Rail Accident Report

175 Pages·2017·20.45 MB·English

Rail Accident Report
Overturning of a tram at Sandilands junction,
Croydon
9 November 2016
Report 18/2017
v2.2 - October 2020
This investigation was carried out in accordance with:
l the Railway Safety Directive 2004/49/EC;
l the Railways and Transport Safety Act 2003; and
l the Railways (Accident Investigation and Reporting) Regulations 2005.
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This report is published by the Rail Accident Investigation Branch, Department for Transport.
Version Date Location Description of change
v1 December
Initial issue
2017
Paras S13 and 53 Typographic corrections
Figures 23 and 45 Titles amended
Data in columns 1 and 2 reversed for
Table 16
bodyside windows
Paras 335 to 338 BS EN reference number corrected
Paras 362 Heading above clause amended
October Header before Reference to RAIB’s July 2017 letter
v2
2018 para 485 added (as footnote).
New appendix containing RAIB’s July
Appendix I
2017 letter
Added after appendices, refers to TfL
Addendum
audit of TOL’s fatigue management
(October 2018)
system
Index Amended to suit changes listed above
v2.1 November Recommendation Intent text augmented to match
2019 10 recommendation
Correction of typographical error (‘4
Para 226 March 2013’ altered to read ‘4 March
October
v2.2 2014’)
2020
Correction of typographical error (‘18
Para 404
May 2017’ altered to read ‘17 May 2017’)
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Sandilands junction
Preface e
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The purpose of a Rail Accident Investigation Branch (RAIB) investigation is to
improve railway safety by preventing future railway accidents or by mitigating their
consequences. It is not the purpose of such an investigation to establish blame or
liability. Accordingly, it is inappropriate that RAIB reports should be used to assign
fault or blame, or determine liability, since neither the investigation nor the reporting
process has been undertaken for that purpose.
The RAIB’s findings are based on its own evaluation of the evidence that was
available at the time of the investigation and are intended to explain what happened,
and why, in a fair and unbiased manner.
Where the RAIB has described a factor as being linked to cause and the term is
unqualified, this means that the RAIB has satisfied itself that the evidence supports
both the presence of the factor and its direct relevance to the causation of the
accident. However, where the RAIB is less confident about the existence of a factor,
or its role in the causation of the accident, the RAIB will qualify its findings by use
of the words ‘probable’ or ‘possible’, as appropriate. Where there is more than one
potential explanation the RAIB may describe one factor as being ‘more’ or ‘less’ likely
than the other.
In some cases factors are described as ‘underlying’. Such factors are also relevant
to the causation of the accident but are associated with the underlying management
arrangements or organisational issues (such as working culture). Where necessary,
the words ‘probable’ or ‘possible’ can also be used to qualify ‘underlying factor’.
Use of the word ‘probable’ means that, although it is considered highly likely that the
factor applied, some small element of uncertainty remains. Use of the word ‘possible’
means that, although there is some evidence that supports this factor, there remains a
more significant degree of uncertainty.
An ‘observation’ is a safety issue discovered as part of the investigation that is not
considered to be causal or underlying to the event being investigated, but does
deserve scrutiny because of a perceived potential for safety learning.
The above terms are intended to assist readers’ interpretation of the report, and to
provide suitable explanations where uncertainty remains. The report should therefore
be interpreted as the view of the RAIB, expressed with the sole purpose of improving
railway safety.
The RAIB’s investigation (including its scope, methods, conclusions and
recommendations) is independent of any inquest or fatal accident inquiry, and all other
investigations, including those carried out by the safety authority, police or railway
industry.
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Sandilands junction
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Overturning of a tram at Sandilands junction,
Croydon, 9 November 2016
Contents
Preface 5
Summary 9
Introduction 18
Key definitions 18
The accident 19
Summary of the accident 19
Context 21
The sequence of events 35
Key facts and analysis 41
Background 41
Identification of the immediate cause 48
Identification of causal factors 56
Identification of underlying factors 74
Factors affecting the consequences 93
Observations 118
The role of the safety regulator 133
Previous occurrences relevant to this investigation 137
Occurrences on Croydon tramway 137
Occurrences outside Croydon tramway 138
Summary of conclusions 139
Immediate cause 139
Causal factors 139
Underlying factors 140
Factor affecting the severity of consequences 140
Observations and other issues 141
The role of the safety regulator 141
Previous RAIB recommendation relevant to this investigation 142
Recommendation that is currently being implemented 142
Actions reported as already taken or in progress relevant to this report 143
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Sandilands junction
Background to the RAIB’s recommendations 145
Recommendations 146
Safety Advice 155
Appendices 156
Appendix A - Glossary of abbreviations and acronyms 156
Appendix B - Glossary of terms 158
Appendix C - Investigation details 163
Appendix D - Loop data 164
Appendix E - Testing and examination of tram 2551 equipment 165
Appendix F - Urgent Safety Advice 169
Appendix G - Post-derailment sequence 170
Appendix H - On-tram data recorder 175
Appendix I - RAIB July 2017 letter to the UK tram industry 177
Addendum (October 2018) 179
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Sandilands junction
Summary y
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The accident on 9 November 2016
S1 For the people of New Addington and the surrounding areas, the tramway which
links them to the centre of Croydon has become part of the landscape of their
lives since its opening in 2000. It has an important role, taking residents to and
from their work, shopping and leisure activities.
S2 Early in the morning of 9 November 2016, 26 commuters boarded the tram which
was to be the fifth service of the day, due to leave New Addington at 05:53 hrs.
It was a dark morning, and heavy rain was falling. The tram, number 2551, left
the terminus on time. Its journey took it past the Addington Village interchange,
and through open country and woodland towards Croydon. It called at five stops
along the route, picking up another 36 passengers and travelling at up to 80 km/h
(50 mph). It then called at Lloyd Park, where seven more people boarded, so
that as the tram moved into the built-up area on the eastern outskirts of Croydon,
it was carrying 69 passengers.
S3 Beyond Lloyd Park, the tramway curves sharply to the right and joins the route
of a former railway line. The tram rounded this bend at about 20 km/h (12 mph),
and then accelerated, on a long straight stretch of line. There are three closely
spaced tunnels on this section, which together are just over 500 metres long.
Less than 100 metres beyond the far end of the tunnels, the tramway leaves the
alignment of the old railway on a sharp left-hand curve and then meets the other
branch of the network, the route from Elmers End and Beckenham, at Sandilands
junction.
S4 The tram passed through the tunnels at around 80 km/h (50 mph). When it
emerged from the far end (figure S1), at 06:07 hrs, it had not slowed down as
trams normally do, and was still travelling at 78 km/h (48 mph). Through the
darkness and heavy rain, the tram approached the reflective sign which marked
the point where its speed should have been reduced to 20 km/h (12 mph)
to negotiate the curve. The driver applied the brakes, but the tram was still
travelling at 73 km/h (45 mph) when it passed the sign, entered the curve, and
began to turn over onto its right-hand side.
S5 The passengers on the tram had no warning of what was to come. Some of
them were standing, but most were seated, and as the tram began to tilt they
were thrown across and around the vehicle. Some described it as “like being in a
washing machine”. The windows on the right-hand side smashed as passengers
were thrown against them, and as the tram hit the ground. Some of the doors
on that side were torn off. People fell through the openings where the doors and
windows had been, and were crushed under the tram as it slid to a stop, about
three seconds after leaving the rails. The tram came to rest after travelling a
distance of about 27 metres from the place where it left the rails (figure S2).
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Sandilands junction
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20 km/h speed sign
Towards Sandilands junction and Croydon
(tram 2551 direction of travel)
Figure S1: View emerging from the tunnels
Line to/from Tram
Elmers End and 2551
Beckenham
To Croydon
Sandilands
south curve
Direction of tram 2551
From New Addington, Lloyd
Park and Sandilands tunnels
Figure S2: Final position of the tram
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Sandilands junction