There was no CCTV from the tram as the system was broken.
Victims: Donald Collett (left) and Philip Logan
British Transport Police
The report tells how passengers described the crash as “being like in a washing machine”. The 36-tonne tram, which was heading from New Addington to Wimbledon, slid 27m on stones before coming to rest.
It confirms a BBC London report from last year that a passenger had reported a similar incident on October 31, when a tram travelling at 28mph was “close to tipping over”.
It says this was not investigated by tram operator Tram Operations Ltd, a FirstGroup subsidiary.
"Loving husband": Relatives of Robert Huxley paid tribute following his death in the Croydon tram tragedy
British Transport Police
Trevor Sterling, of Moore Blatch solicitors, told the Standard: “In my view, what the report reveals is that this was an accident waiting to happen. There should have been enough information available to the company to have them inquire into the need to improve the set-up to that bend.
“The incident involved a failing on the driver’s part - there is no getting around it. But there is in my view no doubt that if it wasn’t him, it probably would have been somebody else at some point.”
Investigators also found that a number of drivers had not reported heavy braking or the use of the emergency brake at that location “because of the perceived attitude of some managers and because they feared the consequences for themselves if they did so”.
The report calls for automatic braking systems, stronger doors and windows, a better understanding of the risks of trams overturning rather than simply derailing and a culture where drivers feel able to report concerns.
Liability has been admitted and legal cases are ongoing to secure compensation for the victims. Some cases could take years to resolve, depending on the long-term impact of their injuries.
Mr Dorris, from Beckenham, was arrested at the scene but was later released.
The 43-year-old was further questioned earlier this year by police on suspicion of manslaughter as part of the interim investigation.
Police inquiries are continuing.
Since the crash, four drivers have admitted to falling asleep while operating trams at the same location.
Sarah Jones, MP for Croydon Central, said: “Some of the findings such as the missed opportunities to prevent this tragedy, and safety improvements needed across the network, are quite shocking, and it’s clear the industry has a lot of work to do.”
Mayor Sadiq Khan said TfL was working with FirstGroup on new safety measures., including an in-cab device to protect drivers against distraction and fatigue.
He said: “I have been personally assured by the RAIB Chief Inspector that TfL has been working closely with RAIB to assist their investigation, to ensure that all necessary safety measures are implemented so that an incident like this can never happen again.”
TfL said it would publish its own report next month. “Since the incident we have introduced a wide range of additional safety measures to make sure such a tragedy can never happen again,” Sahf TfL commissioner Mike Brown.
