If there’s one word to describe the 174-page report published on the Rail Accident Investigation Branch (RAIB’s) 13-month investigation into the Croydon tram crash, it’s thorough.

The in-depth document was released yesterday, and has been combed over by our team.

There are some things we knew - about how the tram was travelling too fast and the fact that Transport for London (TfL) had to bring in new safety measures, signs and speed limits - but there were plenty of revelations too.

As is the case in many fatal disasters, it gives the impression that there were a multitude of things that, combined, created the situation that allowed this tragedy to happen.

So, what are the key points from the report, and what needs to happen at TfL and Tram Operations Limited (TOL) to ensure this never happens again?

Tram windows must be upgraded

An investigation by this newspaper first highlighted the possibility that the type of glass used in the tram windows could have contributed to or exacerbated the number of fatalities and serious injuries.

The RAIB report quite conclusively found that laminated glass should be installed in trams nationwide to prevent passengers from being thrown from vehicles in the event of a derailment or another incident.

But the regulations that dictate what glass must be used in trams are not fit for purpose.

An RAIB diagram showing how the windows broke

After a number of incidents where train passengers were thrown from carriages, the heavy rail industry brought in rules that train windows had to be laminated, but the rules governing trams are simply the same as those that apply to road vehicles, which only have to have toughened glass.

Those regulations must be updated so that laminated safety glass is mandatory in tram windows. The sobering fact is that the RAIB investigators, and their report, make it clear that laminated glass in those windows would have saved lives.

Of course, safer windows do not stop a tram from tipping over, but public transport should be designed to take into account the fact that such things can happen.

Why didn’t TfL or TOL think the possibility a tram might overturn was credible?

One of the most damning aspects of the report was how both Transport for London and TOL, the First Group-owned company that runs the trams for TfL, failed to recognise that the fact a tram might overturn was “credible”.

This seems like a damning failure on their part, especially given that fatal tram derailments are not unheard of, with several similar incidents happening around the world over the past few decades.

Further to that, when a similar incident happened in the days before the crash, the complaints system clearly wasn’t fit for purpose to deal with it.

Inside the derailed tram

It’s not too much of a stretch to suggest that had complaints and reporting systems worked properly, the disaster could have been avoided if prompt lessons had been learned from the near-miss nine days earlier.

As the report concluded: “If there is one overriding lesson to learn from this tragic accident, it is that safe operation of a tram network depends on thinking about possible accident scenarios outside the immediate experience of the managers and their teams. The UK tramway community did not appreciate that such a catastrophic accident could occur.”

Drivers must feel able to report mistakes

Yet another deeply worrying part of the report is how it mentions that some drivers were reluctant to report their own mistakes.

Union Aslef, which represents drivers, was scathing in its criticism of the culture amongst management in a statement yesterday.

They have a point, but it can be difficult to foster a working environment where employees feel comfortable telling bosses about their own errors, knowing it may have consequences for their career.

The report gives a picture of “a lack of trust” between tram drivers and their managers - when drivers were asked by the RAIB to rate their relationships with their senior managers, they scored them at an average of just 3.6 out of 10.

TfL says it has a confidential reporting hotline for employees. But, tellingly, it was not used in the wake of the near-miss that happened nine days before the crash, while between 2011 and 2016, not a single report was made to TOL’s own confidential reporting system.

What other incidents or safety flaws are not being picked up because they’re going unreported?

A tram travelling around the Sandilands bend

When the outcome of not owning up puts lives at risk, there must be a working system where drivers can report anything that might cause danger to the public or themselves.

This is what the RAIB means when it says TOL should foster a "just culture", where staff feel able to report mistakes without fear.

To accomplish this, the report gives a suggestion TOL would do well to heed.

The company’s response to drivers self-reporting mistakes should concentrate on how to learn from that mistake, rather than always taking disciplinary action or making staff undergo “excessive” monitoring.

Drivers are human, and humans will sometimes make mistakes.

But the point is that the tram safety systems - both actual mechanical systems, and things like incident reporting systems - should be designed to allow for that fact.

A device to monitor when drivers’ attention lapses has already been installed, while an automatic braking system is expected to be put in place next year.

But as well as these technological solutions, the working culture has to change so drivers feel able to admit to mistakes.

If drivers have these back-up systems, perhaps they might feel more comfortable doing so.

The assumption that trams are safer needs reconsidering

It’s fair to say there was a widely-held belief, perhaps even a complacency, that trams were one of the safest ways to travel.

Indeed a common refrain in the wake of the disaster was that it was the first tram incident which involved a passenger fatality in Britain since three were killed in Glasgow in 1959.

But data in the report clearly shows that fatalities per passenger journey and kilometre travelled are significantly higher on trams than the national rail network (see the table below which shows how tram casualties are actually more common than on either trains or coaches and buses).

A table showing a comparison of tram, train and road casualties

It seems there are wider problems with the bodies that are supposed to overlook tram safety.

The RAIB report notes that “the overall level of risk on tramways, and the potential for multiple fatality accidents, is higher than previously assumed”, and points out that the Office of Rail and Road (ORR), the industry regulator, classified trams as lower risk compared to trains.

It’s clear that the ORR must take a greater role in tram safety and hold tram networks to the same safety standards as it does mainline rail services.

What happens now?

There are still more investigations ongoing.

TfL will publish its own investigation findings in the new year, and has said all the recommendations will be implemented.

Also, an investigation by the Office of Rail and Road (ORR), which is looking at any potential health and safety breaches, has not yet concluded. The ORR said it is expecting to make an announcement regarding its investigation in the new year.

The big question is what will happen with the driver himself, who was arrested on suspicion of manslaughter and remains on police bail as British Transport Police (BTP) continue their investigation.

BTP are preparing a file to hand to the Crown Prosecution System (CPS), who will decide if the driver should face any criminal action, while any recommendation over corporate charges will likely form part of the ORR’s investigation, though could also be part of the BTP investigation.

Sadly, some of the families don’t feel like they’ve got closure despite the publication of the report. Justice could be what they need.