Croydon Tram Accident

[leopardml2341]

Think of risk as a 'Pie' - it can only be divided into slices and the size of slice 'given' to a particular contributor to overall risk will be determined by many aspects including that contributor's failure mode, its effects, its criticality and its predicted frequency of occurrence. Only when all of those, and more, have been considered are the risk protection mechanisms put in place. Risk of all kinds is unavoidable, what is an acceptable level of risk is often subjective.

It was not a crash. It was a derailment. I see nothing wrong with the thread title and see no need to amend it

But was it truly an accident?

 

Edit: why have my two responses been concatenated?

Edited November 16, 2016 by leopardml2341

[Colin_McLeod]

But was it truly an accident?

Edit: why have my two responses been concatenated?

Unless you think it was done on purpose then yes it was truly an accident. Accidents don't just happen: they are caused. If they were not caused deliberately then they are accidents.

 

Your two responses were concatenated because you posted them so soon after each other. I assume your actions that caused this (fast consecutive posting) was accidental - In this case due to lack of training in that no one explained to you that this would happen.

[leopardml2341]

Unless you think it was done on purpose then yes it was truly an accident. Accidents don't just happen: they are caused. If they were not caused deliberately then they are accidents.

Your two responses were concatenated because you posted them so soon after each other. I assume your actions that caused this (fast consecutive posting) was accidental - In this case due to lack of training in that no one explained to you that this would happen.

Please don't infer that I 'think' (sic) anything, it was an open question to which I have no preconceived answer nor pre-formed opinion.

[Reorte]

The Police used to refer to crashes as Road Traffic Accidents, RTA's, but now refer to them as Road Traffic Collisions, to reflect the fact that over 90% of road crashes, deaths and injuries are the direct result of human error and poor driving (rather than mechanical failure), usually involving one or more Traffic offences and the fact that when things go wrong they generally involve a road vehicle colliding with something such as another road vehicle, object, pedestrian etc. They are are definitely collisions but rarely if ever are they accidental. Someone was almost inevitably doing something they shouldn't have. That does not mean it was pre-meditated, but it was a decision by a human to do something that was not a good idea. so not a random "accident". The phrase accident gives the very incorrect impression the collision was unavoidable. And the vast majority are entirely avoidable. I'm afraid the use of the word accident avoids blame for things that should have blame attributed to them.

Although I'm pretty much repeating myself - that is not what accident means. Accident means it wasn't deliberate, and whilst most people who crash are doing something they shouldn't have been doing if they were not intending to crash then it's an accident. The word accident says nothing about blame one way or the other, and certainly does not mean that no-one is to blame. It is unfortunate that quite a lot of people have come to misunderstand the word.

 

My dictionary gives "accident - an unfortunate incident that happens unexpectedly and unintentionally".

Edited November 16, 2016 by Reorte

[47137]

I am sure, if someone flew a plane into Clapham Junction, the railway part of the event would be passed to the RAIB. For the railway, it would be an accident - solved. No problem.

 

And if the plane was flown by an employee of the railway, the result would be just the same.

 

Richard.

[PenrithBeacon]

I think the meaning of the word 'accident ' has changed over time. It once meant an unavoidable incident it now means an unintentional incident.

 

Regards

[martin_wynne]

I think the meaning of the word 'accident ' has changed over time. It once meant an unavoidable incident it now means an unintentional incident.

 

My old 1959 Collins dictionary says:

 

accident: mishap, ill-chance.

 

accidental: not essential.

 

There doesn't seem to be any "unavoidable" meaning there. Unavoidable means that even if you know about something in advance, you still can't do anything about it.

 

Martin.

[Ken.W]

Hope the investigation looks to and learns from modern Aviation Safety.

 

Air safety remained stubbornly poor until investigators stopped automatically blaming the pilot and started looking at the systems which allowed, even encouraged, mistakes to be made. The effect on safety was immediately positive and lead to the very high air safety levels we benefit from today.

 

If a mistake Can be made, sooner or later it Will be made.

 

In this case that is a ridiculously tight curve for such a large tram in regular passenger-carrying service. Add a long straight stretch leading up to it and this was quite clearly an accident waiting to happen. Nor do I see the need for it looking at a plan of the track, although I've not been there.

 

Hope the investigation turns out to be a modern enlightened one.

Or perhaps this has occurred the other way round, with Air Safety Investigations learning from how rail investigations have traditionally been conducted by HMRI, predecessors to the present HSE and RAIB, since around 1840. Their reports seek to establish cause rather than blame, and recommendations to avoid recurrence have led to many (most) of the safety systems that have been adopted.

Tom Rolt's 'Red for Danger' is recommended reading on this subject.

 

 

 

Edit; omitted ref to RAIB added

Edited November 17, 2016 by Ken.W

[Ken.W]

A similar main line scenario was the curve at Morpeth on the ECML.

 

In recent years, there had been three serious accidents on that curve before an AWS alert was implemented.

Similar, though at Morpeth it was an approx 50% reduction in speed rather than the proportionally more severe 75% in this case. Though it was actually Morpeth which led to the introduction of warning boards for severe speed restrictions, which has been subject to much discussion relating to this incident.

 

The first, in 1969, was Northbound, where the speed into the curve was an immediate 50% reduction, and the subsequent HMRI report led to the introduction of warning boards with an AWS warning for severe reductions in speed on high speed lines, including here.

 

The two subsequent accidents here, in the 80s / 90s? were Southbound, which differs in that, although the speed again halves, due to curvature of the line this occurs in stages over the preceding 3 miles, the immediate reduction on entering the curve being by 20 mph, thus did not qualify for warning boards as recommended following the northbound accident.

This was subsequently changed, plus now of coarse, both directions are also protected by TPWS

[Gwiwer]

Jargon changes over time.  "RTA" for road traffic accident is eschewed in favour or "RTC" for road traffic collision but also because of the frequently-abbreviated Road Traffic Act which is frequently cited as "RTA" including within this topic. Thus "RTC", which is more descriptive and arguably non-judgemental also eliminates potential confusion.

 

The DLR control system has been described above.  It works perfectly well 99.99% of the time and electronic errors are very rare.  However all trains (they seem to call them trains more often now there are two or three "cars" coupled) are staffed by at least one Captain who has ultimate responsibility.  The Captain releases and closes the doors and, as I understand it, provides a safe-to-start indication to the computer control system.  Their other duties are typically revenue enforcement and customer service but they are all trained to drive from the emergency panel at the front nearside seat and do so in the event of a problem which may be outside the scope of the control system such as an accidental overspeed.  They do happen.  And when they do and the excess speed is detected the "train" is brought to an immediate stand by the application of the emergency brake.

 

All the gubbins required for this results in a lot of additional cabling which is fine on the DLR as there is no street running but may not be an option to embed in tarmac or concrete for street sections.  Cost is not the argument here; what cost a life?  It is the physical structure of the system which does not translate into on-street traditional-style tramway operation.

 

I note the commendable speed with which the RAIB has released its interim report.  That should assure all who need reassurance that they are doing all they can as fast as they can and want to have the tramway up and running again very soon.  But as we know the full investigation will take much longer and could yet result in the driver facing court.

Edited November 17, 2016 by Gwiwer

[Edwin_m]

While "road traffic collision" is valid as an alternative to "road traffic accident" the same terminology wouldn't work on rail, because many rail accidents (arguably including this one) are pure derailments with no collision involved. 

[Colin_McLeod]

Please don't infer that I 'think' (sic) anything, it was an open question to which I have no preconceived answer nor pre-formed opinion.

I did not infer anything.

[47137]

Having slept on this, I think the validity of the word ‘accident’ depends a lot on your point of view of an incident.

 

It is reasonable for the press to call it a crash, because this is visibly true, and it helps the reader to comprehend the event much better than ‘derailment’ (which could be quite a minor thing) or ‘incident’ (which tells you nothing). It also helps the press to seem independent, because if they call it an ‘accident’ straight away it looks a bit conclusive.

 

Further ahead, the coroner might return verdicts of accidental death or unlawful killing (or something else), and a court will return a verdict of its own … but the railway can quite reasonably call the event an accident from the outset. Because, from the point of view of the railway, it will always be an accident.

 

And as for the title of this thread … well, I think a lot of us see ourselves as railway operators in miniature, or at least as having a viewpoint closer to that of a railway operator than many other people … and we will call it an accident too.

 

So I hope this helps and doesn't create more arguments.

 

- Richard.

[jamie92208]

Though I agree that there are very few 'real accidents' all the investigation branches, Marine, Air and Rail use the word Accident in their names so it's probably easier to stick with that.

 

Jamie

[Talltim]

Even for road not all RTAs are RTCs. As an example, a lorry losing its load.

[Ken.W]

I note the commendable speed with which the RAIB has released its interim report.  That should assure all who need reassurance that they are doing all they can as fast as they can and want to have the tramway up and running again very soon.  But as we know the full investigation will take much longer and could yet result in the driver facing court.

 

Also, the RAIB's 'request' for interim risk mitigation measures be introduced before re-opening, such as restricting speed on approach to the curve, pending completion of their full investigation and assessment of possible permanent safeguards. Looking for cause and safeguards rather than blame, in the best tradition of the former HMRI

 

[leopardml2341]

I did not infer anything.

 I disagree, because your response starts with the phrase "Unless you think it was done on purpose......" which clearly personalises it to my post.

 

No more debate needed.

[leopardml2341]

Please get back to the subject or the Mods will get it locked and I would like to hear further information about this incident. Thanks.

Phil

Hence my statement no more debate needed!

[The Stationmaster]

Also, the RAIB's 'request' for interim risk mitigation measures be introduced before re-opening, such as restricting speed on approach to the curve, pending completion of their full investigation and assessment of possible permanent safeguards. Looking for cause and safeguards rather than blame, in the best tradition of the former HMRI

 

 

It is an interesting comparison between the way the RAIB works and the way HMRIs worked.  The latter could become extremely forensic in their investigation because that sort of approach was needed in what was still a developing safety culture on the railway, but they always also considered and where necessary reviewed procedure.  RAIB has tended to work (sometimes incorrectly) in a far more procedure based manner since its inception and as a consequence seems to sometimes miss the basic simplicity of events in some incidents (the Reading umbrella fatality being an excellent example of that where although some shortcomings in procedure were noted the actual cause of the man's death was down to something far more basic which effectively escaped notice; the same might also be said of their Report in respect of the Knaresborough run-through and derailment).

 

In the case of this incident I suspect the RAIB will inevitably have to follow a more traditional HMRI course - there will obviously be (as there should be) an exhaustive examination of all the relevant procedures ranging from, I would hope, staff training and monitoring through to such things as risk assessment and near miss analysis and follow up.  But there will I suspect also be something nearer to the human element involved which might have to step beyond procedural matters.  We will no doubt see all in due course and they have - according to one report - promised a report within months (which in itself is quite unusual for them in respect of an incident of this magnitude).

 

Edit to correct typo

Edited November 17, 2016 by The Stationmaster

[kevinlms]

One thing I have spotted & I don't recall anyone mentioning this, in this thread.

 

In the preliminary RAIB report, it clearly depicts in the diagram, a 20 kilometre an hour restriction board. However, all mentions of it elsewhere (learned RMweb members and news items, such as the BBC) all refer to it being a 12 1/2 Mile an Hour speed limit at the end of a 50 mph zone.

 

Did this contribute to the problem, with a potential confusion as to what the speed limit actually is? Yes, I do realise that it was apparently well in excess of either way of calculating it, but the doubt could be there.

 

It strikes me as odd that specific TRAM speed limits, are apparently in KMH, yet the normal road sign speed limits in MPH.

 

That raises the obvious question, why doesn't Britain have one system of identifying speed limits and not BOTH? Yes, MPH is traditional, but why is the tram line different? After all tram drivers have to navigate both types of speed signs, on reserved tracks & public roads.

Edited November 17, 2016 by kevinlms

[Lady_Ava_Hay]

Just to further the debate as to the use of the word 'accident' which seems under some pressure these days, I do recall learning of a defintion which has stuck in my memory mainly because it is apparently too loose a definition until one starts using the idea behind the phrase.

 

An accident occurs when the unprepared meets the unexpected.

 

Looking at the sparse evidence we know about in this particular occurence, one wonders whether the definition actually fits the evidence.

 

As pure speculation, if the driver was travelling at the speed quoted ( it was qualified with 'evidence so far' )and knew it then he was definitely unprepared and, if other drivers including this one, could say that they always took the bend at that speed and had to or they would be late arriving elsewhere and the speed was accepted as the norm by usage, then the derailment and overturn could be considered as unexpected.

 

I have no doubt that the investigators are way ahead of me and are checking everything to see if there were any other factors to have either caused or exacerbated the result.

[jjb1970]

I don’t think the dictionary definition of accident is the issue. The problem people have is the way that the word is received by many. Regardless of its dictionary meaning there is reason to believe that use of the word in relation to train and air crashes, ships sinking, power stations blowing up etc invokes responses to the effect that accidents can’t be avoided, accidents happen, c’est la vie, etc. Which is not helpful to safety, whether or not it is justified in terms of the actual meaning of the word accident there is now an increasing reluctance to use the word accident to describe these sort of events (noting that the RAIB, AAIB and MAIB all retain the word accident in their titles).

[ruggedpeak]

Even for road not all RTAs are RTCs. As an example, a lorry losing its load.

That is exactly the point. A lorry losing its load means that the load was insecure and the LGV driver is legally required to ensure his load is secure. If it comes off then the load was not secure, it is not an "accident" but in principle a failure by the driver or another. And the load has collided with the road in a manner that was not intended i.e. the load and road should not have made any direct contact during the journey. Whether it is a collision is semantics, but it is not an 'accident'.

 

In relation to the Tram incident, currently safety thinking across various sectors is that things are generally not "accidents" but incidents that are mostly avoidable. Again, a common thread of many safety investigations is that disaster often (but not always) comprises a series of small infringements or failures that recur, and on that one occasion these combine to go from an inconvenience or near miss to disaster. And often had only one of those infringements been tackled earlier the disaster would have been avoided. This is why RIAB etc carry out such detailed investigations. Whether or not the driver is the primary cause, they will want to understand if there were processes etc that could have overcome this to prevent what occured.

 

My guess is whatever the actual causes of this terrible tragedy, there will be significant recommendations regarding tram operations as on the face of it trams seem to fall into a bit of a gap between road and heavy rail practices, and this location seems to be unusual relative to most of the tram network.

[Colin_McLeod]

I disagree, because your response starts with the phrase "Unless you think it was done on purpose......" which clearly personalises it to my post.

 

No more debate needed.

.

 

The word "you" may have personalised it if you take the word as being in the second person singular, but it did not infer anything.

 

You may think it was an accident or you may think it was not.

You made the inference not me.

 

Also take my comments in the context of this thread.

 

Several posters are quire sensibly discussing the use of the word accident (not inferring that you were not by the way) and it is clear that the only alternative to an accident is something that was done deliberately.

I thought you had have difficultly with that point, so I made a comment in an effort to explain it but you took it as a personal inference.

 

 

The phrase "No more debate needed" comes across to me as arrogant, by the way.

 

Feel free to continue the debate if you wish but please do not try to bring it to a premature end after making a point.

 

No need for Mods to lock the thread just because the word "accident" is being discussed IMHO

Edited November 17, 2016 by Colin_McLeod

[Reorte]

That is exactly the point. A lorry losing its load means that the load was insecure and the LGV driver is legally required to ensure his load is secure. If it comes off then the load was not secure, it is not an "accident" but in principle a failure by the driver or another. And the load has collided with the road in a manner that was not intended i.e. the load and road should not have made any direct contact during the journey. Whether it is a collision is semantics, but it is not an 'accident'.

Once again, yes it is an accident unless the driver actually intended the load to fall off. The load falling off was an accident caused by the failure of the driver to meet his obligations by ensuring it was secure. If too many people are mis-using the word then they should be educated, rather than have things changed to fit them. In any case use a different word and the same thing will probably happen to that sooner or later.

 

"Incident" covers "accident" but also covers deliberate collisions, and events that cause disruption but don't put anyone in danger (such as a breakdown).