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:

• creating a dedicated safety body for UK tramways 
  
• reviewing how UK tramways are regulated
  
• introducing automatic braking and driver vigilance systems to trams (some tramways already have vigilance systems)
• developing a better understanding of the risks of tramway operations, particularly when the tramway is not on a road
• improving the strength of tram doors and windows
• improving safety management systems, particularly encouraging a culture in which everyone feels able to report their own mistakes
• improving the tram operator’s safety management arrangements.

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The bow tie method is a popular risk analysis tool that is used in many industries, especially those where there are significant safety risks. The bow tie itself is a diagram that helps you visualise the risk you are dealing with in one, easy to understand picture. The power of a bow tie diagram is that it gives you an overview of multiple plausible scenarios, in a single picture. In short, it provides a simple, visual explanation of a risk that would be much more difficult to explain otherwise.
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97 years ago today the Royal Navy had a tragic ‘friendly fire’ accident that resulted in the loss of 105 submariners’ lives. There were many human factors elements to the disaster, including the design of the submarines, loss of situational awareness, communication and planning. 
The events are now known as the “Battle of May Island", although no enemy was present. On the evening of the 31st January 1918 Admiral Beatty took the Grand Fleet to sea from Rosyth in the Forth of Firth, Scotland, for an intensive exercise. The fleet included nine K-class submarines. These used steam power on the surface and ran on batteries when submerged. The process of getting one of these craft ready to submerge was complex and took at least five minutes. 
It was thought that a German submarine was in the area, so all ships concealed their external lights and maintained radio silence.  In addition, the fleet travelled at speed in a single line to make them a more difficult target. Two battleships led the formation, HMS Corageous and HMS Ithuriel, travelling at 19 knots. Following them were five submarines (K11, K17, K14, K12 and K22), running nose to tail, and following the shaded blue stern light of the submarine ahead.  Behind them were five battlecruisers escorted by destroyers, then the other four submarines (K4, K3, K6 and K7), followed by the rest of the fleet of more than 40 ships. Suddenly two British minesweepers, ignorant of the exercise in progress, swept across in front of them. The first two submarines changed course successfully, but the third submarine’s (K14’s) rudder jammed as it turned forcing it to complete a circle. This put it broadside on to submarine K22, which saw it too late to avoid it. The resulting collision left both submarines dead in the water, in the path of approaching surface ships. They were nearly run over and sunk by four of the battlecruisers, but the fifth (HMS Inflexible) was unable to avoid them and hit K22. Miraculously, K22 stayed afloat, but severely damaged. The leading ship, HMS Ithuriel sent a radio message to the other ships to warn of the incident. HMS Ithuriel, followed by the remaining three submarines, then turned to go and help the stricken submarines. These four ships found themselves having to rapidly weave a path through ships coming the other way who were yet to make their turn. However, no message was sent to the rest of the fleet to warn them that they had turned and were now steaming directly towards them with a closing speed of more than 30 knots. Inevitably, the fleets ran amongst each other. The first collision was between the returning submarine K17 and the outward-bound HMS Fearless. The crew of the submarine all escaped into the water as the submarine sank. As the ships all tried to avoid each other two of the outward-bound submarines, K4 and K6, collided. The two submarines were locked together, K4 almost cut in half. Eventually K6 broke free, but K4 sank.
A radio message had finally been sent to the rest of the fleet, but this was too late for them to take evasive action and the huge dreadnoughts and their destroyer escorts, ploughed through scene, killing many of the submariners who were in the sea awaiting rescue.
The result of the exercise was the loss of two submarines, three more crippled, one light cruiser severely damaged and 104 submariners dead. Only ten submariners were pulled from the water, one of these dying later. Given the wartime conditions, the disaster was kept a secret from the British public, with the events being made public only recently. A memorial to the disaster was erected at Anstruther harbour in 2002.