Croydon tram crash deaths were accidental, inquest rules
The deaths of seven passengers in the Croydon tram crash were accidental, the jury at the coroner’s inquest in south London has decided.
In a narrative verdict, the jury said contributing factors were that the driver appeared to have become disoriented and not braked in time, while TOL, the tram operator, had failed to adequately account for the risk of a high-speed derailment, or ensure a “just culture” where drivers felt able to report health and safety concerns.
The verdict came after an eight-week inquest, where the jury heard evidence from accident investigators and police about the 2016 tragedy, the worst to occur on a British tramway for more than 90 years.
Six men and one woman were killed when the tram, carrying 69 passengers, derailed and overturned on 9 November 2016 when speeding around a sharp bend.
The inquest was told by the Rail Accident Investigation Bureau chief inspector, Simon French, that the tram “absolutely” overturned as a result of excessive speed, and that the driver – who had driven trams along the same route almost 700 times in the year – was likely to have had a “microsleep” in the moments before the crash.
Other RAIB inspectors and British Transport Police testified but the coroner, Sarah Ormond-Walshe, decided that additional witnesses, including managers from TOL, the tram operator, and Transport for London, should not be called.
Citing previous cases, she said it was not the job of a coroner to duplicate the investigation unless it was shown to be flawed.
In a decision on 28 June, Ormond-Walshe said she did “not accept that the RAIB investigation was incomplete, flawed or deficient and, in any event, why further evidence is unlikely to be of assistance to the jury”.
Ormond-Walshe directed the jury at Croydon town hall that it could deliver a verdict of unlawful killing or accidental death, although any verdict of unlawful killing would depend on finding gross negligence by the driver, Alfred Dorris. She said that the evidence was far below the threshold of corporate manslaughter.
The seven passengers who died were Dane Chinnery, 19, Donald Collett, 62, Robert Huxley, 63, Philip Logan, 52, Dorota Rynkiewicz, 35, Philip Seary, 57, and Mark Smith, 35. All seven died instantly after being thrown through the windows or doors of the tram in the crash. Nineteen other passengers were seriously injured.
The tram derailed in heavy rain and darkness at a sharp bend in the track before the Sandilands tram stop. It was travelling at 73kph (45mph), although the maximum permitted speed on the curved stretch of track was 20 kph (12.5mph).
French, the RAIB chief, said that surviving passengers “spoke of it like being inside a washing machine”.
French also told the inquest that apparent “culture issues” at operator Tram Operations Ltd had meant drivers were unwilling to own up to having made mistakes, including speeding.
An incident 10 days before the crash when another tram nearly overturned after reaching the same bend at speed was insufficiently investigated, French added.
Ormond-Walshe admitted one witness who had not spoken to investigators. Jim Snowden, a former chief engineer on the network, told the inquest he had raised safety concerns eight years earlier about the stretch of track where the crash occurred, particularly the lack of warning signs.
In a written report from 2008, he had said that there were “long stretches of segregated track and isolated alignments where there are few visual clues as to location during the hours of darkness, there is potential for the driver to lose awareness of the distance to approaching hazards and it may become appropriate to consider the provision of advanced signage as a reminder.”
One of two locations he cited on the network were the Sandilands tunnel immediately before the bend.
Dorris, the driver of the tram, was not called to give evidence at the inquest, having been ruled medically unfit.