Dear Madam Sandilands Inquests I write on behalf of Transport for London (TfL) with regard to the Senior Coroner’s Regulation 28 Report to Prevent Future Deaths (PFD) dated 21 September 2021 following the inquests arising from the deaths of Dane Chinnery, Donald Collett, Robert Huxley, Philip Logan, Dorota Rynkiewicz, Philip Seary and Mark Smith. I would like to take this opportunity to again personally offer my sincere condolences, and those of everyone at TfL, to the family and friends of each of the seven victims of this tragic accident. Since November 2016, TfL has been focused on making sure a tragedy like this can never happen again and has worked closely with the Rail Accident Investigation Branch (RAIB), the Office and Rail and Road (ORR) and other industry partners to introduce a number of additional safety measures on the Croydon tram network. The primary objective of the work undertaken is to prevent an overturning event happening in the first place. Safety will always be TfL’s number one priority. TfL continues to review its operations and to work with the wider tram industry to introduce any further measures that may benefit the people who rely on those services. The PFD report The Senior Coroner’s PFD report addressed to TfL, all UK tram operators, Bombardier Transportation UK Ltd (Bombardier) and others raises the following matter of concern: ‘At least one of the seven died as a result of being ejected through the bottom of the door leaf. A recommendation was made by the RAIB that consideration should be given to the feasibility of strengthening doors, whether in current tram stock or in future tram building. Little seems to have been done since.

2 Consideration should be given to current and future trams as to whether tram doors can be adapted now or in the future’. Bombardier is now known as Alstom following a recent takeover of the company. TfL has carefully considered this matter of concern and I provide details below of the work undertaken in respect of strengthening tram doors. RAIB recommendation As noted in the PFD report, one of the RAIB’s recommendations was to consider the feasibility of strengthening doors. The recommendation stated: ‘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. The findings should then be used to:
i. Provide a time-bound plan to modify doors and windows on existing trams when practical to do so (e.g. during planned refurbishment);
ii. Promote changes to the specifications and standards governing the doors and windows of new trams; and
iii. Inform the Department for Transport of the findings to allow implementation of the safety advice at paragraph 492’.

The intent of this recommendation, as stated in the RAIB report, was to reduce the likelihood of people being seriously injured or killed by being ejected through tram doors and windows (i.e. to provide better containment). I provided evidence to the Senior Coroner during the Inquests on actions taken to strengthen the glazing on the existing fleet of trams. Given the Senior Coroner’s area of concern in the PFD report, my response below is focused on proposals to strengthen doors. Proposals to strengthen doors In respect of doors, the SNC Lavalin study commissioned by TfL stated that “increasing stiffness of doors may help in situations where doors are containing passengers in an overturn situation”. However, the study also stated that “implications on weight and cost are likely to be prohibitive to retrofit. Compliance with standards relating to closing energy may be affected”. Changes to the design of the existing fleet cannot be considered in isolation. There is a tension between a requirement for containment and a requirement to enable evacuation. For example, as the SNC Lavalin reported noted, any redesign must also meet ORR’s guidance which stipulates “the door arrangement

3 should enable passengers and tram crew to evacuate safely. It should be possible for passengers to open designated external doors once the tram is stationary …”. More generally, adding additional weight may have significant knock-on implications for other systems on the tram and its safety. For instance, the braking and acceleration systems of the tram would be significantly affected by the additional mass added to the tram, as well as having a detrimental effect on the overturning speed of the tram. However, we remain committed to investigating whether anything can be done to strengthen the door mechanisms on our existing fleets as well as making sure this is addressed in the specification of any new fleet we procure. To this end, we have been working with Alstom to commission a fresh engineering study to look at whether it is possible to strengthen the existing door mechanisms on the CR4000 fleet. Using a tram TfL has given to Alstom for this purpose, this work is already underway using technical experts from Alstom’s light rail team based in mainland Europe. It will assess all aspects of the door mechanism currently on the fleet, then determine whether it is technically possible to strengthen the existing design in any way and, if a solution is identified, how that can be rolled out across the fleet. Alstom have confirmed to TfL that this detailed assessment of the existing door mechanism design is anticipated to be complete by the end of December 2021. Following the completion of this work, Alstom have committed to providing TfL with a full technical report confirming any improvement actions and final recommendations by the end of January 2022. Once this report is received, TfL will determine the appropriate way forward based on the report, including any funding requirements and timelines. TfL proposes to share this report with the Light Rail Safety Standards Board (LRSSB) as well as any other Tram systems that use the same type of vehicles as TfL’s CR4000 fleet. I will also provide an update to you which can be shared with all the Interested Persons involved in the Inquests. With respect to any new fleet that enters service on the London Tram network, we will ensure that during the specification phase for any procurement the manufacturers will comply with all appropriate LRSSB guidance in force at that time, but also ensure that any design of the door mechanism takes into account the learnings from the work we are undertaking with Alstom.

4 Other matters As you know, TfL has worked hard to consider and respond to all of the RAIB’s recommendations. A bespoke Physical Prevention of Overspeed System (PPOS) has been procured, developed and installed on the London Tram network. This system, the first of its kind in the United Kingdom, provides a high level of safety assurance by automatically braking the tram to a stand in a controlled manner, when an over-speed event is detected at 13 pre-identified locations, where the risk of overturning has been assessed as high. We now use the London Trams Safety Risk Model which is an estimation of risk pre and post fitment of the above systems and safety measures and was introduced in response to the RAIB recommendations. This safety model has shown that the risk of a tram overturning has been reduced by 76% and therefore, by extension, also reduced the risk of someone being ejected through a door in the event of an accident of this type. TfL remains committed to reducing the risk of a tram overturning to as low as reasonably practicable and will review the recently issued LRSSB guidance notes and determine whether there is any more work we can do on the existing fleet to comply with this advice. I trust this response is helpful. Please contact us if we can be of any further assistance.

Dear Madam, BOMBARDIER TRANSPORTATION UK LTD LEGAL COMPANY SECRETARIAT Litchurch Lane Derby, DE24 8AD, United Kingdom Phone:

15 November 2021 Inquests regarding the Sandilands tram crash 9 November 2016 (the “Inquests”) Regulation 28 report to prevent future deaths dated 21 September 2021 in relation to the risk of passenger ejection through tram doors (the “PFD Report”) Response of Bombardier Transportation UK Limited (“BTUK”- Since 29 January 2021 part of the Alstom group “ALSTOM”) We refer to the PFD Report which was sent to Transport for London (“TfL”), ALSTOM, UK Tram, Rail Safety and Standards Board and the Department for Transport (“DfT”). From the outset, we would like to take this opportunity once again of expressing our sincere condolences to those who lost loved ones as a result of this tragic accident. We would also like to put on record our sincere appreciation to you and your team for your efforts to ensure that the Inquests were concluded notwithstanding the challenges posed by the COVID-19 pandemic. Please find below ALSTOM’s response to the PFD Report. Introduction The PFD Report provided that: “At least one of the seven died as a result of being ejected through the bottom of the door leaf. A recommendation was made by RAIB that consideration should be given to the feasibility of strengthening doors, whether in current tram stocks or future tram building…Consideration should be given to current and future trams as to whether tram doors can be adapted now or in the future.” I set out below details of actions which ALSTOM has taken, or proposes to take, in response to the PFD Report, together with a timetable for such action. Steps taken so far An international team including experts from ALSTOM and IFE has been assembled to investigate any changes to current and future tram door design which might be feasible. This is a considerable exercise given the complexity of the tram system. The team, led by , ALSTOM’s Quality, Performance & Integration Director (UK & Ireland), includes experts from a variety of relevant disciplines in the UK, Austria and France. Where appropriate, ALSTOM has sought to draw on the expertise of external consultants, namely SNC Lavalin. The objective of

Bombardier Transportation UK Ltd Registered in England Registered No. 2235994 Registered Office: Bombardier Transportation UK Ltd, Litchurch Lane, Derby, DE24 8AD, United Kingdom Bombardier Transportation UK Ltd is a member of the Alstom Group.

the team is to seek to reduce the risk of passenger ejection in particular through the bottom of the door leaf. To meet the objective, ALSTOM has engaged with TfL to agree a collaborative approach to reviewing the feasibility of strengthening the in-service tram doors in particular the lower part. This has involved information sharing and, importantly, TfL has provided ALSTOM with access to a CR4000 tram. This will enable detailed mechanical assessment of the tram doors and the evaluation of different options for strengthening the doors to lower the risk of passenger ejection. In addition to the above, ALSTOM is engaged in a comprehensive engineering review of the existing CR4000 door design. This ongoing review involves internal and external experts and covers the existing CR4000 door design, service and maintenance activities, with a view to identifying any design improvements which can be made. It is envisaged that this exercise will be completed in December 2021. As well as a desktop review of the door design, the ALSTOM team will also conduct (1) a detailed assessment of the CR4000 tram and (2) a general and door specific failure analysis. This exercise will also help identify any further information gathering work or other in-service door designs that may require further analysis. Future steps Once the studies described above are complete it is envisaged that by February 2022, ALSTOM should be in a position to make more detailed recommendations to TfL and other vehicle owners and operators as appropriate as to whether there are any improvements which can be made to the existing CR4000 fleet that would reduce the risk of passenger ejection through the lower part of the tram door leaf. Using the output from their investigations, ALSTOM will then be able to develop detailed recommendations regarding any changes which are appropriate to future door designs and share those recommendations with other relevant stakeholders and regulators including RSSB (Light Rail) the DfT, Office of Road and Rail, TfL and other local transport authorities who are responsible for establishing or specifying relevant safety standards. In accordance with normal industry practices, those recommendations may then be adopted as industry standards and mandated for future trams designed by both ALSTOM and others. It is envisaged that the recommendations will be available by April 2022. In tandem with ALSTOM’s review of the door design, ALSTOM is continuing discussions regarding changes to the design of in-service doors and future door design standards with IFE, the manufacturer of the doors in the CR4000 trams. Such discussions will continue notwithstanding previous assurances given to BTUK by IFE that the IFE door leaves comply with EN14752 (issued after the design and supply of the CR4000 trams) and that door designs have evolved with a tendency to higher strength. It is anticipated that these initial discussions will be completed by the end of 2021 . Once the evaluation of the current door design has been completed, ALSTOM will also engage other door manufacturers on its panel of specialist door manufacturers namely, Wabtec, Bode and Kangni, to obtain their views on the proposed changes to door standards. It is planned that this dialogue will begin in March 2022, after the initial investigation has been completed.

Bombardier Transportation UK Ltd Registered in England Registered No. 2235994 Registered Office: Bombardier Transportation UK Ltd, Litchurch Lane, Derby, DE24 8AD, United Kingdom Bombardier Transportation UK Ltd is a member of the Alstom Group.

Conclusion We trust that the above provides a clear explanation to HM Senior Coroner of the details of the actions taken and proposed to be taken by ALSTOM, together with the timetable for action. ALSTOM is grateful for the recommendations and would like to reassure HM Senior Coroner, the families of the deceased and the public at large, that it has and will continue to do all that it can to reduce the risk of passenger ejection through the bottom area of tram doors. If it would be of assistance to HM Senior Coroner, ALSTOM would be happy to provide further progress reports to HM Senior Coroner and/or a fuller report setting out the steps taken to review the strengthening of current and future door design and its conclusions regarding the feasibility of door strengthening. It is anticipated that the entire process, as outlined above, will be completed by June 2022. For HM Senior Coroner’s ease of reference and to provide further details of ALSTOM’s timetable for investigating the feasibility of changes to current and future door design, I attach a copy of the timetable prepared by ALSTOM.

Dear HM Senior Coroner

Re: Regulation 28 Report(s) to prevent future deaths in connection with the Inquests touching the deaths of Dane Chinnery, Donald Collett, Robert Huxley, Philip Logan, Dorata Rynkiewicz, Philip Seary and Mark Smith (“Sandilands Inquests”)

I write in relation to the Regulation 28 reports to Prevent Future Deaths (“PFD”) prepared by you following the conclusion of the Sandilands Inquests.

You made four separate PFD reports dated 28 September 2021 concerning (i) anonymous reporting schemes (ii) passenger ejection through tram doors (iii) the lack of a centrally funded national tram safety passenger group and (iv) automatic braking systems. The PFD reports were copied to Tram Operations Limited (“TOL”) as an Interested Person (“IP”) in the Sandilands Inquests.

The PFD reports concerning anonymous reporting schemes and passenger ejection through tram doors were addressed to UK Tram to be disseminated to all tramway operators. In accordance with your request, the purpose of this letter is to summarise the action taken or proposed to be taken by TOL in connection with the two reports or to explain why no such action is proposed.

The PFD reports concerning the lack of a centrally funded national tram safety passenger group and automatic braking were not addressed to tramway operators. Therefore, I do not provide commentary on those issues in this letter.

PFD Report on Anonymous Reporting Schemes

In your PFD report on anonymous reporting schemes, you state that all tramway operators should give consideration to subscribing to Confidential Reporting for Safety (“CIRAS”) or to another similar anonymous staff member reporting scheme, and further to look at whether such schemes are used, and if not, why not.

I confirm that TOL is a member of CIRAS, an independent not-for-profit confidential reporting service to the transport sector, having joined on 1 May 2017. TOL staff may choose to make a report to CIRAS on a confidential basis.

The CIRAS reporting line and signs displaying CIRAS contact details are present in the corridors and mess rooms at our Therapia Lane Depot, which are high footfall locations. CIRAS is a useful tool where staff prefer to remain anonymous. We can use the output of CIRAS reports and CIRAS representative events in a positive way to inform improvement initiatives across the organisation.

There have been no recent CIRAS reports but given TOL’s relatively small size this is not unexpected as TOL’s staff have a number of means of raising concerns. In line with our efforts to achieve a just culture, we have put in place resources to encourage internal reporting. By way of a few examples, there are a number of staff suggestion boxes located at our Therapia Lane Depot where staff may drop-off written feedback. The boxes are checked weekly, emptied on a regular basis and we respond in writing to each piece of feedback and take steps where appropriate.

In addition, staff may speak to their union representatives. Time is allocated each week to ensure that union representatives can carry out their union role (which includes liaising with staff regarding any points they wish to raise). We hold regular meetings with union representatives to ensure that management hear feedback reported through the unions.

Staff may also report directly to senior management. We operate an open door policy and we actively encourage the practice of self-reporting.

PFD Report on Passenger Ejection through Tram Doors

In your opinion, consideration should be given to current and future trams as to whether tram doors can be adapted (strengthened) now or in the future.

Please note that whilst TOL is the operator of the trams, it does not own the trams or have the power to implement changes to them. The trams are owned and managed by Tramtrack Croydon Ltd (“TCL”), trading as London Trams (a wholly owned subsidiary of Transport for London). The ultimate decision on any adaption of tram doors on Croydon Tramlink sits with London Trams in conjunction with tram manufacturers. Therefore, I can provide only limited commentary on this point from TOL’s perspective.

I confirm that TOL welcomes discussion with London Trams in this area, particularly in the context of the future replacement of the CR 4000 fleet. If tram manufacturers are able to strengthen the current doors in a way that is safe for the system as a whole, TOL would support their implementation across the Croydon Tramlink network.

Tram owners and tram manufacturers will be able to provide you with a much more detailed response on this point.

I would like to reiterate that health and safety is of paramount importance to TOL. We are committed to ensuring that our passengers, staff and members of the public remain safe.

I would be happy to assist you further should you require any further information.

Dear Ms Ormond-Walshe Re : Sandilands PFD report 4 I refer to your fourth draft “Regulation 28” Prevention of Future Deaths report arising from the inquests into the fatalities which were caused by the Sandilands tram crash in November 2016. This was directed both to Transport Focus (on whose behalf I am responding) and to the Department for Transport (DfT) (with which we have liaised informally on this topic). The “matter of concern” raised in your report is stated to be The lack of a centrally funded national tram passenger safety group. Under “action to be taken” you state that London TravelWatch is a passenger safety group which covers all public transport in Greater London. There is scope for a centrally funded national tram safety passenger group, covering all the different operators. I propose to recommend to the Department for Transport that consideration be given to setting up such a group. I should explain at the outset that there appears to be a misapprehension here regarding the precise nature and role of our sister organisation London TravelWatch. Its function is to reflect the interests and concerns of the travelling public in general within its geographical sphere of interest, and therefore safety (though important) is only one of the myriad of issues on which it engages with the service providers. It is true that - together with Transport Focus - it has consultative status with the Office of Rail and Road (ORR), the DfT and the Rail Accident Investigation Branch (RAIB) on safety issues, that it is represented on ORR's Rail Industry Health and Safety Advisory Committee, and that it has participated in inquiries and inquests into serious railway and tramway accidents. But this is only a small part of its work, and it is not in any sense "a passenger safety group" per se. Unfortunately, therefore, it does not offer a model on which the wider group that you envisage might be based. We are aware that the PFD report in question has its origin in a recommendation made to you at the conclusion of the Sandilands inquests on behalf of the “5 families” group of bereaved victims of the accident. This read that A UK tram passenger safety group should be established and funded centrally to advise the LRSSB [the Light Rail Safety and Standards Board] on passenger safety issues." Because the concept originated with the 5 families, and because there is no pre-existing group which fulfils a similar function in relation to any other mode of transport which might serve as a model, Transport Focus approached the legal representatives of these families to seek clarification of their

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thinking – e.g. in relation to the composition, remit, funding and modus operandi of such a group. It is a source of much regret to us that we were informed that they had nothing to add to their original submission to yourself, since this has made it very difficult for us to give detailed consideration to the proposal.

As you know, the operational safety of tramways is regulated by the ORR (with whose safety directorate we have liaised closely over many years). The first recommendation made by RAIB in its report on its Sandilands investigation was that The Office of Rail and Road (ORR) should work with the UK tram industry to develop a body to enable more effective UK-wide cooperation on matters related to safety, and the development of common standards and good practice guidance.

This recommendation has since borne fruit in the creation of the Light Rail Safety and Standards Board (LRSSB). It appears self-evident to us that any group of the kind envisaged in your draft report would have to be constituted in such a way as to have a very close working relationship with that body. We understand that LRSSB has itself been deliberating on this draft PFD report, together with the others made by you at the same time, but at the time of writing we have been unable to ascertain in detail any views it may have reached in this connection.

We note that you suggest that the group you are proposing should be “centrally funded”. We take this to mean that its costs should be met by the Department for Transport. If this is correct, the onus will lie on the authors of the proposal to show that this would be an appropriate and cost-effective use of public finance, over and above the substantial funding contribution currently being made by DfT towards the operating costs of LRSSB.

As you are aware, trams (and light railways) currently account for only a small proportion of the total public transport industry in Britain, and the nine systems in operation are highly geographically dispersed. We know that it has been a challenging experience for ORR to bring them together as a group to engage collectively on safety issues, in the guise of LRSSB, and we suspect that without the spur to action provided by the Sandilands disaster, this development might not have occurred. We warmly welcome the advent of the LRSSB, and we look forward to forging, over time, a similar constructive relationship with it to that which we already enjoy with the Rail Safety and Standards Board (RSSB), its counterpart in the main line or “heavy” rail sector.

Although there are obvious technical issues relating to the design, construction and operation of their vehicles and infrastructure which the various systems face in common, we believe that many of the physical safety issues about which their users may be concerned are likely to be specific to the layout and operating practices of each network. It may therefore be most useful, in the first instance, to ensure that there are effective channels for communication and dialogue between users and operators at system level. Part of this process will derive from the industry’s response to the thirteenth recommendation in the RAIB’s Sandilands report, which was directed to improving processes and, where necessary, equipment used for following up both public and employee comments which indicate a possible safety risk.

Although this was addressed specifically to the operators of the Croydon system, its message is of general application, and we understand that all tram network operators have been asked to report to LRSSB on equivalent action they have taken. It is of interest to note (and welcome) that the same message has been received and acted upon in the heavy rail sector, where RSSB has recently published Guidance on Managing Safety-Related Contacts from Members of the Public.

It is clearly important that LRSSB should monitor the takeup and effectiveness of these arrangements at local level, in order to establish whether there are common issues arising across the tram industry which

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need to be addressed collectively – and whether, in the light of these, more formal provision for user engagement on safety issues at industry level is required.

Transport Focus has neither the remit nor the resources to initiate the creation of a bespoke “tram passenger safety group” itself, but – together with our colleagues at London TravelWatch - we will engage with the tram service operators (and/or LRSSB, as appropriate) in relation to any passenger safety issues brought to our notice by users. And if the formation of a group of the kind you envisage is initiated under the auspices of any other body, we will certainly seek to facilitate and support it to the best of our ability.

Dear Miss Ormond-Walshe,

The tragic Sandilands tram accident on 9 November 2016 highlighted the importance of safety on the country’s tram networks. Five years after the accident, our thoughts are with all of those that were affected by those events.

I am writing in response to the four Regulation 28 Reports to Prevent Future Deaths (PFDs) that you sent to the Department on 21 September 2021 and thank you for granting an extension for the response. I am responding as Minister responsible for light rail.

I thank you for raising your concerns and for the actions you recommended be taken. We have worked with, and continue to work with, key stakeholders across the Light Rail sector to fully consider these recommendations and improve tram safety across the country. The safety of passengers on Light Rail systems is of paramount importance to the Department.

Across all the PFD’s recommendations, the Department has been supporting the work of the Light Rail Safety and Standards Board (LRSSB). The Department notes that the LRSSB, set up as a direct consequence of the Sandilands tram accident, has made good progress on your recommendations, and they will be writing separately to you to provide further detail on this.

Recommendation 1: a fresh assessment should be conducted as to whether trams should have automatic braking systems.

We are pleased to note the work that LRSSB has undertaken on this. In May, LRSSB published two guidance documents addressing concerns regarding driver inattention and speed management, including a consideration of the

Baroness Vere of Norbiton Minister for Roads, Buses and Places

Great Minster House 33 Horseferry Road London SW1P 4DR

Web site: www.gov.uk/dft

appropriateness of automatic braking systems. Additionally, several operators are now researching and trialling driver inattention solutions on their systems, including a trial of a potential new technology on the Sheffield Supertram.

Recommendation 2: further consideration should be given on the strengthening of tram doors.

LRSSB is conducting ongoing engagement with various European Standards technical working groups and committees with a view to informing the regulation of security and crashworthiness of tram doors. We will continue to monitor the progress that LRSSB makes, and work with them, and the sector, should adoption of new standards be required. We expect LRSSB to advise on whether a change to the standards is required in 2022.

Recommendation 3: all tram operators should consider subscribing to the Confidential Incident Reporting & Analysis System (CIRAS) or similar staff reporting scheme.

We are happy to note that, as reported by LRSSB, all Tram networks in England now subscribe to CIRAS. Furthermore, we support LRSSB’s plans to distribute a tramway specific guidance note, supported through a comms campaign, aimed at front line staff to promote the benefits of the scheme. Subject to sector-wide agreement, the comms plan is planned to be rolled out by Spring 2022.

Recommendation 4: consideration should be given to setting up national tram safety group.

The Department is consulting with passenger groups, system operators and key stakeholders to assess how passengers can easily raise concerns of their safety with tram operators and how this may be co-ordinated nationwide. We are in discussion with Transport Focus and LRSSB on this and will agree a solution with all stakeholders in 2022.

The Department will continue to work closely with UK Tram, LRSSB, system operators and all key stakeholders on addressing the concerns that have been raised in the PFDs.

We would like to extend our thanks the Senior Coroner and those at the South London Coroner’s Office for all their hard work and diligence in this matter.

BARONESS VERE OF NORBITON

Dear Mary, RE: LRSSB Response to HM Coroner's Regulation 28 Report to Prevent Future Deaths sent to LRSSB on 21st September 2021 - Automatic - Braking
1. The Role of LRSSB
1.1 The Sandilands accident occurred in November 2016 with the Rail Accident Investigation Branch (RAIB) report being published in December 2017 (Sandilands Report). Recommendation Number 1 of that report was for the ORR to work with the UK tram industry to develop a body to enable more effective UK-wide cooperation on matters related to safety, and the development of common standards and good practice guidance. The UK light rail industry responded quickly to Recommendation Number 1, forming a working group of senior industry representatives to consider the most appropriate organisation, and underlying structure, including how the new body should be funded.
1.2 The Light Rail Safety and Standards Board (LRSSB) was incorporated on 14 August 2018 and initially operated in shadow form. In May 2019 LRSSB received its initial funding from the Department for Transport. In conjunction with receiving this funding the Terms of Reference and the LRSSB Business Plan were able to be ratified by the Board of Directors later in May 2019.
1.3 It should be noted that the LRSSB is the safety and standards body for light rail and tramways in the UK and is completely separate (both in ownership and funding sources) from the Rail Safety and Standards Board (RSSB). The RSSB was itself established in 2003 following the recommendations of the Cullen Report into the Ladbroke Grove incident which included the establishment of an independent safety and standards body for the heavy rail sector.
1.4 While LRSSB received an initial 3-year funding settlement from the Department for Transport it has no guarantee of future funding at the end of this initial funding period which expires August 2022. The level of staff employed by LRSSB and consequently Coroner’s Officer South London Coroner’s Office Floor 2 Davis House Robert Street Croydon CR0 1QQ

Your Ref

Web Date

19th November 2021 LRSSB 16 Summer Lane, Birmingham B19 3SD

LRSSB, 16 Summer Lane, Birmingham, B19 3SD • Info@lrssb.co.uk

Registered Business Number; 11516814 the amount of work that it can undertake has a direct relationship with the funding settlement that it receives from the Department for Transport.
1.5 LRSSB is recognised and accepted by the light rail community, the Department for Transport and the Office of Rail and Road in the UK as the industry body responsible for providing standards and guidance relating to safety and the design, construction, maintenance, and operation of light rail systems in the UK. LRSSB has established and is continuing to develop a reference library where such industry standards and guidance can be found.
1.6 It should be noted, however, that LRSSB is an organisation that requires voluntary adherence to its guidance and best practice. Unlike the heavy rail industry, light rail operators are not required to be licensed under the Railways Act 1993 and there are therefore no licence conditions requiring membership of LRSSB or compliance with its outputs, however, currently, all seven 2nd generation UK tram networks are members of LRSSB and are actively engaged. While some parts of the Railways Act 1993 do apply to light rail and tramways, significant parts of that Act do not. This reflects the historic policy position that Government has taken under which light rail and tramway systems have generally been more associated with highways provisions rather than the more heavily regulated mainline railways.
2. LRSSB's current ongoing work with respect to Automatic Braking [Driver Inattention and Speed Management Systems]
2.1 The development of standards and guidance takes a significant number of months. A working group is established within which skilled safety professionals discuss the requirements for the document and the specific matters that it needs to cover before the text of the initial draft is developed. That draft document must be reviewed and tested to ensure that it is fit for purpose before it can be signed off for its release or use by the UK light rail sector. It should also be noted that LRSSB works closely with the ORR in its development of industry standards and guidance.
2.2 In the Preventing Future Matters report published by HM Senior Coroner, South London, LRSSB was asked to respond on the topic of Auto Braking. The report details how trains are fitted with auto-braking systems and, although trams are driven by “line of sight”, whether a fresh assessment of auto braking for trams would be appropriate at this stage.
2.3 In May 2021 LRSSB published guidance on detection of driver inattention (Guidance Document LRG 17.0) and speed management (Guidance Document LRG 18.0) in response to RAIB recommendations 3 and 4 in the Sandilands Report. This guidance is now being implemented and/or trialled across the UK networks, including advanced options to provide continuous automatic vehicle speed monitoring, which is an intelligent safe-speed system for advance warning or hazard speed monitoring.
2.4 LRSSB expect that the actions being taken by individual networks across the country will be supported by suitable and sufficient risk assessments; drawing on the outputs

LRSSB, 16 Summer Lane, Birmingham, B19 3SD • Info@lrssb.co.uk

Registered Business Number; 11516814 of the LRSSB sector risk model and guidance as necessary; and taking account of the effectiveness of other risk controls that are in place.
2.5 In parallel, several individual tram networks continue to undertake their own research into driver inattentiveness and speed monitoring systems as they develop system specific solutions that reflect the characteristics of their network and tramcars. We welcome this work in these areas and expect individual systems to consider the LRSSB guidance as they finalise/update their risk control arrangements, to demonstrate that risk is controlled as low as reasonably practicable.
2.6 LRSSB will continue to monitor advancements in this area and have also recently commissioned a research and development trial for obstacle detection / avoidance systems for use on light rail vehicles. We expect the outcomes of this trial to be available by end January 2022.
3. LRSSB's Conclusions
3.1 Whilst the status of some of RAIB’s recommendations remain ‘implementation on- going’, significant progress continues to be made within the sector. It is important to ensure clarity of progress and conclusions should not be rushed where possible to avoid producing sub-optimal conclusions in the longer term. LRSSB will always look at any proposed changes with a view to the holistic risk profile, however, optimisation of driver inattention and speed management systems should prevent the risk of topple due to excessive speed.

3.2 LRSSB believe that the adoption of the guidance published will significantly reduce the risk of a similar occurrence. LRSSB has placed a 12-month review date to the guidance and intends to monitor implementation along with any supplementary beneficial actions that the networks may have taken.
3.3 LRSSB continues to record, monitor, and assess hazardous events and their precursors through the national Tram Accident and Incident Reporting database (TAIR). All networks submit data to this LRSSB database. These inputs are then fed through to the LRSSB National Risk Model which provides outputs that identify potential current and future risk to both the UK sector as a whole or an individual network. Using this data LRSSB can then focus attention on any new technology or process required. LRSSB will, by the production of standard / guidance or by research and development seek to mitigate the chance of the identified event occurring. LRSSB believe that the use of this “live” database and its outputs will aid the sector in preventing future serious incidents. Issued: - 19th November 2021

Dear Mary, RE: LRSSB Response to HM Coroner's Regulation 28 Report to Prevent Future Deaths sent to LRSSB on 21st September 2021 – Risk of passenger ejection through tram doors.
1. The Role of LRSSB
1.1 The Sandilands accident occurred in November 2016 with the Rail Accident Investigation Branch (RAIB) report being published in December 2017 (Sandilands Report). Recommendation Number 1 of that report was for the ORR to work with the UK tram industry to develop a body to enable more effective UK-wide cooperation on matters related to safety, and the development of common standards and good practice guidance. The UK light rail industry responded quickly to Recommendation Number 1, forming a working group of senior industry representatives to consider the most appropriate organisation, and underlying structure, including how the new body should be funded.
1.2 The Light Rail Safety and Standards Board (LRSSB) was incorporated on 14 August 2018 and initially operated in shadow form. In May 2019 LRSSB received its initial funding from the Department for Transport. In conjunction with receiving this funding the Terms of Reference and the LRSSB Business Plan were able to be ratified by the Board of Directors later in May 2019.
1.3 It should be noted that the LRSSB is the safety and standards body for light rail and tramways in the UK and is completely separate (both in ownership and funding sources) from the Rail Safety and Standards Board (RSSB). The RSSB was itself established in 2003 following the recommendations of the Cullen Report into the Ladbroke Grove incident which included the establishment of an independent safety and standards body for the heavy rail sector.
1.4 While LRSSB received an initial 3-year funding settlement from the Department for Transport it has no guarantee of future funding at the end of this initial funding period Coroner’s Officer South London Coroner’s Office Floor 2 Davis House Robert Street Croydon CR0 1QQ

Your Ref

Web Date

19th November 2021 LRSSB 16 Summer Lane, Birmingham B19 3SD

LRSSB, 16 Summer Lane, Birmingham, B19 3SD • Info@lrssb.co.uk

Registered Business Number; 11516814 which expires August 2022. The level of staff employed by LRSSB and consequently the amount of work that it can undertake has a direct relationship with the funding settlement that it receives from the Department for Transport.
1.5 LRSSB is recognised and accepted by the light rail community, the Department for Transport and the Office of Rail and Road in the UK as the industry body responsible for providing standards and guidance relating to safety and the design, construction, maintenance, and operation of light rail systems in the UK. LRSSB has established and is continuing to develop a reference library where such industry standards and guidance can be found.
1.6 It should be noted, however, that LRSSB is an organisation that requires voluntary adherence to its guidance and best practice. Unlike the heavy rail industry, light rail operators are not required to be licensed under the Railways Act 1993 and there are therefore no licence conditions requiring membership of LRSSB or compliance with its outputs, however, currently, all seven 2nd generation UK tram networks are members of LRSSB and are actively engaged. While some parts of the Railways Act 1993 do apply to light rail and tramways, significant parts of that Act do not. This reflects the historic policy position that Government has taken under which light rail and tramway systems have generally been more associated with highways provisions rather than the more heavily regulated mainline railways.
2. LRSSB's current ongoing work with respect to Risk of passenger ejection through tram doors.
2.1 The development of standards and guidance takes a significant number of months. A working group is established within which skilled safety professionals discuss the requirements for the document and the specific matters that it needs to cover before the text of the initial draft is developed. That draft document must be reviewed and tested to ensure that it is fit for purpose before it can be signed off for its released for use by the UK light rail sector. It should also be noted that LRSSB works closely with the ORR in its development of industry standards and guidance.
2.2 In the Preventing Future Matters report published by HM Senior Coroner, South London, LRSSB was asked to respond on the topic of passenger ejection through tram doors.
2.3 In its role LRSSB has the ability, and is frequently requested to, represent the UK light rail sector on various European Standards technical working groups and committees. The committees can be made up of representation from across Europe and include, owners, statutory bodies, designers, manufactures and operators. If a proposal has been voted for and accepted by BSi, it will then look to adopt the standard for the UK sector. RSSB act as the secretariat for BSi.
2.4 There are many standards applicable to the construction of a metro or tram car. LRSSB is reviewing the provenance and relevance of those pertinent to this issue. Currently one of the committees LRSSB sits on is RAE/001/0-/18 Railway applications
- Interior passive safety BSi eCommittee. Amongst topics being considered are metro

LRSSB, 16 Summer Lane, Birmingham, B19 3SD • Info@lrssb.co.uk

Registered Business Number; 11516814 and tram saloon doors and their security and crashworthiness. LRSSB has also requested that all the technical recommendations from the RAIB Sandilands investigation be considered.

2.5 The UK eCommittee voted positively to have the issues raised by LRSSB included. That resolution then went to the European Committee who approved the creation of a Technical Report Committee.

2.6 LRSSB is also monitoring any advancements made in this area by TfL / London Trams with their manufacturer. If positive action is taken, then LRSSB will use its communication channels to ensure that the sector is fully briefed. Likewise, LRSSB regularly meets with the sector and will ensure that updates to and from the networks are assessed and communicated out accordingly.

3. LRSSB's Conclusions
3.1 Whilst the status of some of RAIB’s recommendations remain ‘implementation on- going’, significant progress continues to be made within the sector. It is important to ensure clarity of progress and conclusions should not be rushed where possible to avoid producing sub-optimal conclusions in the longer term. LRSSB will look at any proposed changes to doors with a view to the holistic risk profile. For instance, the optimisation of driver inattention and speed management systems should prevent the risk of topple due to excessive speed.

3.2 LRSSB will continue to take an active role in the European Standards and BSi working groups as this is where design and manufacturer of future fleets can really be influenced.
3.3 LRSSB will consult with TfL / London Trams to ascertain what remedial action have or can be reasonably taken to address this issue. LRSSB would then publish a briefing or guidance note as to what the sector should be considering. At this time LRSSB are unsure of the timelines for this work but will report back to HM Coroner South London as soon as these have been finalised.
3.4 LRSSB expect that any actions being taken by individual networks will be supported by suitable and sufficient risk assessment; drawing on the outputs of the LRSSB sector risk model and guidance as necessary; and taking account of the effectiveness of other risk controls that are in place. Issued: - 19th November 2021

Dear Mary, RE: LRSSB Response to HM Coroner's Regulation 28 Report to Prevent Future Deaths sent to LRSSB on 21st September 2021 – Anonymous Reporting
1. The Role of LRSSB
1.1 The Sandilands accident occurred in November 2016 with the Rail Accident Investigation Branch (RAIB) report being published in December 2017 (Sandilands Report). Recommendation Number 1 of that report was for the ORR to work with the UK tram industry to develop a body to enable more effective UK-wide cooperation on matters related to safety, and the development of common standards and good practice guidance. The UK light rail industry responded quickly to Recommendation Number 1, forming a working group of senior industry representatives to consider the most appropriate organisation, and underlying structure, including how the new body should be funded.
1.2 The Light Rail Safety and Standards Board (LRSSB) was incorporated on 14th August 2018 and initially operated in shadow form. In May 2019 LRSSB received its initial funding from the Department for Transport. In conjunction with receiving this funding the Terms of Reference and the LRSSB Business Plan were able to be ratified by the Board of Directors later in May 2019.
1.3 It should be noted that the LRSSB is the safety and standards body for light rail and tramways in the UK and is completely separate (both in ownership and funding sources) from the Rail Safety and Standards Board (RSSB). The RSSB was itself established in 2003 following the recommendations of the Cullen Report into the Ladbroke Grove incident which included the establishment of an independent safety and standards body for the heavy rail sector.
1.4 While LRSSB received an initial 3-year funding settlement from the Department for Transport it has no guarantee of future funding at the end of this initial funding period which expires August 2022. The level of staff employed by LRSSB and consequently Coroner’s Officer South London Coroner’s Office Floor 2 Davis House Robert Street Croydon CR0 1QQ

Your Ref

Web Date

19th November 2021 LRSSB 16 Summer Lane, Birmingham B19 3SD

LRSSB, 16 Summer Lane, Birmingham, B19 3SD • Info@lrssb.co.uk

Registered Business Number; 11516814 the amount of work that it can undertake has a direct relationship with the funding settlement that it receives from the Department for Transport.
1.5 LRSSB is recognised and accepted by the light rail community, the Department for Transport and the Office of Rail and Road in the UK as the industry body responsible for providing standards and guidance relating to safety and the design, construction, maintenance, and operation of light rail systems in the UK. LRSSB has established and is continuing to develop a reference library where such industry standards and guidance can be found.
1.6 It should be noted, however, that LRSSB is an organisation that requires voluntary adherence to its guidance and best practice. Unlike the heavy rail industry, light rail operators are not required to be licensed under the Railways Act 1993 and there are therefore no licence conditions requiring membership of LRSSB or compliance with its outputs, however, currently, all seven 2nd generation UK tram networks are members of LRSSB and are actively engaged. While some parts of the Railways Act 1993 do apply to light rail and tramways, significant parts of that Act do not. This reflects the historic policy position that Government has taken under which light rail and tramway systems have generally been more associated with highways provisions rather than the more heavily regulated mainline railways.
2. LRSSB's current ongoing work with respect to Anonymous Reporting (CIRAS).
2.1 The development of standards and guidance takes a significant number of months. A working group is established within which skilled safety professionals discuss the requirements for the document and the specific matters that it needs to cover before the text of the initial draft is developed. That draft document must be reviewed and tested to ensure that it is fit for purpose before it can be signed off for its release or use by the UK light rail sector. It should also be noted that LRSSB works closely with the ORR in its development of industry standards and guidance.
2.2 In the Preventing Future Matters report published by HM Senior Coroner, South London, LRSSB was asked to respond on the topic of Anonymous Reporting. The report details how all tramway operators should look at using CIRAS (or a similar anonymous reporting scheme) and whether such schemes are used and if not, why not.
2.3 LRSSB believes that all seven UK Tramways subscribe to a confidential reporting scheme. It is understood that the scheme they are all members of, is CIRAS. LRSSB has also had this confirmed by the CIRAS body.
2.4 LRSSB is a member of the CIRAS committee representing the light rail sector, that is Chaired by the independent Chair of the CIRAS Board. The committee is made up from representatives of member companies and unions in addition to independent experts. The committee assists the organisation in ensuring its ongoing effectiveness and helps it adapt to the needs of its members and staff. LRSSB communicates information, reports and analytics raised at the CIRAS Committee to the sector via the Light Rail Heads of Safety Group.

LRSSB, 16 Summer Lane, Birmingham, B19 3SD • Info@lrssb.co.uk

Registered Business Number; 11516814
2.5 LRSSB will continue to monitor advancements in this area and will update its documentation accordingly.
3. LRSSB's Conclusions
3.1 Whilst it has been identified that the sector does use CIRAS, LRSSB believes that the production of a tramway specific guidance note, allied to a positive communication campaign, aimed directly at front line staff, will highlight, and promote the benefit of such schemes.
3.2 In collaboration with CIRAS, LRSSB intends to provide documentation detailing such schemes and their benefits. This documentation is currently in preparatory draft form, but LRSSB expects publication to be before the end of this business year (March
2022). Issued: - 19th November 2021