23 May Transport for London (TfL) Board Meeting

MQT on 2018-06-21
Session date: 
June 21, 2018
Question By: 
Keith Prince
GLA Conservatives
Asked Of: 
The Mayor


During the 23 May Transport for London (TfL) Board Meeting which you chaired, the Chair of the Safety, Sustainability and Human Resources Panel informed the meeting that TfL Management had confirmed to him on 3 separate occasions that Internal Report IA 17 780 "Audit of First Group TOL's Fatigue Risk Management System" dated 15 September 2017 had been sent to the RAIB, SNC-Lavalin, the Office for Rail and Road (ORR), British Transport Police (BTP) and the Coroner, the first two organisations well in time for the findings to be considered in their final reports publisher, respectively, in December 2017 and January 2018.  Given the scale and severity of the safety faults identified in IA 17 780 and to ensure all lessons are learned from the Sandilands Crash, will you:

1) Formally request the RAIB and SNC-Lavalin to re-issue their reports after taking into account Internal Report IA 17 780's findings?

2) Formally investigate why (a) TfL management failed to release Internal Report IA 17 780 immediately to the RAIB, ORR, BTP, SNC-Lavalin and the Coroner upon its restricted distribution to 9 Senior TfL Officials on 15 September 2017 and (b) it appears to have released the document to the regulators, investigators and police only after this manifest failure was made public by a blogger?


Answer for 23 May Transport for London (TfL) Board Meeting

Answer for 23 May Transport for London (TfL) Board Meeting

Answered By: 
The Mayor

Transport for London (TfL) and I are completely committed to learning all lessons from the tragedy at Sandilands to ensure that such an incident can never happen again. The measures TfL has taken and continues to take in response are summarised on the TfL website. TfL has also shared the outcome and findings of the investigations across its operations to ensure the lessons from Sandilands are learnt more widely.

As I explained in my response to Mayor's Question 2018/0794, TfL commissioned an audit in May 2017 in response to concerns about driver fatigue, following an incident recorded by a member of the public on a tram in Church Street.  The resulting report is the Internal Audit Report IA 17 780 'Management of Fatigue in Tram Operations Limited' (TOL), and is separate from the investigation into the Sandilands overturning.

As I explained in my response to Mayor's Question 2018/1130, TfL drew the Church Street incident to the attention of the Rail Accident Investigation branch (RAIB) and Office of Rail & Road (ORR) as soon as it was made aware of it.

The ORR informed TfL that it would be investigating the Church Street incident as part of its business as usual activities. In particular, it said it would be investigating TOL fatigue management. The outcome of this investigation was between ORR and TOL. The RAIB did not update TfL on how it used this information. However, it confirmed that it had seen the footage and would give it due consideration in its investigation.

TfL would not normally forward audit reports to the ORR, RAIB or BTP, as these authorities would normally request any information they required. TfL always provided the authorities with any information requested. Given this, and their awareness of the Church Street incident, I do not consider it necessary for the RAIB or SNC-Lavalin to reissue their reports.

On 22 January, the chair of TfL's Safety, Sustainability and Human Resources Panel asked if the fatigue audit had had been sent to the external bodies investigating the Sandilands incident. At the meeting TfL said it believed it had been sent, but discovered afterwards that it had not. This was due to a human error, for which TfL apologises. The report was then sent to the RAIB, BTP and ORR on 12 February 2018.  I consider this to be an adequate explanation of the circumstances behind the sharing of the report, and do not intend to launch a further investigation. At the request of its board, TfL is preparing a report setting out the circumstances of the human error.