Croydon Tram Accident Report Analysis - Part 2
In BLACK are comments taken from the RAIB Investigation Report.
In RED are my comments and evidence on this report.
In ITALIC are "First Group Statements".
In RED are my comments and evidence on this report.
In ITALIC are "First Group Statements".
Seven people were killed, nineteen were seriously injured, and 43 had minor physical injuries (including the tram driver). Only one person was physically unhurt. A substantial number of people involved with the accident suffered shock and/or emotional trauma. This catastrophic accident was the worst to occur on a British tramway for more than 90 years.
The accident on 9 November immediately brought into question the way which the speed of trams is controlled, and raised many other issues linked to the design, operation and management of trams and the routes they travel on. You would think that even before these tram's started running that the above would have been put into practise, who governs this? REMEMBER THIS STATEMENT, "As nothing less than excellence will do, we’re totally dedicated to achieving the highest safety standards possible". What happened here then?
Based on early findings, the RAIB issued urgent safety advice to the operators of the Croydon tramway in November 2016, advising them to take action to reduce the risk of trams approaching the curve at excessive speed. In response to this, the infrastructure manager installed additional signs on the route before resuming services after the accident, and also installed similar signs at three other locations on the tramway. Too little - far too late! REMEMBER THIS STATEMENT, "From day one here, you’ll find that we put safety at the heart of everything we do". So what happened on day one?
The accident on 9 November immediately brought into question the way which the speed of trams is controlled, and raised many other issues linked to the design, operation and management of trams and the routes they travel on. You would think that even before these tram's started running that the above would have been put into practise, who governs this? REMEMBER THIS STATEMENT, "As nothing less than excellence will do, we’re totally dedicated to achieving the highest safety standards possible". What happened here then?
Based on early findings, the RAIB issued urgent safety advice to the operators of the Croydon tramway in November 2016, advising them to take action to reduce the risk of trams approaching the curve at excessive speed. In response to this, the infrastructure manager installed additional signs on the route before resuming services after the accident, and also installed similar signs at three other locations on the tramway. Too little - far too late! REMEMBER THIS STATEMENT, "From day one here, you’ll find that we put safety at the heart of everything we do". So what happened on day one?
On 31 October 2016, less than two weeks before the accident, there had been an incident in which a tram went too fast round the curve at Sandilands. On that occasion a different tram driver mistook his position in the tunnel, braked late, and entered the curve at more than 45 km/h (28 mph), a speed at which it is likely that the tram was close to tipping over. For various reasons, this incident was not fully investigated by Tram Operations Ltd (TOL), which is the operator of the trams, until after the accident on 9 November. Although the tram did not overturn, this incident revealed the potential for a driver’s mistake to cause overspeeding and then overturning. Immediate question, REMEMBERING THIS STATEMENT, "our Injury Prevention programme. Unprecedented in our industry, this firmly embeds safety into our everyday culture". Why did they fail to see the implications of this near miss? Especially with this being the precursor to the accident. It speaks for itself, dealing with this in a professional manner would have definitely prevented the loss of life and injuries. REMEMBER THIS STATEMENT, "Our goal is zero incidents and zero injuries. First to Zero"! Sadly in their goal to achieve this they never left zero.
Some tram drivers on the Croydon system reported to the RAIB that there have been occasions on which they had used heavy braking or used the hazard (emergency) brake in order to control their speed at this location. None of them reported these events to the managers at TOL, mainly because of the perceived attitude of some managers and because the drivers feared the consequences for themselves if they did so. This meant that TOL management did not understand the extent of late braking, and so took no action to mitigate the risk. This is endemic to the CULTURE that is in place, its a culture of fear, if you spoke out regarding health & safety issues you were a threat, so instead of dealing with the safety issues they targeted the messenger. They used their favourite weapon named IGNORANCE. The very CULTURE they created became a KILLER! I have been screaming about this attitude for over 14 years but nobody would listen.
Some tram drivers on the Croydon system reported to the RAIB that there have been occasions on which they had used heavy braking or used the hazard (emergency) brake in order to control their speed at this location. None of them reported these events to the managers at TOL, mainly because of the perceived attitude of some managers and because the drivers feared the consequences for themselves if they did so. This meant that TOL management did not understand the extent of late braking, and so took no action to mitigate the risk. This is endemic to the CULTURE that is in place, its a culture of fear, if you spoke out regarding health & safety issues you were a threat, so instead of dealing with the safety issues they targeted the messenger. They used their favourite weapon named IGNORANCE. The very CULTURE they created became a KILLER! I have been screaming about this attitude for over 14 years but nobody would listen.
REPORTING SAFETY ISSUES AND THE CONSEQUENCES
I know first hand what happens when you report anything regarding health and safety to First Group Management. From the very top at CEO level to the lowest grade manager's they are rotten to the core. I must have put in nearly one thousand reports in my time as a driver and health and safety representative, the amount of responses can be counted on one hand! This is what they call a safety culture. They had to admit their ignorance in a case management discussion with Employment Tribunal Judge Colin Grazin which can be viewed on this website.
From the next paragraphs below you will notice that this ignorance is still going on and is in my mind one of the main causes of the accident.
TOL processes require that tram drivers involved in accidents, incidents and near misses report the matter immediately to a line controller. In situations where a driver wants to report an issue that does not require an immediate call to the line controller, or they wish to report something confidentially, this can be done through FirstGroup’s own confidential reporting telephone ‘hot line’. At the time of the accident on 9 November 2016 TOL did not subscribe to CIRAS24, a body that was created in 1996 to manage confidential safety reporting on the UK railway system, but which now includes some other industries (for example, some bus operators). Anything reported confidentially only ever created a witch hunt with the management more concerned about who did it than the contents of the complaint!
Of the 59 drivers responding to the RAIB’s driver questionnaire, 21 reported that they had missed their initial braking point approaching the south curve at Sandilands25. Nine responses indicated that drivers had used the hazard brake to comply with the 20 km/h (12 mph) speed restriction around the curve and other drivers reported the need for heavy braking. None of these incidents had been reported to line controllers. 146 questionnaires were sent to drivers, with only 59 responses it tells me that some of these drivers maybe had a distrust regarding confidential reporting and did not want to be identified. JUST IMAGINE IF THOSE 9 DRIVERS WHO DIDN'T REPORT THEIR NEAR MISS INCIDENTS actually had the trust and confidence in their management to report? THE ANSWER IS OBVIOUS if looked at by a management who could manage - IT WOULD HAVE PREVENTED THE DEATHS.
To CEO Tim O'Toole, (Now Matthew Gregory) is this the "CORE VALUE" of your "SAFETY CULTURE"? Remember you are ultimately responsible. The statements below should tell you all about your safety culture.
Responses to the RAIB’s driver questionnaire indicate that the absence of reporting was a consequence of drivers believing that this would result in unnecessary action (eg excessive monitoring) and/or disciplinary action being taken against them (the driver involved in the overspeeding incident on 31 October 2016 cited similar reasons for not reporting what had happened). Among drivers responding to the questionnaire, 29 out of 59 respondents (49%) felt that self-reporting a driving mistake or irregularity would have this consequence. The term "blame" was mentioned in 10 out of 59 (17%) of tram driver's questionnaire responses.
I know it's wrong and everything should have been reported, but their fear was real, they faced possible demotion and dismissal and this would have happened.
From the next paragraphs below you will notice that this ignorance is still going on and is in my mind one of the main causes of the accident.
TOL processes require that tram drivers involved in accidents, incidents and near misses report the matter immediately to a line controller. In situations where a driver wants to report an issue that does not require an immediate call to the line controller, or they wish to report something confidentially, this can be done through FirstGroup’s own confidential reporting telephone ‘hot line’. At the time of the accident on 9 November 2016 TOL did not subscribe to CIRAS24, a body that was created in 1996 to manage confidential safety reporting on the UK railway system, but which now includes some other industries (for example, some bus operators). Anything reported confidentially only ever created a witch hunt with the management more concerned about who did it than the contents of the complaint!
Of the 59 drivers responding to the RAIB’s driver questionnaire, 21 reported that they had missed their initial braking point approaching the south curve at Sandilands25. Nine responses indicated that drivers had used the hazard brake to comply with the 20 km/h (12 mph) speed restriction around the curve and other drivers reported the need for heavy braking. None of these incidents had been reported to line controllers. 146 questionnaires were sent to drivers, with only 59 responses it tells me that some of these drivers maybe had a distrust regarding confidential reporting and did not want to be identified. JUST IMAGINE IF THOSE 9 DRIVERS WHO DIDN'T REPORT THEIR NEAR MISS INCIDENTS actually had the trust and confidence in their management to report? THE ANSWER IS OBVIOUS if looked at by a management who could manage - IT WOULD HAVE PREVENTED THE DEATHS.
To CEO Tim O'Toole, (Now Matthew Gregory) is this the "CORE VALUE" of your "SAFETY CULTURE"? Remember you are ultimately responsible. The statements below should tell you all about your safety culture.
Responses to the RAIB’s driver questionnaire indicate that the absence of reporting was a consequence of drivers believing that this would result in unnecessary action (eg excessive monitoring) and/or disciplinary action being taken against them (the driver involved in the overspeeding incident on 31 October 2016 cited similar reasons for not reporting what had happened). Among drivers responding to the questionnaire, 29 out of 59 respondents (49%) felt that self-reporting a driving mistake or irregularity would have this consequence. The term "blame" was mentioned in 10 out of 59 (17%) of tram driver's questionnaire responses.
I know it's wrong and everything should have been reported, but their fear was real, they faced possible demotion and dismissal and this would have happened.
Had more drivers felt they were able to self-report irregularities, such as missing braking points and then using the hazard brake or heavy full service braking, it is possible that TOL might have identified the need to investigate the reasons why these events were occurring on the approach to Sandilands south curve and then taken any necessary action, such as briefing all drivers or requesting improvements to the infrastructure.
There is absolutely no way if reported TOL (First Group) would have had the intelligence to realise the implications these near misses had. Why did they fail to take action with the earlier extremely relevant incident where the tram nearly overturned? This was their WARNING SHOT!
TOL has stated that no reports relating to tram drivers were made to First Group’s confidential reporting system between 2011 and 2016.
Would you trust the hand that will bite you - remember witch hunt!
The review of Driver Management arrangements has found there to be a good culture around safety, competence and incidents at the senior management level though the impression of some drivers is that these good aspects may not always be reflected down the length of the management chain to drivers on a day to day basis.
Nothing changes, of course they give the impression at "senior management level" this is where the PROPAGANDA MACHINE originates from.
From comments of drivers it appears that there may be some issues with this culture of promoting safety being less prevalent with the first line of driver management which is done by the control staff.
Nothing changes, this is the first line for any driver when reporting anything, I personally think this line of management are frightened to escalate safety issues to the next line for the exact same fear the drivers have - in other words the whole management structure is an hierarchy of fear.
The company needs to evaluate the way that controllers and drivers interact. There is some concern that not all issues that are reported by drivers to controllers are seen to be actioned.
Nothing changes, this website shows this management for what they are, they ignore all aspects of safety in the day to day running of their company and look to discipline their staff for the most trivial of incidents.
Drivers may not always be able to be briefed by those they have reported to about the actions, progress and limitations that relate to the issue. This may be leading to an impression that some issues are not being treated properly. This in turn may be discouraging drivers from reporting issues.
Nothing changes, IGNORANCE THROUGHOUT THEIR WHOLE MANAGEMENT STRUCTURE IS BLISS.
It is their weapon of choice which is specifically designed to discourage reporting, as for safety briefs or briefs of any sort, they simply never happen.
TOL reviewed the recommendations and took a number of actions in response. These included the initiation of a regular staff survey to gather ideas to improve staff engagement, a review of the process for checking time sheets for excess hours, and formally recording route hazard assessments (paragraph 197) as part of its SMS (Safety Management System).
Nothing changes, remember IPP the system designed to give the recipient feedback, the very same system that failed at every level especially at Board level, evidence available in the section - "LEAD BY EXAMPLE - FIRST GROUP SAFETY PRINCIPLES".
The statement to formally record route hazard assessments as part of their SMS is unbelievable, this should have been part of this system in the first place, in fact this is why this accident happened because they FAILED miserably to carry out a route risk assessment.
There is absolutely no way if reported TOL (First Group) would have had the intelligence to realise the implications these near misses had. Why did they fail to take action with the earlier extremely relevant incident where the tram nearly overturned? This was their WARNING SHOT!
TOL has stated that no reports relating to tram drivers were made to First Group’s confidential reporting system between 2011 and 2016.
Would you trust the hand that will bite you - remember witch hunt!
The review of Driver Management arrangements has found there to be a good culture around safety, competence and incidents at the senior management level though the impression of some drivers is that these good aspects may not always be reflected down the length of the management chain to drivers on a day to day basis.
Nothing changes, of course they give the impression at "senior management level" this is where the PROPAGANDA MACHINE originates from.
From comments of drivers it appears that there may be some issues with this culture of promoting safety being less prevalent with the first line of driver management which is done by the control staff.
Nothing changes, this is the first line for any driver when reporting anything, I personally think this line of management are frightened to escalate safety issues to the next line for the exact same fear the drivers have - in other words the whole management structure is an hierarchy of fear.
The company needs to evaluate the way that controllers and drivers interact. There is some concern that not all issues that are reported by drivers to controllers are seen to be actioned.
Nothing changes, this website shows this management for what they are, they ignore all aspects of safety in the day to day running of their company and look to discipline their staff for the most trivial of incidents.
Drivers may not always be able to be briefed by those they have reported to about the actions, progress and limitations that relate to the issue. This may be leading to an impression that some issues are not being treated properly. This in turn may be discouraging drivers from reporting issues.
Nothing changes, IGNORANCE THROUGHOUT THEIR WHOLE MANAGEMENT STRUCTURE IS BLISS.
It is their weapon of choice which is specifically designed to discourage reporting, as for safety briefs or briefs of any sort, they simply never happen.
TOL reviewed the recommendations and took a number of actions in response. These included the initiation of a regular staff survey to gather ideas to improve staff engagement, a review of the process for checking time sheets for excess hours, and formally recording route hazard assessments (paragraph 197) as part of its SMS (Safety Management System).
Nothing changes, remember IPP the system designed to give the recipient feedback, the very same system that failed at every level especially at Board level, evidence available in the section - "LEAD BY EXAMPLE - FIRST GROUP SAFETY PRINCIPLES".
The statement to formally record route hazard assessments as part of their SMS is unbelievable, this should have been part of this system in the first place, in fact this is why this accident happened because they FAILED miserably to carry out a route risk assessment.
Drivers’ reported perception of TOL management 244 The RAIB’s driver questionnaire asked TOL’s tram drivers about their relationships with their direct line manager (a line controller) and with senior managers within TOL27.
They were asked to rate these relationships between 1 and 10. A rating of 1 indicated that their manager was difficult to talk to, there was a lack of trust or a ‘them and us’ attitude was perceived.
A rating of 10 indicated a healthy relationship, an open-door policy and good support. Table 12 below shows the results of this question.
They were asked to rate these relationships between 1 and 10. A rating of 1 indicated that their manager was difficult to talk to, there was a lack of trust or a ‘them and us’ attitude was perceived.
A rating of 10 indicated a healthy relationship, an open-door policy and good support. Table 12 below shows the results of this question.
Relationships with line controllers and senior managers as assessed by tram drivers who responded to the RAIB’s questionnaire 245. The average results for both relationships, driver with line controller and driver with senior manager, are similar and suggest a lack of trust in drivers’ relationships with these staff. What an absolute shambles this management are shown in the driver responses above, is there any wonder this accident happened, the responses from TPE drivers in the "Your Voice" survey were similar and in some cases First Group never published the responses.
More drivers rated their relationship with a senior manager at a lower level than their relationship with a line controller. The questionnaire results also suggest a belief among some tram drivers that there is a blame culture within TOL (paragraph 228).
Suggestions of a blame culture can also be found in TOL procedure SM0007 . Management of signals passed at stop’ which says that ‘formal disciplinary proceedings will always be implemented where a driver is alleged to have been wholly or partially responsible for passing a signal at stop. Nothing changes, a Blame Culture has always existed it was a simple control measure that helped create an alienation culture and forge an even larger divide between staff and management which as we all know is detrimental to all aspects of safety.
Of the 59 Croydon tram drivers who returned the RAIB’s driver questionnaire, eight said that they had reported being unfit to work because they were tired (although the source of their fatigue was not recorded on the questionnaire).
Of these, one driver responded that they feigned illness rather than saying they were tired and another responded that following his report of being unable to continue because he was tired, he was ‘berated’ for it and comments were made about him by some line controllers (this may reflect a wider issue relating to TOL’s overall approach to incident reporting discussed at paragraphs 224 to 231). Six drivers responded to the questionnaire saying that they were unaware that fatigue could be reported.
Nothing changes, the attitude of immediate management has always been vindictive, the berating of a driver in this incident is all too familiar. The knock on effect in alienating an individual in this way stops that person from using any dialogue in the future, in my experience they refuse to get involved and participate in normal group chats within the work environment, just like the driver above who felt they had to feign illness.
First Group are a law unto themselves, their management should face corporate manslaughter charges and be jailed, but I doubt very much that will happen through the levels of corruption in this country. It's only a matter of time before First Group will once again be responsible for the deaths of more people.
More drivers rated their relationship with a senior manager at a lower level than their relationship with a line controller. The questionnaire results also suggest a belief among some tram drivers that there is a blame culture within TOL (paragraph 228).
Suggestions of a blame culture can also be found in TOL procedure SM0007 . Management of signals passed at stop’ which says that ‘formal disciplinary proceedings will always be implemented where a driver is alleged to have been wholly or partially responsible for passing a signal at stop. Nothing changes, a Blame Culture has always existed it was a simple control measure that helped create an alienation culture and forge an even larger divide between staff and management which as we all know is detrimental to all aspects of safety.
Of the 59 Croydon tram drivers who returned the RAIB’s driver questionnaire, eight said that they had reported being unfit to work because they were tired (although the source of their fatigue was not recorded on the questionnaire).
Of these, one driver responded that they feigned illness rather than saying they were tired and another responded that following his report of being unable to continue because he was tired, he was ‘berated’ for it and comments were made about him by some line controllers (this may reflect a wider issue relating to TOL’s overall approach to incident reporting discussed at paragraphs 224 to 231). Six drivers responded to the questionnaire saying that they were unaware that fatigue could be reported.
Nothing changes, the attitude of immediate management has always been vindictive, the berating of a driver in this incident is all too familiar. The knock on effect in alienating an individual in this way stops that person from using any dialogue in the future, in my experience they refuse to get involved and participate in normal group chats within the work environment, just like the driver above who felt they had to feign illness.
First Group are a law unto themselves, their management should face corporate manslaughter charges and be jailed, but I doubt very much that will happen through the levels of corruption in this country. It's only a matter of time before First Group will once again be responsible for the deaths of more people.
"Poor safety culture", such a shame that those in a position to do something before this tragic accident sat back and did absolutely nothing despite my evidence which told everyone, "First Group are IGNORANT towards safety, this will ultimately end in deaths of innocent people".
RAIB from their investigation state, "There needs to be improvements to safety management systems, particularly encouraging a culture in which everyone feels able to report their own mistakes".
Yet CEO Tim O'Toole has the cheek to state, "We're all very proud of the safety culture and record at First Group".
"Proud of the safety culture", the very safety culture that has killed numerous people and you are "PROUD"? What about the "management culture" that is responsible for this tragic accident?
I will say this again, someone please investigate this rabble in their management behaviour towards safety, because if you ignore my concerns it is ONLY A MATTER OF TIME before they will once again be responsible for more deaths.
RAIB from their investigation state, "There needs to be improvements to safety management systems, particularly encouraging a culture in which everyone feels able to report their own mistakes".
Yet CEO Tim O'Toole has the cheek to state, "We're all very proud of the safety culture and record at First Group".
"Proud of the safety culture", the very safety culture that has killed numerous people and you are "PROUD"? What about the "management culture" that is responsible for this tragic accident?
I will say this again, someone please investigate this rabble in their management behaviour towards safety, because if you ignore my concerns it is ONLY A MATTER OF TIME before they will once again be responsible for more deaths.