London Bridge : Train hit buffers 13/12/24

[contrex]

I believe the issue at Cannon Street was that the doors of the train had started to be opened (in those days, not all trains had interlock), and this changed the structural integrity of the unit causing it to weaken and crumple.

Weren't ancient underframes, body corrosion, and just plain lack of crashworthiness in Bulleid's design also factors?

 

[Ashley Hill]

Has there been any further updates on why the driver was allegedly arrested?

 

[Tetchytyke]

RAIB have today published their investigation into the collision between a train and the buffer stops at London Bridge back in December 2024. People may remember that the driver was initially arrested at the scene.

Report 09/2025: Buffer stop collision at London Bridge station

RAIB has today released its report into a buffer stop collision at London Bridge station, 13 December 2024.

www.gov.uk

The accident occurred because the driver of the train did not apply the brakes in time on approach to the buffer stops, almost certainly because they experienced a microsleep, due to fatigue. There are several factors that may have contributed to the driver’s fatigue. Two probable causal factors in the accident were that the base duty roster was constructed in a way that increased the risk of fatigue and that the driver had also worked many of their rostered rest days in the period up to the accident, further increasing the risk of fatigue. A possible causal factor was that the driver had less than their normal amount of sleep the night before the accident.

A further causal factor was that none of the engineered protection systems fitted to the train intervened to prevent the collision. The Train Protection and Warning System fitted on approach to the buffer stops did not automatically apply the train’s brakes because the train was travelling below the set intervention speed. Other safety systems fitted on board the train could not detect the short loss of driver alertness that occurred.

The fact that the driver appears to have had a fatigue-induced microsleep would explain why he was initially arrested.

The RAIB have found that the primary causal factors for this fatigue-induced microsleep were that the "base roster was constructed in a way that increased the risk of the driver becoming fatigued" and that the "driver had worked a number of rest days in the period up to the day of the accident which further increased the risk of fatigue."

In my opinion, that certainly doesn't reflect well on the management at GTR.

 

[Ellwill]

In my opinion, that certainly doesn't reflect well on the management at GTR.

Unfortunately not surprising in the slightest. There was another case recently discussed on the forum where they were hauled over the coals at tribunal after conspiring to sack a whistleblower over cab noise complaints:
https://www.railforums.co.uk/threads/article-in-private-eye-gtr-driver-wins-employment-tribunal-over-safety-issues-and-whistleblowing.292531
Link - Thread on forum discussing previous employment tribunal decision made against GTR

 

[harz99]

RAIB have today published their investigation into the collision between a train and the buffer stops at London Bridge back in December 2024. People may remember that the driver was initially arrested at the scene.

Report 09/2025: Buffer stop collision at London Bridge station

RAIB has today released its report into a buffer stop collision at London Bridge station, 13 December 2024.

www.gov.uk

The fact that the driver appears to have had a fatigue-induced microsleep would explain why he was initially arrested.

The RAIB have found that the primary causal factors for this fatigue-induced microsleep were that the "base roster was constructed in a way that increased the risk of the driver becoming fatigued" and that the "driver had worked a number of rest days in the period up to the day of the accident which further increased the risk of fatigue."

In my opinion, that certainly doesn't reflect well on the management at GTR.

You missed out the words "may" and "probable" from your selective quoting, and the driver working many of his rest days prior to the incident is entirely voluntary on his part, and presumably like rosters, within legal parameters and Trade Union agreements so I respectfully don't agree with your opinion.

 

[Watershed]

Paragraph 71 is particularly damning, in my view:

In the 22 days preceding the accident the driver was rostered to have 12 rest days. The driver worked 9 of these, leaving them with 3 actual rest days in that 22-day period. In November, the driver was rostered 8 rest days and worked 6 of them, while in October they were rostered for 10 rest days and again worked 6 of them. Overall, in the 3 months before the accident, the driver had taken 10 rest days, an average of less than one a week.

Getting 3 days off a month is nowhere near enough, particularly when doing shift work. The desire to earn more through RDW is understandable - but clearly, limits should be imposed to require a minimum level of rest.

 

[172007]

Paragraph 71 is particularly damning, in my view:

Getting 3 days off a month is nowhere near enough, particularly when doing shift work. The desire to earn more through RDW is understandable - but clearly, limits should be imposed to require a minimum level of rest.

And yet we know plenty who go right upto the 13 days year in year out and have better safety recotds than most.

 

[Watershed]

And yet we know plenty who go right upto the 13 days year in year out and have better safety recotds than most.

The fact they might not have anything on their record doesn't necessarily mean that there aren't near misses or unrecorded microsleeps.

 

[AlterEgo]

Has the police investigation into the driver been discontinued, or is this still active?

 

[greatkingrat]

Has the police investigation into the driver been discontinued, or is this still active?

From past experience, the RAIB wouldn't release a report if proceedings against the driver were ongoing.

 

[Russel]

And yet we know plenty who go right upto the 13 days year in year out and have better safety recotds than most.

With respect, that doesn't mean much at all.p

Said drivers could have had plenty of near misses, but if they aren't picked up on one reported, officially, one will maintain a spotless record

 

[Tetchytyke]

You missed out the words "may" and "probable" from your selective quoting

That's not the gotcha you seem to think it is. The word 'probable' in an incident investigation report is a strong word.

presumably like rosters, within legal parameters and Trade Union agreements so I respectfully don't agree with your opinion.

Paragraphs 61 to 68 addresses this.

Paragraph 68 says "The processes used by GTR when constructing and managing drivers’ rosters did not identify all these fatiguing factors. As a consequence, the rostering process did not effectively assess and control the risk of fatigue which probably led to the driver being sufficiently fatigued to experience a microsleep."

So, again respectfully, it seems you also disagree with RAIB.

Has the police investigation into the driver been discontinued, or is this still active?

In my experience, RAIB wouldn't release the report if a criminal investigation was still ongoing.

the driver working many of his rest days prior to the incident is entirely voluntary on his part

Perhaps it is voluntary, perhaps it isn't, but either way that's still a failing of GTR management. Just because someone is volunteering to do so much work doesn't mean that you have to accept their offer. Responsible management should be monitoring someone's workload and work patterns and declining their offer. As RAIB noted at paragraph 72, this is in ORR guidance.

As RAIB also identified, GTR management seemingly didn't even consider it an issue: "Before rest day working is allocated to a driver, the only check made by the resource managers is compliance with the Hidden limits. No checks are made to see if the rest day work being allocated increases the risk of fatigue for the driver concerned."

 

[mandub]

Does anyone know what aspects of the base roster construction the RAIB consider to increase the risk of fatigue?
Do they specify in their report to the TOC what specifically they mean by this?
A lot of drivers at a lot of depots are gonna wonder

 

[greatkingrat]

Are there any TOCs that actually turn down rest day volunteers for fatigue reasons (assuming not breaching Hidden)?

 

[WeGoAgain]

Are there any TOCs that actually turn down rest day volunteers for fatigue reasons (assuming not breaching Hidden)?

Highly doubtful. - Trains 'must' run.

 

[Tetchytyke]

Does anyone know what aspects of the base roster construction the RAIB consider to increase the risk of fatigue?

The RAIB referred to the ORR guidance.

But RAIB did specifically highlight the following in this specific driver's roster:
• early starts (05:00 – 07:00)
• very early starts (before 05:00)
• less than 2 days off after a block of early starts
• more than 12 consecutive day shifts
• more than 55 hours worked in a 7-day period
• successive shift start times varying [by] more than 2 hours.

They also highlighted that "two shifts that the driver worked at the beginning of the week of the accident had backward rotating shift patterns. This means that each of the shifts was started earlier than the last one and this backwards rotation may contribute towards fatigue."

 

[Ashley Hill]

I find it strange that drivers (and guards) have often been slated on the forum for NOT working rest days resulting in the cancellation of services. Yet here it suggests that working them may have been a contributing factor in this incident.

 

[75A]

Anyone that regularly works RDO's & Sunday will tell you it is very tiring.

 

[Ashley Hill]

Perhaps TOCs + FOCs should not rely on RDW.

 

[Horizon22]

Perhaps TOCs + FOCs should not rely on RDW.

Sure, then maybe they should have permission to increase establishment from the DfT?

As an aside, obviously there is some focus on GTR and their rostering, but there is an element of personal responsibility and almost anyone who works shifts will know that working essentially 27-28 days in a month is a very bad move. That is a lot of RDW to do

== Doublepost prevention - post automatically merged: 17 Dec 2025 ==

They also highlighted that "two shifts that the driver worked at the beginning of the week of the accident had backward rotating shift patterns. This means that each of the shifts was started earlier than the last one and this backwards rotation may contribute towards fatigue."

Backwards rotation is - unfortunately - very common for drivers. Work a late Saturday (finishing essentially Sunday morning) and back early Monday. 24h turnaround more or less. No good for anyone’s fatigue, but that doesn’t in itself lead to incidents.

 

[66701GBRF]

Perhaps TOCs + FOCs should not rely on RDW.

Would cripple FOCs and ticket prices for passengers would go through the roof even more.

 

[6Gman]

Would cripple FOCs and ticket prices for passengers would go through the roof even more.

How much of an increase in complement do you think it would need?

 

[Russel]

I find it strange that drivers (and guards) have often been slated on the forum for NOT working rest days resulting in the cancellation of services. Yet here it suggests that working them may have been a contributing factor in this incident.

It's not that black and white though, is it, there's a difference between the unions putting a stop to RDW and drivers working every hour possible and creating safety issues because they can't keep their eyes open.

 

[172007]

Lets add a little perspective to this thread. Whay are the notorious hours that many Resident Doctors work during their first few years. Many claim to grab a few hours here amd there in locker and rest rooms. It does not make it right bit its clearly conmon place / indemic in US culture countries when it comes to work.

 

[Horizon22]

How much of an increase in complement do you think it would need?

This would vary wildly across companies and individual depots. However I don’t think it would be less than 10% overall.

== Doublepost prevention - post automatically merged: 17 Dec 2025 ==

Lets add a little perspective to this thread. Whay are the notorious hours that many Resident Doctors work during their first few years. Many claim to grab a few hours here amd there in locker and rest rooms. It does not make it right bit its clearly conmon place / indemic in US culture countries when it comes to work.

Resident (previously junior) doctors, used to do crazy hours. I have relatives who clocked 90-100 hrs a week in the 80s. The Working Time Directive put an end to the worst of those processes.

 

[father_jack]

I find it strange that drivers (and guards) have often been slated on the forum for NOT working rest days resulting in the cancellation of services. Yet here it suggests that working them may have been a contributing factor in this incident.

Well said. Like I've said elsewhere on this forum only to be castigated the "grabbing" in the industry has too many unintended consequences. Trade union policy is overtime is for training and short term coverage. Certainly 75% of rest days should never be worked.

 

[signed]

Lets add a little perspective to this thread. Whay are the notorious hours that many Resident Doctors work during their first few years. Many claim to grab a few hours here amd there in locker and rest rooms. It does not make it right bit its clearly conmon place / indemic in US culture countries when it comes to work.

I am not condoning such practices.

But what is often touted (by commercial hospitals and schools) as the benefits of 24h calls and extreme work weeks is that it prepares you for your career as a doctor. I.e. you see and do as much as you humanely can.

 

[Mattplans]

Can we resolve the mountain of speculation at the first pages of the thread. Why was it necessary for the driver to be arrested?

Also, is it likely the driver is still driving for Southern today?

 

[Purple Train]

Also, is it likely the driver is still driving for Southern today?

I have no specific answer; however, the RAIB uses the present tense in paragraph 20 of its report (as linked in post #123):

The driver joined Southern in 2019 as a new train driver and is based at Norwood depot. Their competence, traction and route knowledge assessments were up to date.

I don't know if this is a red herring.

 

[NSEWonderer]

Driver wouldn't have been sacked for that, they'd have mentioned if they had a checkered history. I must say its always sobering to see what only 3mph of train can lead to after being fatigued.

I remember when this first happened how hasty the police were according to reports to put in an arrest.

Above shows the postion the buffers were left in after the slow speed collision.