Croydon Tram Accident

[ruggedpeak]

I knew two of the people involved in the commissioning stages and early driver training at Croydon; they had been involved in similar work at Eurotunnel, and prior to that, had worked at BR.

Putting my ultra cautious safety hat on, neither of those were operations that probably had such a road/racetrack (i.e. non-heavy rail) like scenario of a fast straight into a sharp 90 degree bend with a visual approach of another tunnel suggesting to the unwary the line goes straight on?

 

I am probably stretching it a bit here, but F1 would not allow such a feature on a modern circuit without suitable runoff as it is entirely foreseeable that if for whatever reason a car is unable to lose speed into the bend (and off a straight may be over 200mph) there needs to be another option other than a big crash. It is curious that on the little we know this does not seem to apply here for a public carrying vehicle. Fast straight, very tight bend, apparently no alternative or safety options if speed is too high for the bend.

[Fat Controller]

Most socialising is done on early shifts as that is when one has the evening free, so quite often one goes to work having had very little sleep. Once when working as a guard on London's Underground I  closed my stinging eyes to rest them whilst sitting on one of the passenger seats next to my gangway. We were in the tunnel between stations and I must have drifted towards sleep for although I was aware when the train stopped at the next station I had by then 'become a passenger', and I kept my eyes closed waiting for the familiar sound of the doors opening. When that didn't happen I opened my eyes, and only then realised it was me who had to open the doors! That experience was a good lesson to learn for my future career as a motorman, and later as a manager of train crews when I had to investigate incidents like this one. It is the job of management to do risk assessments beforehand and I have to admit that I find these reserve track sections of the tramway too similar to a railway with two car trains to be treated any differently just because other sections have some street running.

SNCF has been sponsoring research on shift patterns, sleep patterns and phenonema such as 'microsleeping'. One method of gathering data was to use devices that measured eye-movement; some car drivers were fitted with these devices prior to driving to the South for their summer holidays. The recording devices suggested that, in a six-hour drive on very busy motorways, drivers were asleep for ten minutes or so, with some periods of sleep lasting more than a couple of minutes; alarmingly, devices monitoring vehicle speed showed no fluctuations during these periods.

Our drivers' and crew hours are very closely monitored: if crews finish late because of an incident, the Driver Leader will give them revised start times for the next day, and communicate these to Control.

[Gwiwer]

I have drawn comparisons before in this thread with the Melbourne tramways which I am very familiar with as a former employee and general enthusiast.   And again I can suggest that there is little evidence to suggest that the transition from "heavy rail" style reserved track to street running through a sharp bend has caused any form of incident.  There are some locations where speeds up to 60kmh are authorised on former suburban rail routes which end abruptly with 90-degree turns into street running.  Until the advent of data-recorders it was common for late-running trams to take the light rail line at up to 80kmh.  While there are stops and traffic lights controlling intersections and the egress from light rail to street running if no-one requires the stop and the light is cleared by the approaching tram via the transponder then it gets a clear turn which is restricted to 20kmh.  Again I have known the curves in question taken at rather more than the limit but at no time has the speed been so great as to be of undue concern.  A worst it has resulted in wheel squeal and passengers holding tight to what ever is to hand.

 

What RAIB determines to be necessary, if anything, to minimise or prevent any repetition on Tramlink will have repercussions across other British tramways.  But there has been no history that I am aware of anywhere of curves being regularly taken at such excessive speeds as to alarm passengers or cause incidents.  There will be isolated incidents but if a pattern emerges then it is for RAIB to issue directives or learning points to address that.

 

Driving passenger vehicles is almost always a shift-work job.  Those of us who are, or have been, so engaged are only too well aware of the stresses that imposes on social and professional lives.  Waking at 2 or 3am after an often fitful sleep of perhaps 5 - 6 hours makes starting fresh and alert a challenge but it is one we are obliged to rise to if we choose to drive for a living.  No-one forces us to do that.  It is not for everyone.  The accumulated fatigue is supposedly managed by restricting driving hours and minimum rest periods but no-one has ultimate control over our non-working lives.  It is up to each and every driver to take full responsibility for the lives they are responsible for, to be fully fit for duty or to be honest about going sick if unfit.  I don't drive (currently) in the job but must blow zero alcohol at every random test and must not be at work with any drugs (not even over-the-counter stuff) in my system unless disclosed to a senior person and approved.  I can be sent home without pay for as little as sucking a cough lolly on duty unless disclosed first and OK'd.  That is how stringent the safety regulations are.  

 

RAIB will investigate the driver's record, actions on the day and probably for the days beforehand.  They may investigate the records of other drivers for comparison or to establish if any patterns exist in non-compliance.  We shall have to await their deliberations.

[ruggedpeak]

SNCF has been sponsoring research on shift patterns, sleep patterns and phenonema such as 'microsleeping'. One method of gathering data was to use devices that measured eye-movement; some car drivers were fitted with these devices prior to driving to the South for their summer holidays. The recording devices suggested that, in a six-hour drive on very busy motorways, drivers were asleep for ten minutes or so, with some periods of sleep lasting more than a couple of minutes; alarmingly, devices monitoring vehicle speed showed no fluctuations during these periods.

Our drivers' and crew hours are very closely monitored: if crews finish late because of an incident, the Driver Leader will give them revised start times for the next day, and communicate these to Control.

A few years ago I witnessed this. I was in a convoy of cars driving in the Pyrenees. The lead car entered a very tight hairpin bend with a 200 foot drop on the outside. The driver then had a microsleep and woke up a few seconds later as the car was about to go off the edge. He snatched the wheel at the last second and got round. He was totally freaked out (unsurprisingly) and told us when he woke and snatched the wheel the dashboard lit up with warning signs and beeps and the car made some awful noises. I inspected the tyre marks in the gravel a couple of centimetres from the edge. You could clearly see where the car was approaching the edge and where he swerved and where the tyres had dug in as the car took over. I have no doubt the electronic traction control on the car saved him, an older vehicle would not have got round without the ETC.

 

Moral is don't drive dangerous roads when you haven't slept properly for a week! He was one of those who thought he could burn the candle at both ends - only modern safety tech means he's still here today. We all learnt a useful lesson about fatigue that day. It was quite sobering being on an isolated road looking down a cliff wondering what we'd have done if he gone over.

[The Stationmaster]

SNCF has been sponsoring research on shift patterns, sleep patterns and phenonema such as 'microsleeping'. One method of gathering data was to use devices that measured eye-movement; some car drivers were fitted with these devices prior to driving to the South for their summer holidays. The recording devices suggested that, in a six-hour drive on very busy motorways, drivers were asleep for ten minutes or so, with some periods of sleep lasting more than a couple of minutes; alarmingly, devices monitoring vehicle speed showed no fluctuations during these periods.

Our drivers' and crew hours are very closely monitored: if crews finish late because of an incident, the Driver Leader will give them revised start times for the next day, and communicate these to Control.

 

That leads me to one general factor (which might or might not be relevant to this incident( and taht is changes in where people live and how far they travel to work.  In the past the vast majority of railway footplate staff, and no doubt tram and 'bus drivers, lived quite close to their place of work and thus had a simple and relatively short journey to/from work which meant more of their off duty time was spent relaxing.

 

Nowadays in some cases their journey could be an hour or more and might involve driving in busy traffic in both directions so not only is their actual time 'resting' reduced but they are exposed to a longer period of concentration.  This doesn't apply to such things as travelling or driving a van to reach the site where work starts within their turn of duty as there is - if properly applied suitable legal protection and an implied requirement to risk assess such activity but this doesn't apply outside their working hours.  I know there was some study of the impact of travel (to work) times in the early '90s and there has probably been somem since but I believe it could develop as an increasingly important factor in workplace safety particularly in jobs requiring high levels of concentration.  The good old answer of 'I consider I was sufficiently rested before taking duty' is one which increasingly should face more searching questioning at inquiries.

[Rivercider]

I remember that the subject of microsleeping came up in conversation in our office about 15 years ago,

after one of the drivers said it had been the topic of conversation in the mess room.

He said that most of the drivers present admitted to it having happened, he certainly did,

and was of the opinion over time it probably happened to every driver who worked night shifts.

 

I was only a clerk but on more than one occasion, having worked a 12 hour night shift,

I got home having no recollection of the ten minute walk from the station to my house, a bit scary

 

cheers

[rockershovel]

There was, at one time, quite a sizeable contingent of railway and LUL staff commuting from Peterborough to Hornsey, Kings X and various LUL locations.

[royaloak]

Not only is there good reason to think it is not fiction, I suspect it was totally legitimate. There were several test trains that were authorised to travel at high speed, there were probably half a dozen or more drivers that had travelled at that speed or more officially.

 

Not only that but I had two of the commemorative ties that were probably being referred to - they were official ones given out to everyone that was on or associated with the prototype HST when it broke the world record. They had a small print of the front of the prototype HST power car with 'HST 143' written on them IIRC. They came with a little card too. I donated one to the Deltic Preservation Society to auction to raise funds, and the post office lost the other...

The 140 club is for drivers who have achieved that figure on a normal passenger train, not on a test run.

 

Edit-

This was over 20 years ago, things are very different on the railways today and even a small indiscretion will lead to tea without biscuits! 

Edited November 19, 2016 by royaloak

[Colin_McLeod]

How did they reconcile wearing a special tie with not advertising to management that they broke a safety rule (speed limit)?

[ruggedpeak]

How did they reconcile wearing a special tie with not advertising to management that they broke a safety rule (speed limit)?

Don't wear it at work?

[royaloak]

Moral is don't drive dangerous roads

Please describe a dangerous road please as I have never been on one, I have been on roads where people drive too fast for the prevalent road or weather conditions but I have never been on a dangerous 'road'!

[royaloak]

How did they reconcile wearing a special tie with not advertising to management that they broke a safety rule (speed limit)?

The tie was for the test run drivers which was the official one, there was the unofficial one as well.

 

Once the OTMR was fitted management couldnt understand why drivers were no longer able to make up time like they used to, it was only when it was pointed out that data recorders were now fitted that the penny dropped.

[royaloak]

How did they reconcile wearing a special tie with not advertising to management that they broke a safety rule (speed limit)?

Things were different then, Management were aware of the 'club'.

[jjb1970]

Human factors are funny things as it is far too easy to dismiss things that can become significant causal factors in a disaster or to write things off as being the actions of idiots. When thinking about many human factors considerations people think about them in a controlled way, under no pressure, without being aware of consequences of decisions etc and completely lose sight of the fact that those conditions are not representative of the state of mind of individuals involved in an incident, they're under no pressure and have time to evaluate the conditions around what went wrong before coming to decisions. People do silly things and make mistakes, but in most cases the people involved would otherwise be considered competent and capable of fulfilling their duties. One of the biggest pitfalls in safety is to dismiss people as idiots or incompetent and pretend that something happened because of aberrant behaviour and that we wouldn't end up in such a position.

 

As an example, from another industry, I'll make this vague for obvious reasons. Several people were killed and another received life changing injuries when a large piece of equipment exploded. The explosion was caused by operating the equipment in a way which was known to be outside its operating limits. The reason why the person concerned did it could never be established (he blew himself up) but something that was subject to extensive work was that a critical piece of information on the items capability used non-standard nomenclature and it was felt that the wording used could potentially have caused a critical misunderstanding. Words matter and variations or differences that seem obvious in normal circumstances may not be as obvious in the circumstances leading to an incident.

[ruggedpeak]

Please describe a dangerous road please as I have never been on one, I have been on roads where people drive too fast for the prevalent road or weather conditions but I have never been on a dangerous 'road'!

A dangerous road might be a single track, steep, numerous hairpins and about one foot of verge before a drop off a cliff on one side and a rock wall on the other (as I described). As found in many mountainous regions. Or a road deep in the Canadian Rockies in the depths of winter or a remote track in the Sahara, where getting stuck or having a breakdown could be fatal and is rather more likely than the M25 on a weekend. All of which I have driven and are dangerous by any accepted definition of the word.

[Oldddudders]

There was, at one time, quite a sizeable contingent of railway and LUL staff commuting from Peterborough to Hornsey, Kings X and various LUL locations.

 

When I worked at Grove Park, SE London, we had one or more drivers living in Peterborough. People want to improve their lifestyle, get better this and that, and moving out to expanding towns has always been a popular route. When I worked alongside BR's Privatisation team in the mid-90s, there were secretaries - yes, young women on modest salaries - commuting from Wellingborough. Of course their travel was cheap, but the day was long. 

[Zomboid]

Sadly we seem to have something of a culture, Amazon delivery for example, where safety/common sense comes a poor second to "productivity", for want of a better word.

 

Whether this was involved here I have no idea so will wait to see if there's a management aspect to this.

 

Stu

People complain loudly (not necessarily the same people) when things get stopped or delayed for "health & safety", often pointing out that something has been done like that for years.

Certain sections of the media will take up both sides of that argument, depending on which agenda they're pushing in a given article.

[ruggedpeak]

One of the biggest pitfalls in safety is to dismiss people as idiots or incompetent and pretend that something happened because of aberrant behaviour and that we wouldn't end up in such a position.

Unless they are politicians, in which case it is entirely reasonable. Said an 'industrial washing machine salesman'. Allegedly.

[edcayton]

I have drawn comparisons before in this thread with the Melbourne tramways which I am very familiar with as a former employee and general enthusiast.   And again I can suggest that there is little evidence to suggest that the transition from "heavy rail" style reserved track to street running through a sharp bend has caused any form of incident. yet

[RJS1977]

Not only is there good reason to think it is not fiction, I suspect it was totally legitimate. There were several test trains that were authorised to travel at high speed, there were probably half a dozen or more drivers that had travelled at that speed or more officially.

 

 

 

Indeed, I reckon I 'clocked' an HST at 140+ in the Didcot area 20 or so years ago although as it was by timing mileposts, there may have been some error involved. Either way though it would have been more than 125.

[The Stationmaster]

The 140 club is for drivers who have achieved that figure on a normal passenger train, not on a test run.

 

Edit-

This was over 20 years ago, things are very different on the railways today and even a small indiscretion will lead to tea without biscuits! 

 

Must have been longer ago than that - by 1985, if not earlier, HSTs had limiters on and couldn't get anywhere near 140 mph (although possibly down a very long straight gradient but certainly not powering).  

 

We looked at various possibilities for the high speed 'record breaking' runs we did on the the WR in 1985 and the engineers were adamant that it would be extremely difficult to de-modify the trains to get to 140mph (which was what I originally asked for).  Hence we reduced the Bristol run to a 5 trailer set in order to improve the acceleration and gain time that way plus we made special arrangements to exceed certain normal linespeeds where the track geometry allowed it to de done.  In all those cases the speed was limited by signalling - I think the 'Top Of The Pops' run to Bristol was the first train on BR to be given what amounted to 'Line Clear' by radio with me agreeing over a special radio link with Swindon panel that we had a clear run and then advising the Traction Inspector in the cab that he had authority to exceed the line speed through Swindon.  We had to do it that way as we ran in the evening peak and couldn't retime most trains so we needed to be sure a particular train had cleared Swindon before we got authority to exceed normal linespeeds.)

 

Sorry for going OT

[andyman7]

I travelled on the tram today between Birkbeck and Croydon town centre - this section is one of those that has required augmented speed restrictions. There was new signage with more restrictive limits but most noticeable is on the approach to the point where the tram diverges from the railway solum via a sharp curve to take the route towards Addiscombe, there are now flashing beacons which activate when a tram approaches, attached to the catenary posts. 

Given that the accident occurred at 6am in the pitch dark during rain, I can see that these provide a much more unmissable signal to slow down than the previous fixed lineside speed restriction plate. We took the curve very cautiously.... 

[Dagworth]

In the UK the minimum rest period between shifts is 12 hours and 36 hours clear for a rest-day. There are some very tight and regulated limits on total hours and total days without a break under Hidden that came about because of the Clapham crash.

 

The other problem from my own experience as a driver was management who didn't know what shift work entailed. Our depot worked a two shift system, late one week and early the next. I hated earlies and had a regular swap with a guy who didn't like lates. For two years I didn't do any earlies which was great (and much safer) as my body-clock was not in that perpetual shift lag state. Then management decided that we weren't allowed to do that anymore for no apparent reason except management didn't want it.

 

Andi

[TheSignalEngineer]

In the UK the minimum rest period between shifts is 12 hours and 36 hours clear for a rest-day. There are some very tight and regulated limits on total hours and total days without a break under Hidden that came about because of the Clapham crash.

 

The other problem from my own experience as a driver was management who didn't know what shift work entailed. Our depot worked a two shift system, late one week and early the next. I hated earlies and had a regular swap with a guy who didn't like lates. For two years I didn't do any earlies which was great (and much safer) as my body-clock was not in that perpetual shift lag state. Then management decided that we weren't allowed to do that anymore for no apparent reason except management didn't want it.

 

Andi

For footplate staff a second contributory accident was that at Stafford in August 1990 where a driver was unfortunately killed. It turned out that he was working his 26th consecutive shift. http://www.railwaysarchive.co.uk/documents/HSE_Stafford1990.pdf

 

A big difficulty we had in policing working hours at our works depot was people moonlighting and turning up for a day shift after doing a night shift as a security guard or similar activities. Fragmentisation of the industry makes it even more difficult with the number of agency staff particularly in on-track roles. I had people turn up for weekend shifts when they had already done a full week with a civils contractor on building works.

Edited November 19, 2016 by TheSignalEngineer

[Edwin_m]

I travelled on the tram today between Birkbeck and Croydon town centre - this section is one of those that has required augmented speed restrictions. There was new signage with more restrictive limits but most noticeable is on the approach to the point where the tram diverges from the railway solum via a sharp curve to take the route towards Addiscombe, there are now flashing beacons which activate when a tram approaches, attached to the catenary posts. 

Given that the accident occurred at 6am in the pitch dark during rain, I can see that these provide a much more unmissable signal to slow down than the previous fixed lineside speed restriction plate. We took the curve very cautiously.... 

These lights have always been provided at Croydon and on other tram systems.  They light up if the system detects a signal passed at danger, and any driver seeing the lights should stop immediately (so as to stop both the SPAD tram and any other that might be in conflict with it).  If they are now operating for all trams then I would think that creates a serious risk of confusion.