Croydon Tram Accident

[Mad McCann]

As one who has worked shifts most of his working life (and has the health issues to prove it), I can vouch for the above. When I left full time employment in 2014, I noticed a definite improvement in my sense of well being although ironically it was only after this that my health issues truly appeared openly.

 

After about two and a half years on a 15-hours a week part-time job, I started a new job last April and was right into full-time shift work with long days up to near twelve hours on occasion and I could feel the same run-down feelings returning. Although I made the decision to revert to part time in July, it was only last month when I was able to do that. During that six months, I really felt the physical toll and especially so on the early starts, a few of which were pre-5am. This meant on occasion a 3.30 rise to see to the dog before cycling in. Fortunately now, I only work three days a week with only a few early starts at 06:30 and one at 06:20. It's true that on an early start you don't really get a decent sleep. This is because (certainly in my case) you're waiting for the alarm to go off, however early you go to bed and you're guaranteed to wake up at least  twice during your sleep period. The only saving grace of this full-time stint was that there was no night shift, I really used to fare badly on that.

Fortunately, I now have a much better balance and the shifts don't really intrude on normal day to day life. I feel a lot better again as a result.

 

Having driven on the open road in the dark in rural areas, I recognise that under those circumstances, it is easy to become disorientated momentarily, especially in conditions of darkness. it would appear from studying the above, something of that ilk has occurred in this instance with unfortunately tragic results. I think therefore that 'blame' would be utterly inappropriate and this will just have to be accepted as dreadful, but essentially freak occurence.

 

D4  

[34theletterbetweenB&D]

...I have met plenty that claim they can get by on four hours sleep or can't sleep at night, without fail they are the same people falling asleep during the day.

 Of course, shift working cannot be avoided in many walks of life but it's always early shift that offers the greatest temptation for people to burn the candle at both ends...

 While I don't necessariy agree that it is early shift or shift working that offers the temptation - regular nine to five types who bowl into the office at 9am, direct from a night club they left at 6.30 am anyone? - I do agree that the effect of shift working, and especially where swing shifts may be involved, has to be taken seriously. But usually it's the 'I can get by on insufficient sleep' attitude that's at the bottom of the problem. I have seen them fall asleep at the controls and the like, and in the 'best ever' slump onto a conveyor belt and end up on the floor a dozen yards away (nowhere more serious than the packing shop fortunately). Dismissed him, but some other bugger re-engaged him the following week, such was the employment situation at the time...

 

When I was last involved in a manufacturing op which presented significant hazard, there was talk of a task test to gauge fitness at start and after breaks. Anyone know if anything came of that? I liked the idea, but most of my management colleagues were agin. The two who ran a night taxi business, I could see their motivation...

[The Stationmaster]

I was another who vastly preferred late turns to earlys and was almost as happy with night turns as lates.  If 12 hour shifts were involved I would plump for nights every time, as much as anything to avoid getting up at 05.00 or worse.  The problems do however go beyond that nowadays I think with many people living much further from their place of work and consequently becoming involved in potentially tiring travel before even starting work.  Add various modern day social pressures to that mix and things can be even worse.

 

Some operators did a lot of research into shift patterns including taking advice on circadian rhythm  and the impact of sleep patterns etc but from what was being said on London BBC tv last night there appear to have been wider problems on Tramlink about safety reporting and an alleged 'fear culture'. (which might be an exaggeration from the media of course but perhaps no smoke without fire?)

[Siberian Snooper]

I didn't mind shifts in the yard as I would be on nights for a month at a time, so I got into a pattern. On the buses it was a change every week and towards the end a midweek step change sometimes, I struggled with that as I couldn't get into a rythem, even now I have retired I still get nights where I don't get a good night's kip.

[D854_Tiger]

I was another who vastly preferred late turns to earlys and was almost as happy with night turns as lates.  If 12 hour shifts were involved I would plump for nights every time, as much as anything to avoid getting up at 05.00 or worse.  The problems do however go beyond that nowadays I think with many people living much further from their place of work and consequently becoming involved in potentially tiring travel before even starting work.  Add various modern day social pressures to that mix and things can be even worse.

 

Some operators did a lot of research into shift patterns including taking advice on circadian rhythm  and the impact of sleep patterns etc but from what was being said on London BBC tv last night there appear to have been wider problems on Tramlink about safety reporting and an alleged 'fear culture'. (which mie ght be an exaggeration from the media of course but perhaps no smoke without fire?)

 

There is an easy way to overcome the fear culture, which I suspect the inquiry has used, poll the workforce anonymously on safety issues, on a regular basis, using an independent agency.

 

A forum where drivers can admit their mistakes, the circumstance and where, could be a very effective way of highlighting any issues that need addressing or where an unhelpful culture towards safety exists.

 

In my experience no senior manager, no middle manager, no supervisor or worker at the coalface ever goes into work thinking today would be a good day to kill an innocent member of the public.

 

Invariably though when it happens, there has been oversight but usually unintended and in a way no one saw coming.

[jjb1970]

I think there are a lot of variables to consider when assessing work patterns. I think if shifts are regular then they are fine. Variable patterns and short notice changes are much more of a problem than the concept of shifts.

I worked a pattern of 6 hours on/6 hours off for 6 week trips for a few years and never found the work pattern to be a problem. In electricity generation I worked 12 hour shifts and liked it as we got so many days off. On the other hand I worked on UMS ships doing duty every third day and that could easily get very tiring on a problematic ship or if there was a lot of night time stand byes.

[Pacific231G]

There is an easy way to overcome the fear culture, which I suspect the inquiry has used, poll the workforce anonymously on safety issues, on a regular basis, using an independent agency.

 

A forum where drivers can admit their mistakes, the circumstance and where, could be a very effective way of highlighting any issues that need addressing or where an unhelpful culture towards safety exists.

 

In my experience no senior manager, no middle manager, no supervisor or worker at the coalface ever goes into work thinking today would be a good day to kill an innocent member of the public.

 

Invariably though when it happens, there has been oversight but usually unintended and in a way no one saw coming.

There is a system used in aviation both private and public transport called CHIRP  (Confidential Human Factors Incident Reporting Programme) Where anyone employed or engaged in aviation can report an incident confidentially but not anonymously (whch protects it against spurious or malicious reports) to an independent charitable foundation. Confidentiality is an essential feature of it as it means that if you see someone - especially if you are the someone -doing something dangerous especially if it causes a near miss (figuratively as well as literally) you can report it and reports are carefully anonymised and published so people can learn by others' mistakes. They also use aeromedicine and other experts to look at patterns revealed by the reports.

To quote the Trust's description 

CHIRP complements the CAA Mandatory Occurrence Reporting system and other formal reporting systems operated by many UK organisations, by providing a means by which individuals are able to raise safety-related issues of concern without being identified to their peer group, management, or the Regulatory Authority.

 

I'm frankly astonished if something like this doesn't exist in the railway industry. No driver who want to keep his or her job is likely to report falling asleep at the controls or even becoming disoriented but if several had reported it confidentially then the problem would have been known and any operating company would have been clearly negligent if it didn't act on it . 

 

CHIRP has now been extended to the maritime industry. There's more about it here. https://www.chirp.co.uk/what-we-do/aviation-programm

[Chris116]

There is a system in the rail industry called CIRAS. I have copied from their web site the outline of how it works.

 

CIRAS is a independent system. It is governed by the “CIRAS Committee” which consists of representatives from the UK rail industry, Transport for London, UK Light Rail, Trams and other UK transport modes.

It also consists of a selection of independent professionals who bring with them expertise from other industries and academia such as Oil and Gas, HSE, Trade Unions. The Committee is responsible for ensuring that industry receives a service that is independent, confidential, affordable and focused on helping make the UK transport industry environment even safer for all concerned.

We take our role in helping to deliver a safer work environment extremely seriously and are proud of the part we play. We do, however, recognise that there will be times when our members, or our stakeholders, may not be entirely happy with aspects of the way our services have been delivered. In such circumstances we have a robust complaints process designed to resolve any situation.

I hope that helps everyone.

[RfDforever]

I'm a little surprised that some who post are not aware of CIRAS but my reading of the report suggested that it doesn't apply to tram systems anyway - although that didn't stop someone reporting safety concerns about Croydon trams to them. The report also seems to imply that when those outside the company with safety reservations (who cannot use CIRAS) are not taken particularly seriously - at least, not until there's a accident that supports the basis of their concerns. 

It does seem from the report that tram safety is much more aligned to road rather than rail safety standards. Modern trains are pretty successful at preventing passengers from being thrown through doors or windows in the event of an accident, for instance.

[wombatofludham]

I have heard from someone in the rail industry that CIRAS doesn't enjoy the kind of trust CHIRPS does in aviation. I don't know how true it is but the suggestion was the concept of "no blames, no packdrill" wasn't being fully followed by some managers given incidents were identifiable.

 

If this is true then it is concerning as CHIRPS does appear to have had benefits in aviation and the principle is something the rail industry ought to be able to easily adopt given the long tradition of safety development and investigation on the railways. As I say I don't know for certain if this was an isolated case or something more widespread. It'll be interesting to hear from current front-end and safety critical railway staff as to how widespread or not the view is.

[meil]

Does CIRAS cover heritage railways?

[Southernman46]

CIRAS is about as useful and effective as a chocolate teapot - fine for drivers walkways in Tees yard or LUL mess room chairs - but for ANYTHING really serious like flying frangible shoegear - absolutely toothless - complete and utter waste of time and resource

and yes I am bloody bitter twisted and angry with that feckin useless and SUPPOSEDLY anonymity protecting organisation.

That poor tram driver - I hope his conscience & soul survives this - he didn't set out to kill 7 people - he just made one disastrous error

[Chris116]

As I understand it, CIRAS covers ALL railways so Heritage Railways are covered and the forward on their web site specifically mentions "light rail and trams" so I cannot understand claims that Tramlink is not covered.

[chriswright03]

No matter what confidential systems are in place I still think it is highly unlikely that a driver will dob himself in for nearly falling to sleep at the controls. 

 

Yes shift work is difficult and having worked various forms of it for 40 plus years I know about those difficulties from experience.  Sleep pattern being disturbed by daft shift systems where you have a quick change over so that you were off 8 hours before being back on (Continental system as it was known) in the Police were a killer.  Thing is instead of having a week of night, lates and then earlies you condensed your workingweek by 16 hours so were off longer and sooner on rest days.  Thing is you needed to be because you were knackered!

 

Having recently retired from funeral care where regularly we had a week of on call where we would be called out in the night to collect the deceased was worse for me than working full nights.  A colleague I worked with told me how he nearly fell asleep at the wheel just a few miles from his house returning from a call out.  It was only 11pm!  He then told me that he didn't go to bed when he was on call because he could not stand having to wake up and go out straight away.  So rather than have any sleep at all he would try and stay up all night but his wife then didn't think he should be sleeping in the day.  Hence he was exhausted.

 

As someone has already pointed out there are those who do not have a full sleep period and look like Zombies when they rock up for work.  Those people are their own worst enemy as they will be watching crap on telly or playing games instead of resting then expect to go to work and perform to the required level and they can't.  Are they going to be honest and use a confidential system to report they are tired?  I don't think so. 

 

Human error is difficult, if not impossible to eliminate and reporting systems will not work for those who do not have the commons sense to ensure they are fit for work.  It would seem that there are many lessons to be learned from this tragedy including the fitness of the trams themselves.  Whether the driver was at fault or not does not seem to have been proved one way or the other but the fact that they have established there is a fear culture needs to be stamped on very quickly and acted upon.

[jim.snowdon]

As I understand it, CIRAS covers ALL railways so Heritage Railways are covered and the forward on their web site specifically mentions "light rail and trams" so I cannot understand claims that Tramlink is not covered.

Membership of CIRAS, especially outside of the main line railway industry was never, as I understand it, compulsory, particularly as the body originated within the RSSB, which itself does not cover the non-regulated railway sector. I would very much doubt that RAIB would be in error over their statement, but you do need to allow for the 13 month time difference between the event and now. RAIB will report on the situation at the time; if London Trams and TOL have subsequently become members after the event, that will not be covered by the report.

 

Jim

[jim.snowdon]

What is more pertinent is understanding why the driver missed the usual, and arguably indistinct, clues as to his location relative to the approaching curve. The RAIB report makes interesting reading on this and, in essence, what it points out is that on a long stretch of track such as the approach through the tunnels, particularly in the dark, there is very little information coming in to the brain to maintain alertness. It 's what the report refers to as brain underload, and put simply, the mind gets bored and partly switches off. The issue of spatial disorientation on parts of the tramway is not a new one, in that it is something that was considered in the wake of the two tram derailments that occured at Phipps Bridge in 2005/6. It led to my drawing up ideas for advance signage of hazards, such as points and sharp bends, as, as TCL's Chief Engineer at the time, discussing these with others in the industry, including TOL, and with HMRI. Interest was limited, with the reaction being that the driver's route knowledge was sufficient. Interestingly, the potential for similar advance signage, using the same principles as for highway signage, is touched upon by the RAIB in their report.

 

Jim

[martin_wynne]

on a long stretch of track such as the approach through the tunnels, particularly in the dark, there is very little information coming in to the brain to maintain alertness.

 

In this cab ride video  through several tunnels, there are up-down zig-zag lines on the tunnel walls to give a sensation of speed. By varying the spacing of the zig-zags the need to brake could be reinforced. When I first watched it I thought about the Croydon accident. Is this sort of marking used in the UK, or common elsewhere?

 

 

 

edit: Good demonstration of the effect is at 12mins 40secs.

 

Martin.

Edited December 8, 2017 by martin_wynne

[jim.snowdon]

In this cab ride video  through several tunnels, there are up-down zig-zag lines on the tunnel walls to give a sensation of speed. By varying the spacing of the zig-zags the need to brake could be reinforced. When I first watched it I thought about the Croydon accident. Is this sort of marking used in the UK, or common elsewhere?

 

 

 

edit: Good demonstration of the effect is at 12mins 40secs.

 

Martin.

Martin,

 

I see what you mean, although I think the original intentin was to provide a guide to anyone in the tunnel as to which way to go for the nearest refuge. It isn't something I have seen in any other railway tunnel and the nearest equivalent that I have come across anywhere has been the luminescent markers installed by British Waterways in the longer canal tunnels that give the distance to the nearer portal.

 

In the context of Croydon (or any other tramway with like circumstances, ie an absence of visual cues, especially in the dark), I am inclined to think that simpler discrete markers would be beneficial. Route knowledge is all very well, but it does depend upon the driver having sufficient sensory cues (visual or audible) to be able to identify his or her location. Even then, dependence on a single cue is not good, as if it it missed for any reason, the entire benefit is lost.

 

Jim

[Pacific231G]

In this cab ride video  through several tunnels, there are up-down zig-zag lines on the tunnel walls to give a sensation of speed. By varying the spacing of the zig-zags the need to brake could be reinforced. When I first watched it I thought about the Croydon accident. Is this sort of marking used in the UK, or common elsewhere?

 

 

 

edit: Good demonstration of the effect is at 12mins 40secs.

 

Martin.

Hi Martin

I remember first seeing those zig zag markings in Austria many years ago but I've seen them since in a lot of European tunnels. Their purpose is to let PW staff, particularly the lengthsmen who regularly walk the track without a look-out,  know without having to guess in which direction the nearest refuge is. In the film you can clearly see the refuges at the low point of each zig zag. If they help to avoid driver disorientation that's a bonus but it's not why they're there. I can't recall which countries use them but they make a great deal of sense and avoid the situation of a worker hearing a train whiste and trying to get to a refuge forty metres ahead when there's one ten metres behind. They would be particularly useful in low visibility but I don't know if they were feasible when steam trains were in use.

 

On a related theme I've often wondered why Britain's railways traditionally made far less use of white paint (or whitewash) to help the safety of staff on the ground than in some other countries?. In France and I think elsewhere it was normal to have everything a railway worker might trip over or bump into, particularly in the dark, including the ends of check and wing rails, the edges of barrow crossings, the counterweights on point levers, and even the corners of buildings. Refuges not only in tunnels but also in retaining walls and the edges of safe walking routes through yards were/are also very clearly marked. I don't know if this means that staff spent more time physically on the ground around the track than they did here with points often being unlocked then locally operated and more use of hand signals. I think some of this sort of marking was used in Britain during the wartime blackout and I've seen it ocasionally at the ends of live rails and more widely around London Underground but it never seems to have really taken off here.  .  

Edited December 8, 2017 by Pacific231G

[Mark Saunders]

In this cab ride video  through several tunnels, there are up-down zig-zag lines on the tunnel walls to give a sensation of speed. By varying the spacing of the zig-zags the need to brake could be reinforced. When I first watched it I thought about the Croydon accident. Is this sort of marking used in the UK, or common elsewhere?

 

 

 

edit: Good demonstration of the effect is at 12mins 40secs.

 

Martin.

 

Alas I cant see that doing anything as it is only visual the use of an audible warning that needs to be acknowledged in the same way as AWS is far better!

 

The thing that strikes me is that there is no joined up thinking between tram and train with each having to learn by its own mistakes!

 

Mark Saunders

[Pacific231G]

CIRAS is about as useful and effective as a chocolate teapot - fine for drivers walkways in Tees yard or LUL mess room chairs - but for ANYTHING really serious like flying frangible shoegear - absolutely toothless - complete and utter waste of time and resource

 

and yes I am bloody bitter twisted and angry with that feckin useless and SUPPOSEDLY anonymity protecting organisation.

 

That poor tram driver - I hope his conscience & soul survives this - he didn't set out to kill 7 people - he just made one disastrous error

It's a bit like the unfortunate bosun on the Herald of Free Enterprise. He fell asleep on his bunk while intending to just rest for a few minutes and didn't close the bow doors. He got a lot of the blame but might just as easily have tripped and been knocked out. It was the criminal lack of any system, human or technological, to check that the ship was safe to sail that really caused the disaster and even before it happened there were concerns about TT's attitude to ship safety. IMHO to err is human but to fail to allow for that is corporate manslaughter.

 

If CIRAS is not completely anonymous and not trusted to be so then a chocolate teapot would be a fitting description. 

[jjb1970]

In the case of the Herald of Free Enterprise I think the bigger issue goes further back than the crew or TT, why did the world ignore the known and understood vulnerabilities of Ro0Ro vessels for so long?

[Talltim]

The thing that strikes me is that there is no joined up thinking between tram and train with each having to learn by its own mistakes!

 

Mark Saunders

 

And for rail and bus

453

Following a collision between a bus and a tram in Croydon in September

2008 (RAIB bulletin 01/2009), the RAIB recognised the risks associated with

passengers being ejected through bus side windows. In this instance, the fixing

between the window and the bus body failed, rather than the failure of the window

glass observed at Sandilands. Bus safety lies outside the RAIB’s scope so the

RAIB could not make a recommendation related to the bus accident. The RAIB

therefore wrote to relevant parties.

454

The RAIB’s letter to the Department for Transport (DfT), sent on 6 January 2009

described the circumstances of the accident and then stated: ‘the side windows

at the front of the upper deck of the bus appeared to offer little protection to

people sitting in the front seat in case of a collision of this type...we suggest that

this accident has revealed an issue which should be allowed for in the standards

and/

or regulations governing the design of buses.’

455

The DfT’s response dated 9 February 2009 stated ‘There is no specific

requirement for buses to have side windows and no requirement on strength of

fixing when windows are fitted. This is the case in both domestic and international

legislation’. There is no evidence that DfT considered whether an amendment to

standards or regulations was appropriate.

456

The RAIB’s letter to TfL, dated 6 January 2009 also described the circumstances

before stating: ‘we have identified the following matters which we would like to

draw to your attention...the side windows at the front of the upper deck of the bus

appeared to offer little protection to persons sitting on a front seat in case of a

collision of this type’.

457

TfL responded with a letter dated 9 February 2009 stating: ‘we will be reviewing

[the matters raised by the RAIB] along with recommendations from our own

investigations, through our internal safety governance arrangements, and

taking action where appropriate to an agreed and prioritised timetable.’ TfL

has no record of taking any further action except for a note recording that ‘DfT

wrote to the RAIB that in their assessment, it is unlikely that any regulation was

contravened in the design and fixing of the window.’

Basically the DfT went 'you rail people can try to be safe, we are going to ignore the safety of bus passengers'

[Fat Controller]

Alas I cant see that doing anything as it is only visual the use of an audible warning that needs to be acknowledged in the same way as AWS is far better!

 

The thing that strikes me is that there is no joined up thinking between tram and train with each having to learn by its own mistakes!

 

Mark Saunders

 

Hi Martin

I remember first seeing those zig zag markings in Austria many years ago but I've seen them since in a lot of European tunnels. Their purpose is to let PW staff, particularly the lengthsmen who regularly walk the track without a look-out,  know without having to guess in which direction the nearest refuge is. In the film you can clearly see the refuges at the low point of each zig zag. If they help to avoid driver disorientation that's a bonus but it's not why they're there. I can't recall which countries use them but they make a great deal of sense and avoid the situation of a worker hearing a train whiste and trying to get to a refuge forty metres ahead when there's one ten metres behind. They would be particularly useful in low visibility but I don't know if they were feasible when steam trains were in use.

 

On a related theme I've often wondered why Britain's railways traditionally made far less use of white paint (or whitewash) to help the safety of staff on the ground than in some other countries?. In France and I think elsewhere it was normal to have everything a railway worker might trip over or bump into, particularly in the dark, including the ends of check and wing rails, the edges of barrow crossings, the counterweights on point levers, and even the corners of buildings. Refuges not only in tunnels but also in retaining walls and the edges of safe walking routes through yards were/are also very clearly marked. I don't know if this means that staff spent more time physically on the ground around the track than they did here with points often being unlocked then locally operated and more use of hand signals. I think some of this sort of marking was used in Britain during the wartime blackout and I've seen it ocasionally at the ends of live rails and more widely around London Underground but it never seems to have really taken off here.  .  

They're used in Italy, and possibly France; I did suggest to our management that we use them, but nothing ever came of it.

[Mad McCann]

As an aside; whilst illness was discounted it can certainly be a significant factor in driver awareness. To recount an incident from personal experience, shortly before I reverted to part time, I was late on in a shift that had lasted about ten hours, including break and throughout the afternoon I could sense that I was coming down with some kind of virus. As the shift progressed into its last hour or so, I could feel extreme fatigue and physical weakness setting in with my reactions and concentration beginning to suffer to a degree that I was increasingly troubled by although fortunately I finished the shift without incident. I booked off very gratefully that night and decided once I got home that I'd not be going in the next day, advising the inspector accordingly.

 

As it happened, after a good night's sleep (I would have been on an 05:50 start as I remember) I did feel somewhat better and I went back to work the day after that, but I felt that being in that condition made me unsafe to drive and regardless of losing a day's pay, I was resolutely unwilling to take a risk with anybody else's life and limb.

 

At the end of the day you have to accept that you have physical limitations and moral responsibilities and I'd do no different in the future, regardless of what anybody upstairs said. Fortunately, our local management and union representation appear to be pretty good in that respect.

 

D4