A former Transport for London (TfL) board member has written to the boss of the UK’s rail accident investigation agency demanding that the body revise the conclusions of its report on 2016’s fatal Croydon tram crash.

Michael Liebriech, who was the chair of TfL’s safety panel at the time of the crash, wrote that the current report was not a “credible and complete” account of the disaster, in which seven people were killed.

Read more: Exclusive: TfL took legal advice on cancelling First Group tram contract after fatal Croydon crash

The letter to the Rail Accident Investigation Branch (RAIB), which City A.M. has obtained, comes a month before a long-awaited inquest into the crash is set to begin, on 17 May.

Liebriech raised three areas in which he said the existing report is deficient, including its failure to analyse a series of safety audits of the Croydon tram operation carried out between 2014 and 2017.

As City A.M. has revealed, these audits show that fatigue management had been highlighted as a problem on the network as early as 2014.

RAIB’s report, which was published in December 2017, concluded that the driver of the tram likely suffered a “micro-sleep episode”.

Despite raising concerns that the fatigue management practices of TOL – the First Group subsidiary that runs the tram network – were “not always in line with published industry practice”, RAIB concluded that it was “not a factor in the accident”.

In its conclusions, the body wrote: “Although it is possible that the driver was fatigued due to insufficient sleep there is no evidence that this was the result of the shift pattern that he was required to work.”

In his letter, Liebriech said that this conclusion was “untenable” due to the additional evidence that has now come to light.

Liebriech wrote:  “For it to be a credible and complete investigation into the causes of the crash you need to do the following:

“1. Add a complete analysis of the six safety and fatigue audits of the Croydon Tram or TfL’s Tram Operations dating between 2014 and 2017 which you missed in whole or in part;

“2. Add an analysis of the contractual relationship between TfL and First Group and its impact on safety management; and

“3. Change your conclusion to accept that fatigue risk management was at the very least a possible causal factor in the Sandilands crash.”

“Should you refuse to make these changes, and should the inquest fail to endorse your report as the definitive and complete investigation into the reasons for the crash – in particular if its findings deviate from your report on any of the three points I have repeatedly raised over the past 18 months – I believe you will have no alternative but to resign.”

A spokesperson for the RAIB said: “The RAIB is currently focused on providing the greatest possible support to the inquests into the deaths of those who tragically died at Sandilands Junction on 9 Nov 2016. These inquests are due to start on 17 May. 

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“We plan to provide to the coroner any additional information that is necessary to address issues raised by Mr Liebreich, along with our assessment of other information that has been disclosed by others in preparation for the inquests.

“As published, RAIB’s report provides an authoritative and evidence-based account of the accident and its causes.  The 15 recommendations in the RAIB’s final report identify a wide range of areas for safety improvement that encompass both fatigue management and risk assessment.”  

Audits in focus

Much of Liebriech’s letter focuses on RAIB’s failure to investigate the audits, which, he said, contain a number of “anomalies”. 

One of these, which was being carried out at the time the crash occurred but was swiftly abandoned, was not even requested by the investigator during its probe.

A year later, another report was watered down by TfL executives in order to placate First Group, as City A.M. has revealed. 

Although RAIB did mention this audit in an addendum to its original report released in 2018, it did not sufficiently investigate it, wrote Liebriech. 

Summing up, he said: “What these six audits show is that there was a pattern of weak fatigue management of the Croydon Tram spanning the years 2014 to 2017, as well as a failing safety audit system within TfL which repeatedly gave a clean bill of health to operations later heavily critiqued in your report.”

Both TfL and First Group have defended their actions in the aftermath of the crash, saying they had co-operated with all investigations and implemented additional safety measures on the network.

Read more: Exclusive: Transport for London aware of Croydon tram fatigue problem two years before deadly crash

However, earlier this year it was revealed that there were three near misses on the tram network in 2020, including a slow-speed derailment.

TfL’s commissioner Andy Byford has said that the operator is taking the incidents “very seriously”.