Exclusive: Transport for London aware of Croydon tram fatigue problem two years before deadly crash
Transport for London (TfL) officials were told of concerns about driver fatigue on the Croydon tram network two years before a fatal crash which killed seven people – believed to have been caused by a driver falling asleep.
An independent audit of the Croydon Tramlink carried out in March 2014 and seen by Morning Wire identified “fatigue management” as one of “seven weaknesses” with the transport system’s safety management system.
The report said that fatigue management measures in place do “not match current Office of Rail and Road (ORR) expectations in respect to the management of fatigue”.
The independent auditors also recommended the development of a fatigue management system.
Yet though TfL made note of these “seven weaknesses” in its own report that same month, it nonetheless gave the network its highest rating.
“On the basis of the work completed we have concluded that competence and fitness of… tram operators is Well Controlled”, it said.
TfL said that the “Well Controlled” finding referred to its own audit team being satisfied that the independent report “fulfilled the requirement for effective audit arrangements”.
Although the findings of the audit, which was carried out by AbsTracked Solutions, are mentioned in TfL’s report, it did not list them, and made no mention of fatigue management being a problem.
The Croydon tramlink is operated by Tram Operations Ltd (TOL), a subsidiary of FTSE-250-listed First Group. TOL provides drivers and managers for the network.
Also in March 2014, CIRAS – the body for confidentially reporting safety issues on the railways – received a complaint detailing concerns about fatigue arising from TOL’s driver roster management.
On 9 November 2016 a tram derailed and overturned at a junction near the Sandilands stop in the worst rail accident in the UK in a decade. 62 people were also injured, 19 seriously.
An investigation later found that the driver had most likely had a “microsleep” episode when approaching the bend.
But a 2017 report into the accident carried out by the Rail Accident Investigation Board (RAIB) made no mention of the 2014 AbsTracked Solutions audit or its concerns.
In AbsTracked Solutions’ report, it says that with regards to fatigue management, TOL “focuses on the management of hours worked rather than the management of fatigue”.
Addressing fatigue issues is listed as the fourth of seven recommendations made by the auditors.
The report calls for the “development of a fatigue risk management system” and for TOL to “identify the most effective measures that can be taken within the priorities of other safety demands”.
The existence of the independent audit – and the seven weaknesses – was first revealed in 2019 after repeated questioning from London Assembly Member Caroline Pidgeon.
“The audit is carried out by an external body AbsTracked Solutions and includes competence, fitness, drugs and alcohol and fatigue management”, TfL’s 2014 audit reads.
“The audit report for March 2014 was evidenced and found to be adequate. Seven weaknesses in TOL’s SMS were identified which were evidenced on TOL’s audit findings tracker”.
In response to questions in December last year, Mayor Sadiq Khan said: “During the fieldwork TfL’s auditor would have seen what the seven weaknesses referred to in the audit were and the resulting actions required”.
A TfL spokesperson said: “The TfL reference to ‘well controlled’ is based on our Internal Audit team being satisfied the independent TOL audit report fulfilled the requirement for effective audit arrangements and is not a comment on the detailed findings or actions of TOL’s audit.
“The conclusion of the TfL audit was that TOL were managing the actions and areas of weaknesses highlighted in the independent report directly, as is appropriate for one of our operators.”
Last week it was revealed that TfL had been carrying out its own safety audit of TOL at the time of the 2016 Croydon tram crash, which emails seen by Morning Wire confirmed was later “cancelled”.
The existence of this audit, which concluded that safety issues are “adequately controlled”, was never reported to TfL safety board members.