The victims of the Croydon tram crash died as a result of an accident, and were not unlawfully killed, the jury at the inquest into their deaths has concluded.
Seven passengers died and a further 51 were injured when a tram derailed in south London on November 9 2016, in the worst accident on a British tramway in more than 90 years.
Dane Chinnery, 19, Philip Seary, 57, Dorota Rynkiewicz, 35, Robert Huxley, 63, and Philip Logan, 52, all from New Addington, and Donald Collett, 62, and Mark Smith, 35, both from Croydon, were killed in the crash.
On its 10th day of deliberations at Croydon Town Hall, south London, the 10-person jury reached a unanimous conclusion that their deaths were a result of an accident.
The families of those killed in the crash have branded the inquest a "farce", claiming Transport for London (TfL) and the tram operators should have been called to give evidence.
Some of the relatives of those who died sobbed in the public gallery as the jury delivered their findings.
Alfred Dorris, 47, was believed to have "nodded off" for up to 49 seconds in the Sandilands tunnel in Croydon, South London, before his tram hit a sharp bend at nearly four times the speed limit.
The jury found the driver "lost awareness and became disorientated … probably due to a lack of sleep" as he approached the Sandilands bend.
The foreman of the jury at the inquest said: "As a result of which, the driver failed to brake in time and drove his tram towards a tight curve at excessive speed.
"The tram left the rails and overturned onto its right side, as a result of which the deceased was ejected from the tram and killed."
Croydon tram crash, where seven people died
It can now be reported that south London senior coroner Sarah Ormond-Walshe refused to call a number of people who the victims’ families wanted to give evidence about alleged safety failings.
Those potential witnesses include senior managers of operator Tram Operations Ltd – a subsidiary of FirstGroup – and Transport for London, plus other experts and tram drivers.
Ms Ormond-Walshe had ruled at a special hearing that there was no need to call the two organisation’s bosses because the inquest only needed to rely on the Rail Accident Investigation Branch investigation report.
The victims’ families will now call on the Attorney General Michael Ellis QC to apply to the High Court to grant a new inquest.
‘Culture of fear’ may have discouraged drivers from reporting health and safety concerns
The jury rounded on Tram Operations Limited, which runs the system and employs Mr Dorris.
In their narrative, they said the company, owned by First Group, had a risk assessment system which "failed to sufficiently identify the risk of the tram overturning and crashing at the tight Sandilands curve at high speed with the probabilities of fatalities."
They said TOL ran the network on a "line of sight driving and route knowledge but failed to identify additional measures to mitigate risk."
They added: "The lack of a ‘just culture’ discouraged drivers from reporting health and safety concerns."
The inquest heard allegations that a culture of fear may have discouraged some drivers from reporting incidents where they may have nodded off or become disorientated.
Just nine days before the crash another speeding driver in the same tunnel nearly derailed his tram but was too afraid of "belittling" bosses to report the "near miss".
The incident was only discovered when a female passenger reported it to TfL complaining she was in fear for her life and suffered shock and minor injuries.
It also emerged how six tram drivers who "fell asleep at the wheel" and who were involved in "near misses" were subsequently disciplined or sacked in the six years up to the crash.
Matthew Gregory, Chief Executive of First Group, said: "Since the incident, we have fully engaged with all subsequent investigations, implementing recommendations that arose from them and will take into account any further learnings that may arise from the inquest. FirstGroup has an unwavering commitment to safety, it is front and centre to our culture and to everything we do."
He added: "New safety measures we have introduced with TfL include improved speed monitoring and restrictions; in-cab safety devices; an enhanced roster planning process; and further training to increase awareness of the risks posed by fatigue and how it can be managed."
The inquest heard allegations that a culture of fear may have discouraged some drivers from reporting incidents where they may have nodded off or become disorientated
Credit: RAIB/PA Wire
Meanwhile, it can be revealed a chief engineer had written a report in 2006 warning Tram Operations Ltd that Sandilands Tunnel needed to try a lower speed limit of 37mph (60kph) because drivers were "braking heavily" and at "the last moment" before approaching the now notorious bend.
Jim Snowdon, chief engineer at Tramtrack Croydon Ltd, which ran the infrastructure before TfL took over in 2008 warned there were "few visual clues as to location … [in the tunnel and] there is the potential for the driver to lose awareness of the distance to approaching hazards".
He did not think Tram Operations Ltd responded to his report, adding how there was "hostility" between that company and his.
Families of victims left ‘bitterly disappointed’
Jean Smith, 64, mother of Mark Smith who died in the accident, said: "I am bitterly disappointed as justice has not been done today. It has been a total farce as we have only heard half of the evidence and no one who could potentially have been responsible for the crash has been called as a witness.
"It’s morally wrong that we haven’t been able to hear from anybody from TfL, TOL or the driver during the proceedings, whatever legal precedent says. It feels like they have been able to hide from giving evidence and it simply isn’t fair or just. Justice has been suffocated because of the coroner’s ruling.
"All we want as families is justice for our loved ones, yet four and half years on, the inquest has created more anguish and pain because we have been left with so many unanswered questions."
Ms Smith added: "We have been asked to accept the findings of the Rail Accident Investigation Branch (RAIB) without question, but this is completely unjust. Our legal team will be writing to the Attorney General to ask him to seek an order for a new inquest and separately, to seek permission for judicial review. This fight is not over."
Ben Posford, partner and Head of Catastrophic Injury at London law firm Osbornes Law, which represented five of the seven families, said relatives were angry that after an agonising wait they still have not secured justice for those they lost.
He said: "The families of those who died are understandably angry and upset at today’s conclusion and that they have been unable to hear from those responsible for the systemic failings that led to their loved one’s deaths.
"They have had an agonising wait for justice but have been let down by the process that has allowed the managers of TfL and TOL to dodge giving evidence and avoid giving the families the answers they so desperately need. Instead of gaining a greater understanding of how and why their loved ones died, they have been badly let down.
"Ultimately they feel that nobody has been held accountable for the tragic events almost five years ago and will keep fighting for justice for their loved ones. As a result, we will be pursuing the legal options open to us by calling on the Attorney General to apply to the High Court for a new inquest. The families will also be considering judicial review proceedings against the coroner, to get the answers they deserve."