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. © Crown copyright 2018 You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned. This document/publication is also available at www.raib.gov.uk. Any enquiries about this publication should be sent to: RAIB Email: [email protected] The Wharf Telephone: 01332 253300 Stores Road Website: www.gov.uk/raib Derby UK DE21 4BA 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’) This page is intentionally left blank Report 18/2017 4 v2.2 - October 2020 Sandilands junction Preface e c a f e r P 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. Report 18/2017 v2.2 - October 2020 Sandilands junction This page is intentionally left blank RReeppoorrtt 1188//22001177 6 vv22..22 -- OOccttoobbeerr 22002200 SSaannddiillaannddss jjuunnccttiioonn 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 Report 18/2017 7 v2.2 - October 2020 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 Report 18/2017 8 v2.2 - October 2020 Sandilands junction Summary y r a m m u S 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). Report 18/2017 9 v2.2 - October 2020 Sandilands junction S u m m a r y 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 Report 18/2017 10 v2.2 - October 2020 Sandilands junction