| On the 9 November 2016, a tram on the Croydon tramway network overturned at Sandilands. The tram had been travelling at 73 km/h when it entererd a curve that had a maximum speed limit of 20 km/h. The speed caused the tram to overturn as it passed through the curve, and resulted in passengers being thrown around inside the tram, with some being ejected through broken windows. Of the 69 passengers involved in the accident, seven died and 61 were injured; 19 seriously. The Rail Accident Investigation Branch's report has been released today and makes some far-reaching recommendations for the way tram operations in the UK are regulated and managed. Sadly, many of the recommendations are made about things that are already known about (and managed) in the rail sector, but which were not applied to tramway operations - tramways are often regarded as being more akin to road operations than rail operations. The accident at Sandilands makes it clear that rail sector engineering standards and management systems (for example fatigue management) are highly relevant to tram operations. The investigation report concludes that it is probable that the tram driver temporarily lost awareness on a section of route on which his workload was low. A possible explanation for this loss of awareness was that the driver had a microsleep, and that this was linked to fatigue. Exacerbating this was that there were few landmarks so that the driver was unable to quickly reorient himself. The report makes 15 recommendations to improve tramway safety. Some apply to the operator of the Croydon tram network (First Group), but many apply across all UK tram operations:
|  Image: Rail Accident Investigation Branch |
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John Baker, our Managing Partner, recently gave a short talk on the state of leadership and management in the UK as part of his role as Regional Board Member of the Chartered Management Institute in Bristol. The talk covered recent research by the Chartered Management Institute on how managers and leaders are trained and low-cost ways that managers and leaders can develop their knowledge and skills. The event was run by SevernNet, a not-for-profit enterprise, run by, and working for the benefit of, the businesses, organisations and the community extending from Royal Portbury Dock through Avonmouth, Severnside to Western Approach Industrial Park. Here at Silver Moor we have a range of services that can support businesses of all sizes, including short training workshops, coaching and business mentoring.
 The R101 airship wreckage Just after 2 a.m. on Sunday 5th October 1930, the hydrogen-filled British airship, R101, crashed into a wooded hillside near Beauvais in France. The disaster is notable for the multitude of human factors that were present. Probably the most significant was the time pressures that the design and construction team faced. These resulted from a deadline imposed by the Air Ministry for the first flight - to India and back - to take place in September 1930. This was so that the Air Minister could arrive back in England, aboard an airship, for the Imperial Conference in October. The British government wanted to show off to the collected prime ministers of the Empire what it could do when put in charge of large industrial projects. Future airship development (and thousands of jobs) were dependent on meeting this deadline. The whole design and construction was fraught with technical challenges; solving one problem created many new ones. The airship was heavy - the hydrogen gas was not sufficient to support the airship's weight. Significant efforts were made to lighten the airship, and an extra bay was inserted in the middle of the airship. This was a major operation - the airship had to be cut in two, a new section (11 metres long) inserted and the whole thing joined back together. This section contained an extra gasbag and gave the airship an extra 7 tonnes of lift. It also meant that the airframe would now be subject to different stresses and strains that had not been considered at the initial design stage. Lightening the airship meant that its viability as a commercial venture was likely to be doomed, as many of the luxury fittings had to be stripped out. Obviously this would not impress the passengers nor the high-ranking officials who would go aboard the airship in Egypt (a planned stop-off point on the journey) and India. So, despite concerns about weight, a 180-metre long Axminster carpet was fitted in the main corridor and another similar one fitted in the tennis court-sized main lounge. Given that a layer of dust an eighth of an inch thick across the top of the airship was said to weigh a ton, this extra load would have been significant. There was also a lot of heavy cargo - deemed essential for taking to Egypt and India as a showcase of British exports. This included casks of ale, cases of champagne and silverware. Concerns about weight were so severe that the crew had been told to leave their parachutes behind in the sheds at Cardington.  R101 at its mooring mast A further problem, one that compounded the airship's weight problem, was the loss of hydrogen gas used (in common with most airships of the time, explosive hydrogen was used, not helium). The gasbags inside the airship were found to rub against the exposed girders and bolts of the frame structure, causing holes to form. Because of the time pressures the team were facing, attempts were made to insert padding between the frame and gasbags - an almost impossible task given the size of the airship and the fact that the gasbags moved around in flight and contacted unpadded parts of the structure. Before its final flight it was known that the gasbags had "many holes in them". On top of all this, the UK Air Ministry at the time, whose role it was to scrutinise and advise the airship design and construction team at Cardington, was made up of aeroplane experts. This meant that there was little effective impartial challenge to the work. All the test flights had been carried out in perfect flying conditions, so the airship was virtually untested in poor weather. Today, these factors are more commonly known as 'safety culture'. At 6.24pm on the 4th October 1930, R101 left the Cardington mast in misty fine rain and darkness, with predicted heavy rain over France. 4 tonnes of ballast had to be dropped before the ship gained height. The craft struggled to gain height, going as low as 150 metres and only achieving 300 metres over the Channel and into France. At 02.00am the ship reached Beauvais and passed to the east of the town. At this time witnesses suggested that the ship was beginning to have difficulty with the gusting winds. Shortly after, the ship made a long and rather steep dive. The gusting winds and rain are believed to have caused the outer fabric to tear, and the dive to have caused an exposed gasbag at the front of the airship to split. The loss of gas at the forward part of the ship, combined with a sudden downward gust of wind would have forced the nose down. The ship began to drop again through a downward angle and at this point the nose hit the ground. Although the speed and angle of this collision was similar to that of a perfect landing, it is likely that one of the hot engines came into contact with a stream of escaping gas. Shortly after, 156,000 cubic metres of hydrogen caught fire. Forty eight people died in the disaster - only eight escaped the wreckage and of these only six survived.
The size of R101 is hard to comprehend; it was nearly 237 metres long and 40.6 metres in diameter. It took 200 people to 'walk' the airship from its shed to the mooring mast (although 550 were used on the final movement, in case of blustery weather). The sheds at Cardington still exist, one as a film studio and the other as the home of the Airlander project. There is a website that gives the history of these enormous structures. There are memorials at Cardington and in Beauvais, France. Much has been written about the disaster, but James Leasor's excellent book is well worth a read.
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