The death of seven passengers in the Croydon tram crash were accidental, the jury at the coroner's inquest in south London decided, in a verdict angrily met by the families of the victims.
In a narrative verdict, the jury said the contributing factors were that the driver became disoriented and failed to brake in time, while Tram Operations Ltd (TOL), the operator of the tram, had failed to properly account for the risk of high-speed derailment, or had failed to ensure a "just culture" where drivers felt able to report health and safety issues.
The families of the victims called the investigation a farce. Their lawyers said that they would write to the attorney general and ask the High Court for judicial review of the coroner's decision not to admit a number of witnesses from the tram operating company, including other drivers.
The jury found that the seven deceased passengers - Dane Chinnery, 19; Donald Collett, 62; Robert Huxley, 63; Philippe Logan, 52 years ; Dorota Rynkiewicz, 35; Philip Seary, 57, and Mark Smith, 35, suffered head, chest and other injuries after being thrown from the streetcar in the crash on November 9, 2016.
The foreman of the jury said: "The tram driver became disoriented, which resulted in loss of awareness of his surroundings, probably due to a microphone -sleep. As a result, the driver did not brake in time and drove his tram into a tight curve at excessive speed.
The verdict follows nine days of deliberation after the eight-week inquest, where the jury heard testimony from accident investigators and the police about the 2016 tragedy, the worst to happen on a UK tram in over 90 years.
The investigation was recounted by the 'train accident The Chief Inspector of the Bureau ofinquiries, Simon French, that the tram overturned due to excessive speed, and that the driver, who had driven trams on the same route nearly 700 times in the year, was likely to have had a "micro-sleep ". ”In the moments before the accident.
Other inspectors from the RAIB and the UK Transport Police testified, but coroner Sarah Ormond- Walshe, ruled that additional witnesses, including officials from TOL, the tram operator, and Transport for London, should not be called.
Jean Smith, 64, the mother of Mark Smith, said after the verdict: “I am bitterly disappointed that justice has not been served today. This was a complete farce as we only heard half of the evidence and no one who could have been potentially responsible for the accident was called as a witness.
" ItIt is morally reprehensible that we were unable to hear anyone from TfL, TOL or the driver during the proceedings, regardless of the legal precedent. It feels like they may have been hiding from testifying and that is just not fair or just. Justice has been stifled because of the coroner's decision.
Citing previous cases, Ormond-Walshe decided that it was not for the coroner to reproduce the inquest unless it was shown to be defective. In a June 28 ruling, she said she "does not accept that the RAIB 's investigation is incomplete, flawed or flawed ", adding that "other evidence would probably not be useful to the jury ". "dcr-s23rjr"> Ormond-Walshe told the Croydon town hall jury that he could pronounce a verdict of unlawful murder or accidental death, although any verdict of unlawful murder depends on the finding of gross negligencefrom the driver, Alfred Dorris. She said the evidence was well below the threshold for corporate manslaughter.
Ben Posford, of Osbornes Law, the lead lawyer for five of the seven families, said they were "understandably angry and upset by today's finding, and were unable to hear from those responsible for the systemic failures which led to the death of their loved ones.
"Ultimately, they feel that no one was held responsible for the tragic events nearly five years ago and will continue to fight for justice for their loved ones. Accordingly, we will pursue the legal options available to us by calling on the Attorney General to refer the matter to the High Court for a new investigation. "
The tram derailed in heavy rain and darkness in a vTight turn of the track before the Sandilands tram stop. It was traveling at 73 km / h (45 mph), although the maximum speed allowed on the curved section of the track was 20 km / h (12.5 mph). The six men and a woman died instantly after being thrown from windows or tram doors, RAIB said. Nineteen other passengers were seriously injured.
French, the head of the RAIB, said the surviving passengers "referred to them as being at inside a washing machine ".
French also told the survey that there are apparent " cultivation problems "at TOL had meant that drivers were unwilling to admit their mistakes, including speeding. An incident 10 days before the accident, when another tram almost overturned after reaching the same bend at high speed, has not been sufficiently investigated, French added.
Ormond-Walshe admitted a witness who had not spoken to investigators. Jim Snowden, a former chief engineer of the network, told the inquest he raised eight security concerns years earlier concerning the section of track where the accident occurred, in particular the absence of warning signs.
In a Written report from 2008, he said there were "long stretches of separate tracks and isolated alignments where there is little visual clue to the location during the hours of darkness, there is a potential for the driver to lose awareness of the distance to which hazards are approaching and it may be appropriate to consider the placement of early warning signs as a reminder. on the network was the Sandilands tunnel just before the bend.
Dorris, the conductor of the tram, was not called to testify at the investigation, having been judged medically infit.
FirstGroup, owner of TOL, said that since the accident it has introduced safety measures, including improved speed monitoring, cabin safety devices, better checklists and more training on the risk of fatigue. Its managing director, Matthew Gregory, said: “Since the incident, we have been fully engaged in all subsequent investigations, implementing the recommendations that have arisen and will take into account any further learning that may arise from it. investigation. "