The acquittal of the driver of the Croydon tram which overturned on a tight bend killing seven people in November 2016 is welcome. Of course some of the bereaved may be disappointed at not getting what they felt was justice but in fact it would have been a far greater injustice had Alfred Dorris been convicted.
There has, historically, been a tendency for individuals to be blamed for causing rail – and indeed aviation – accidents but for the most part such disasters have been the result of systemic and organisational failings, rather than the fault of a single individual. Even the most cursory investeiation of the Croydon accident will show that this was certainly the case in Croydon. Of course driver Dorris made a mistake, but the circumstances leading up to that fateful day reveal a catalogue of, at times, wilful mismanagement and inadequate responses to warnings which made such an accident almost inevitable. If it had not been Dorris, it would have been another driver. Put quite simply, the tram system was unsafe and that should have long been apparent to its managers and others responsible for its safety.
First, the issue of driver tiredness caused by onerous shift systems was not properly considered by the tram operator, TOL, a subsidiary of FirstGroup. There were reports of at least half a dozen drivers falling asleep at the controls but as the response to this by the company was to sack those involved, there were probably countless other incidents. The company operating the service, TOL, failed to address the issue despite the clear evidence of frequent incidents of driver tiredness.
Secondly, there was the track layout and its obvious risks. The accident occurred at a 90 degree bend which had a speed limit of just 20 kph but was preceded by a long stretch with three tunnels where the limit was 80 kph. Concerns about this section of track had long been expressed and yet lighting in the tunnels was in a poor condition, warning signs had been removed and other safety features not introduced. There had been numerous previous examples of overspeeding on this stretch of track including one just ten days before the disaster which was never properly investigated. However, because legally a tram system does require the same safety features as a railway, there was no warning device to alert drivers to overspeeding, as there would have been in a similar situation on a railway line.
All this was compounded by the wholly inadequate investigation held by the Railway Accident Investigation Board which deliberately seems to have downplayed any suggestion that tiredness caused by the shift pattern could have contributed to the accident. This inadequate investigation had wider consequence because the coroner in the subsequent inquest refused to allow witnesses to cover any issues which she felt had already been looked at by the RAIB, known as the Norfolk Ruling. This meant that the inquest failed to consider a wide range of contributory factors and its jury was limited to findings of ‘accidental killing’ or ‘unlawful killing’. The latter would have implied it was the driver’s fault and therefore after an astonishing nine days of deliberation, the jury returned a verdice of ‘accidental killing’ which inevitably left the bereaved dissatisfied.
Moreover, the investigations and reporting were coloured by the fact that the accident was caused by a derailment when, in fact, had the tram derailed, it probably would not have overturned, which is what caused the deaths and injuries. This is an important distinction in learning the lessons from the disaster. There were, too, attempts to cover up investigations after the accident with Transport for London, for example, failing to submit to the original RAIB inquiry a vital safety audit about fatigue management. Subsequently the RAIB had to issue an addendum in relation to fatigue and yet still did not fully reopen its investigations into what was clearly a contributory cause of the accident. This undermining of the proper process suggests a wider culture within Transport for London over its lack of proper oversight of TOL. Moreover, there was something of a revolving door for staff between TfL and TOL which subsequent investigations did not look into.
The acquittal, together with the failings of the investigations, mean that the bereaved are left with a feeling that the whole process has been unsatisfactory, leaving them with a deep sense of injustice.
Quite rightly both Transport for London and TOL have pleaded guilty to similar charges but in truth they have never really responded properly to what was a totally avoidable tragedy and a further independent investigation should be undertaken. As the headlines of the various articles about this accident suggest, there are still numerous ‘unanswered questions’ about this disaster. There should not be.