At approximately 09:44 hrs on Wednesday 16 May 2012, a pedestrian was struck by a tram as she crossed the tramway on a foot crossing on the approach to Sandilands tram stop in Croydon. The impact resulted in the pedestrian falling into the space between the platform and the tram. She remained trapped in that position as the tram continued into the platform and suffered serious injuries.
The investigation found that the pedestrian had not looked for an approaching tram before she crossed. However, there was a possible obstruction to the pedestrian’s view of approaching trams as she walked towards the entrance to the tram stop and the configuration of the crossing meant that she approached it with her back to trams running on the nearest track.
Risk assessments had been undertaken in relation to safety at Sandilands foot crossing (and other foot crossings on the Croydon tram network) in 2008/9 and 2011. The investigation found that methodology employed in the 2008/9 assessment was not a suitable basis for prioritising the foot crossings for safety improvements. With the agreement of the Office of Rail Regulation, London Tramlink mainly prioritised crossings remote from tram stops for safety improvements from 2009 onwards. The 2011 risk assessment, while intended for the purpose of assessing whether the track at tram stops should be filled in between the rails, also identified that the foot crossing at Sandilands represented the highest risk of the 52 crossings that were considered in the review. London Tramlink did not make any safety improvements to reduce the probability of a pedestrian being struck on the foot crossing at Sandilands in response to the findings. Although London Tramlink had taken some action to help it understand the generality of the risk at foot crossings on its network, and had introduced a speed restriction of 25 km/h for trams passing over foot crossings on the approach to all tram stops, its processes for managing the risk at individual crossings were not effective.
The investigation also found that two factors affected the consequences of the accident. Firstly, the tram driver did not apply the hazard brake (which achieves a higher rate of retardation than the brake normally employed for stopping trams) after the tram struck the pedestrian. Secondly, there was enough vertical and horizontal clearance to create a survival space for the pedestrian in the position where she fell after the accident.
The RAIB has made five recommendations. Three recommendations have been made to London Tramlink in relation to risk assessment at foot crossings, processes for ensuring pedestrians have clear sight of approaching trams and improving organisational competence in safety decision-making. One recommendation has been made jointly to London Tramlink and Tram Operations Ltd in relation to investigation of accidents and incidents. One recommendation has been made to the Office of Rail Regulation in relation to reissuing guidance on various aspects of the design of tram stops and foot crossings.
The RAIB has also identified a learning point for tram operators regarding use of the hazard brake when a tram has struck a pedestrian.
Response to recommendations:
- RAIB will periodically update the status of recommendations as reported to us by the relevant safety authority or public body
- RAIB may add comment, particularly if we have concerns regarding these responses.