Report 06/2017: Fatal accident near David Lane tram stop
RAIB has today released its report into a fatal accident near David Lane tram stop on 15 August 2016.
At 22:57 hrs on 15 August 2016, a member of the public was struck by a tram between David Lane and Basford tram stops on the Nottingham Express Transit (NET) system. The person sustained fatal injuries.
The tramway between these two tram stops is not normally accessible to the general public. However, the member of the public had entered the tramway after alighting from a tram at David Lane tram stop. A tram driver had reported seeing the member of the public on this section of the tramway nine minutes before he was struck.
The supervisors in the NET control room implemented arrangements to warn tram drivers approaching the area between the tram stops. However, after a while, a supervisor formed the opinion that the member of the public had left this area of the tramway and stopped warning drivers between David Lane and Basford tram stops. This meant that the driver of the tram involved was not advised to reduce the tram’s speed or exercise caution in this section.
The member of the public was by that time lying motionless along the track. The driver passed through the section at normal speed and could not see the person in time to stop the tram before striking him.
The misunderstanding happened because the supervisor thought he understood from a reporting call handled by another supervisor that the member of the public had reached Basford tram stop. The audio reception of the call was poor and the basic principles of safety critical communication were not followed during the call. Furthermore, there was no effective exchange of information between the supervisors and the misunderstanding was not detected and challenged by others in the control room.
In light of the actions already taken by Nottingham Trams Limited since the accident, the RAIB has made only one recommendation which relates to NET’s on-going culture change programme. In addition, the RAIB has raised two learning points: one relating to using the full beam setting on trams and the other on the importance of effective safety critical communications.
Notes to editors
- The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
- RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
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Newsdate: 5 April 2017
PDF, 6.13MB, 35 pages
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Published: 5 April 2017