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Trams & Trump: who is to blame?

The 9th November 2016 will be remembered by many as the day a very controversial person became the elected president of the USA. For me, it will be the day seven Londoners died in a tram accident, a tram that had the ability to carry only 70 passengers seated and 138 people standing.

Tram vs trump image

I live in South East London and often suffer Southern Rail’s terrible service, so cancelled trains and disrupted travel is the norm for me. However, as I arrived at the bus stop on Wednesday morning (seven miles from Croydon), I knew something was wrong. Traffic gridlock, all of my usual trains cancelled or severely delayed and the public transport available was even more overcrowded than usual.

Then I heard that a tram had overturned in Croydon. My initial thought was “that’s what’s causing all of this palaver”, with little inkling of the tragic loss of human life which had just taken place.

Seven people are dead and many more - critically ill.

The driver is being questioned for manslaughter charges.

The Potters Bar train crash also killed seven, but it was four carriages long and travelling at 98 MPH.

Investigations suggest that the tram was exceeding the 12mph speed limit and that the tight bend, which follows a tunnel where trams reach speeds of 50mph, gives the driver minimal time to reduce speed.  

Yes, the driver may have blacked out or maybe he fell asleep but despite this, the lives lost seems disproportionate to the size and the speed of the vehicle.

So who is at fault?

The automotive and aerospace industries are known for rigorous safety measures and vehicle testing. I have recruited for many manufacturing businesses over the last few years but yesterday I realised I am not overly familiar with the manufacturing of train, tube or tram carriages.

I know my network will likely have some thoughts on the many questions I have about the lives lost on the 9th November 2016. I know I am not the only one who would be interested to hear your thoughts on the below questions.     

  1. Are trams, trains or tube carriages tested in the same way an aeroplane or car might be?
  2. Why is there no maximum speed limit on a tram?
  3. Does the number of deaths in this accident seem disproportionate to the number of passengers being carried?
  4. Once a tram, train or tube carriage is refitted/refurbished, does it get tested further?
  5. Is over crowding on trains, tubes and trams putting all commuters at risk of this being a more frequent event?
  6. What can train manufacturers and rail/tube/tram operators do to prevent this from EVER happening again?

My thoughts are with the families of those who have lost their loved ones and my prayers are willing all the injured a speedy recovery.

Claire Lauder is the Director of Manufacturing and Engineering.

Comments

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Leon Labovitch

25 Nov 2016 12:14 PM

I’ve seen some news coverage of the tram crash and agree it’s a really bad disaster. Like airplane crashes, most are due to Human Factors i.e. human errors of judgement or failed protocol. I hope most of your questions will be answered by the investigation, but with more questions than answers at the moment, it’s hard to make conclusions. Let’s see if it was human error or a technical fault or a mixture of both.


Colin Bidewell

24 Nov 2016 14:09 PM

Wondering when the practice employed with the DLR ie driverless trains will extend into other (light) rail systems and the human intervention will be reduced.

Yes, tram and train systems have intersections with other transport modes that the DLR doesn't ie level crossings etc; but sensor technology should evolve to deal with that...with the human guard being there to address whatever it is that the sensors pick up.


Peter Wells

18 Nov 2016 17:50 PM

Hello Claire, hope you are well and pleased you were not on the tram.
I'm no expert here but believe the comments above - 'cheese grater and quality of people' - will be a big part of the explanation for the very tragic outcomes of the accident.
Additionally, we don't do public transport very well in UK, our cities are not designed to accommodate trams and TFL involvement should also be questioned - money rather than safety will be a factor. Our lack of proper transport infrastructure investment is a big handicap and transit systems with many people standing and packed in are inherently dangerous. Overcrowded cities?
As to Trump, I appreciate the reasons so many seem disheartened at the result produced by our (fickle?) friend democracy. We have our Remoaners and the USA have their CLINTophiles.
On the BBC question time programme following the US election, three women panellists - an SNPMP, an American professor of literature and the ever reliable Yvette Cooper Balls - spent the whole hour in harridan mode, screeching insults at the President-Elect of our most important ally in the world.
At least Cooper Balls should know better than this - us British have a deserved reputation for being good losers once the result of an intensely fought contest is known.
The behaviour of bad losers is one of life's less edifying spectacles.


Claire Lauder

17 Nov 2016 14:31 PM

On behalf of Niall Cleary

Good moring Claire,

Many thanks for your blog.

I too was surprised at the casualty levels.

Having viewed the scene I was amazed at the sharpness of the curve the tram has to negotiate but recognise that this was probably likely due to the constraints of the environment. This would not be allowed for roads being installed now.

Given these constraints the designers must have known this corner had a high safety risk and I would have thought a more robust fail-safe intervention would have been designed in – such as automated speed controls or a run off. Relying on a driver alone suggests a formal Failure Mode Effect and Criticality Analysis (FMECA) was either not considered (which I don’t believe) or was not rigorous enough. I am surprised it passed the HSE test.

You are right to say the aerospace and automotive industry are much less likely to let this type of incident occur as they will build-in fail-safes or redesign to eliminate such risks. The pressure of competition, regulation, reputation as well as doing the right thing loom large in their minds.

In this case I do think several will be found liable and this should not be treated as an “accident”. Whilst the driver might be one of those liable, the design process has clearly been shown to have failed to recognise and / or mitigate against this. If there are similar designs elsewhere in the UK the operators will do well to review the risks with their engineers and HSE colleagues.


Claire Lauder

17 Nov 2016 11:29 AM

On behalf people in my network....

Tim Thexton

Hi Claire

I read the blog with interest.
I have a number of opinions on various items that impinge on this case.
1. The comparison of a tram with an aircraft is fallacious. If we imagine rolling an aircraft at 70km/h in a tight curve, then there would probably be some fatalities and a number of seriously injured.
2. For a tram to come off the rails and tip over, the first question, apart from a material question with regard to the rails being in tact or a deliberate sabotage act, is why was the tram travelling so fast? Was this speed too high for the curve and the tram was forced off the rails by the centripetal force? Why is the curve so tight? Is the rail sufficiently banked?
After those questions, this leaves the following options:
a. the tram was at the correct speed in the tunnel and the brakes failed to slow it:
i. the driver failed to apply the brake correctly
ii. the driver correctly applied the brake and the brake failed to act correctly
iii. the driver was unable to apply the brake correctly (illness, 3rd part interference, etc....
b. the tram was above the limit set for the tight curve:
i. there is insufficient warning of the necessary speed reduction
ii. the limit is et too high
3. There is no "black box" on the tram, so we have no record of the actions or inactions of the driver.
4. Why was the curve designed so tightly following a straight downhill tunnel? Could the tunnel also have been curved? Note: There is a history of train accidents across the world over the history of railways and trams of crashes in curves where there is a downgrade with a sharp curve at the bottom - some have been extremely serious.
5. Can there be automated braking of the tram, independent of the driver by electronic means when approaching the curve?
6. There are no seat belts in a tram, so any injuries will be worse than with belts.
7. A plane has a pilot and a co-pilot, so there is a backup and even then there are mishaps.

I think in this case, after the inquiry and if no material failure, we will be left with "driver error". However, I cannot understand, personally, why build a curve of that small radius at the end of a downhill slope - bad planning, bad engineering, certainly some blame there. Who decided and why that the track should be curved in that way at that point?


JOHN ASHLEY O'NEILL

16 Nov 2016 14:54 PM

Automation can Save Lives

Some obvious big differences between aircraft travel and trains is the use of seat belts for all higher risk events e.g. take off, landing, turbulence.
It is quite possible that passengers sitting and wearing seatbelts on the Croydon train would have fared much better. However because we have a grossly inadequate rail infrastructure in the UK; the Govt, rail companies and passengers accept the growing risks that overcrowding brings.

Even if seated passengers were belted in, there would have been casualties because so many travellers are required to stand. They become flying 80Kg missiles when there is a sudden change in train velocity, colliding with standers and sitters alike. To avoid this danger no passengers must be let on the train to stand. Clearly unenforceable during busy periods.

Regarding the Croydon incident specifically, I would have thought this is a glaring case for automation. Let software control the train speed on the line, not a human. Most people do not appreciate it, but today aircraft are flown by software and the pilot is largely redundant. In fact most if not all the non-terrorist air incidents for some years, were concluded to be attributable to pilot error, because they took over the controls at a critical point.


Rosie Keighley

16 Nov 2016 11:02 AM

Comment from Gary Sheard:

IF one is looking for blame - we’d better first be sure what the cause was?

Then it’s down to HSE, and the Tram Engineering Committee’s to raise the standards…and for us engineers to then meet or beat them.


Rosie Keighley

16 Nov 2016 11:00 AM

Comment from Barry Ryan:

I read your blog with interest and although I haven't worked on Trams - I have worked on Light Rail (DLR) and for Bombardier Rail Carriage Refurbishement.

All rail (like car's) transport, is subjected to "crashworthyness" testing, in terms of structural strength and the ability of the train to retain it's structural strength and cabin intergrity in the event of a collision.

What happened at Croydon, went beyond those limits. The primary reason was probably, that as trams move relatively slow as compared to trains, then a roll-over scenario, as happened, was never ever taken into consideration during the design phase of the tram development.

Further, in the case of Croydon, the incident appears to centre around tram speed and driver error. Not structural integrity, or the ability of the tram to survive such a catastrophic impact. In fact, if you look at the pictures as shown on TV news channels, then you can see that the carriages appeared to remain intact. Because trams, like trains, have large windows, because people like to see where they are going - then, as the tram went over onto it's side, those windows would have naturally broken, together with their framework supporting them.

Passengers would have been thrown in that direction, and death and serious injury would come about as a result of people coming into direct contact with the ground. They would have effectively gone through a cheese grater.

A key part of the examination, will centre around the drivers ability, or inability, to control the speed of the tram as it went into a bend at a speed it wasn't intended to do. Was the speed "governed"? - was the emergency braking in the trams design and functionality? If so, why didn't it kick in? Was the driver in control at the time? etc. etc...

There will be many questions.

Worth considering, DLR is a driverless system and train speeds are computer controlled and as a result, there has never been a fatality due to speed on DLR.

Why didn't the Croydon tram system have a preventative system built in, that takes "speed" out of the driver's ability to control?

Food for thought as well as for a "Lessons Learned Report" that will inevitably come later.

It's just a crying shame, that several people died over something that could have and should have been "engineered out"


Rosie Keighley

16 Nov 2016 10:58 AM

Comment from Neil Smith:

When you put this in perspective – lives lost – it does not matter and the world will continue to turn in spite of Trump but in terms of the issues you raise, I have worked in the automotive and aerospace sectors and the rigour they put into “widgets” is phenomenal, using six sigma to drive continuous improvement for decades now.

The issue, I guess, is not with the carriages or trains, but with the people, process and safeguards across the rail network (the system) and if only they could harness the rigour of lean six sigma to really understand what goes on, remove waste, duplication, flaws and bolster safeguards in such a way that overall the system runs leaner, better…..using the “science” of six sigma, I’m sure passenger lives would be saved.

I have not worked in the train sector but having interviewed many from that space myself, I’ve never been impressed with the talent and leadership therein, which worries me that we’ve not got the best people running these business and really thinking about all stakeholders. I am sure safety could be improved without increasing costs if only they could get rid of the waste and re-invest that into the passenger side.

It’s all about fail-safes.

Lean six sigma makes you think about every tiny element of a system – and from that figure out what to do in any and every scenario and build fail-safes into the system. So, if this happens, this is what we can do to prevent that in if the situation is compounded by another variable emerging, here’s another fail-safe on top….and so on and so forth, until you’ve got everything covered. It’s not always perfect first time but is an iterative learning process and given the number of accidents on the rails over the years, you would have thought by now, that iterative process would have pretty much matured into something neigh on perfect.

Just my opinion, of course.


Rosie Keighley

16 Nov 2016 10:50 AM

"I’ve seen some news coverage of the tram crash and agree it’s a really bad disaster. Like airplane crashes, most are due to Human Factors i.e. human errors of judgement or failed protocol. I hope most of your questions will be answered by the investigation, but with more questions than answers at the moment, it’s hard to make conclusions. Let’s see if it was human error or a technical fault or a mixture of both.'
Comment from Leon Labovitch


John French

16 Nov 2016 10:28 AM

Having reviewed the rail safety record for UK, I have to validate your concern. Japan is the benchmark, with zero incidents since 1964. Rail safety in UK needs immediate attention with zero incidents being the only acceptable goal. Meanwhile Trump is a wake up call also. We all need to be aware of corruption in our governments and the media. It is also at an unacceptable level and the goal also needs to be zero!