the safe speed. The sooner some automated speed limiters are introduced to remove this responsibility from the driver the better.

Tram accidents like those on heavy rail are a very rare occurrence compared to accidents involving road vehicles. Tram drivers will have been trained to a higher standard than car bus or heavy vehicle drivers and the tests they need to get the job and before being allowed to go solo are more difficult.
 

the sniper

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Is there anybody who can actually see any point in prosecuting the Driver? Entering the corner at that speed would seem clearly involuntary. What does a further punishment serve to do, is it to dissuade others from accidentally replicating something which nobody would knowingly do...?

I can see the argument for saying there were too few safe guards, hence going after the operator.
 
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Journeyman

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Those who seek revenge, mostly, I suspect :(
Yeah, I think having to live with the deaths of seven people on your conscience for the rest of your life is punishment enough for most reasonable human beings. Given that negligence or intent can't be proven, I think we just have to accept that imprisonment achieves nothing.
 
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