By Luke Vance Barr and Jamie Macwhirter
The Rail Accident Investigation Branch report said that the driver, Alfred Dorris, did “not apply sufficient braking” prior to the derailment and that the most likely cause for this was a “temporary loss of awareness” which “possibly caused him to microsleep”.
A total of seven people died and more than 50 were injured when a speeding tram derailed at a sharp bend close to Sandilands station in November 2016.
The report also suggests that there were “insufficient safety measures” in place and makes 15 recommendations for improvement.
A lawyer representing three of the people victims said it is “crucial” that the recommendations made by the investigation are implemented.
Tracey Benson, of law firm Slater and Gordon, said: “The Croydon tram crash inextricably altered our clients’ lives forever.
“One has been left to bring up her son without the man she loved, while two other have suffered from post-traumatic stress because of the horror they endured on that day. So for them to hear that the crash was completely avoidable and should never have happened is difficult for them to bear.”
The tram involved was the the 06:00 service running from New Addington to Wimbledon via Croydon. The seven killed were Dane Chinnery, 19; Dorota Rynkiewicz, 35; Mark Smith, 35; Philip Logan, 52; Philip Seary, 57; Donald Collett, 62; and Robert Huxley, 63.
Out of the 61 other passengers who were also injured, 19 of these suffered serious injuries and only one person came out unharmed.
The tram was travelling at 73 kilometres per hour at the time of the crash, which was three times the 20 kilometres per hour speed limit. All passengers who were killed, and also many of those who were seriously injured, “fell through the windows or doors as the tram tipped over”.
Referring to the driver’s “loss of awareness”, investigators said that he was possibly suffering from fatigue due to insufficient sleep, however this was not linked to his working shift pattern.
The report added: “It is also possible that, as he regained awareness, the driver became confused about his location and direction of travel through the tunnels.”
Tests conducted found that the driver had no traces of drugs or alcohol in his system, nor suffered from any significant medical issues.
The report defined microsleep as “unintentional periods of sleep lasting anywhere from a fraction of a second to a few minutes.”
It was also reported that “the risk of trams overturning on curves was not properly understood by the tramway” and that a similar speeding incident also took place just days before, with no action taken.
Finn Brennan, a spokesperson for the ASLEF union representing train drivers, said the report showed that the tragedy was the result of “systemic failure”.
He told East London Lines: “Scapegoating any individual here entirely misses the point. This tragedy happened because the regulators regarded the tramway as a bus on rails and used much lower safety standards.
“There needs to be safety systems in place so when an individual makes a mistake for any reason, it doesn’t lead to a tragedy like this.
“If the tramway system had the same safety measures as exist on the mainland railway or the London Underground, this simply wouldn’t have happened.”
Simon French, Chief Inspector of Rail Accidents said: “We are recommending action in five main areas. The first is the use of modern technology to intervene when trams approach hazardous features too fast, or when drivers lose awareness of the driving task.
“Work needs to be done to reduce the extent of injuries caused to passengers in serious tram accidents, and to make it easier for them to escape.
“There need to be improvements to safety management systems, particularly encouraging a culture in which everyone feels able to report their own mistakes. Finally, greater collaboration is needed across the tramway industry on matters relating to safety.”
A criminal investigation into the accident is currently being led by British Transport Police. Dorris, 43, has been arrested on suspicion of manslaughter and is currently on bail.
In response to Thursday’s report, Transport for London said: “Since the incident, we have introduced a wide range of additional safety measures to make sure such a tragedy can never happen again.
“These include new signage and warning systems for drivers, additional speed restrictions, enhanced speed monitoring and an upgrade of the CCTV recording system.
“An in-cab driver protection device has been trialled and is now fitted to every tram, meaning that any sign of driver distraction or fatigue results in the driver being alerted immediately. Work to install a system to automatically reduce tram speeds if required is also underway.”
TFL also revealed how they have since altered their customer complaints process so that all are now streamed through one designated team. They will also publish their own report into the crash in the new year.
As for the tram operator, FirstGroup, their Chief Executive Tim O’Toole said: “Over the past year we have taken a series of actions, working closely with Transport for London on whose behalf we operate the system, to implement additional measures including enhanced speed monitoring and restrictions, improved signage and renewed guidance on fatigue management.
“Our commitment to the safety of our passengers, our employees and other parties who engage with us is unwavering. Safety is a core value for FirstGroup and central to our culture as a company.”
Sarah Jones, MP for Croydon Central, said: “Our first thoughts will always be with the victims’ families.
“They will be reliving this tragedy yet again, and it will be another difficult day for them. The most important thing we can do for them is show that lessons have been learned and make sure this never happens again.”