RAIB recommendations
The Office of Rail and Road should work with the UK tram industry to develop a body to enable UK-wide co-operation on matters related to safety, common standards and good practice guidance.
UK tram operators, owners and infrastructure managers should jointly conduct a systematic review of operational risks and control measures associated with the design, maintenance and operation of tramways.
UK tram operators, owners and infrastructure managers should work together to review, develop, and provide a programme for installing suitable measures to automatically reduce tram speeds if they approach higher risk locations at speeds which could result in derailment or overturning.
UK tram operators, owners and infrastructure managers should work together to research and evaluate systems capable of reliably detecting driver attention state, and initiating appropriate automatic responses if a low level of alertness is identified.
UK tram operators, owners and infrastructure managers, in consultation with the DfT, should work together to review signage, lighting and other visual information cues available on segregated and off-street areas, based on an understanding of the information required by drivers on the approach to high-risk locations such as tight curves.
UK tram operators and owners should, in consultation with appropriate tram manufacturers and other European tramways, review existing research and (if necessary) undertake further research to identify means of improving the passenger containment provided by tram windows and doors.
UK tram operators and owners should install (or modify existing) emergency lighting so that the lighting cannot be unintentionally switched off or disconnected during an emergency.
UK tram operators and owners should review options for enabling the rapid evacuation of a tram which is lying on its side after an accident.
The ORR should carry out a review of the regulatory framework for tramways and its long-term strategy for supervision of the sector.
Tram Operations Limited and London Trams should commission an independent review of its process for assessing risk associated with the operation of trams (for example - collision, derailment and overturning of trams).
Tram Operations Limited, drawing on expertise from elsewhere in the FirstGroup organisation, should review and (where necessary) improve the management of fatigue risk affecting its tram drivers, with reference to ORR’s good practice guidance.
Tram Operations Limited should undertake a review, informed by expert input from external sources, covering the way that it learns from operational experience.
Tram Operations Limited and London Trams should, in conjunction with Transport for London, improve processes and (where necessary) equipment used for following up both public and employee comments which indicate a possible safety risk. The improved process should ensure complaints are dealt with promptly and within time periods.
London Trams, in consultation with Tram Operations Limited, should review and (where necessary) improve its processes for inspecting and maintaining on-tram CCTV equipment, to greatly reduce the likelihood of recorded images being unavailable for accident and incident investigation.
London Trams, in consultation with Tram Operations Limited, should review and (where necessary) revise existing tram maintenance and testing documentation to take account of experienced gained and modifications made since the trams were brought into service. It should also review and (where necessary) revise the processes for ensuring that these documents are kept up to date in future.