At around 13:29 hrs on 15 December 2017, an empty pushchair became trapped on the outside of a tram at Radford Road tram stop, Nottingham, when its plastic rain cover was caught between closing doors. It was then dragged to the next tram stop where it was crushed against the kerb. Nobody was physically injured.
A passenger had pushed the pushchair off the tram as the doors were closing because she wished to remain with another passenger who had been removed from the tram by a Nottingham Trams’ travel officer. The rain cover was too thin to trigger the system which automatically reopens the doors if an obstacle is detected. The final visual door check, which drivers are required to carry out before departing from a tram stop, did not result in the driver being aware that the pushchair, shown as a small object on a CCTV monitor in his cab, was in an unsafe position. A larger image of the pushchair was not available to the driver when doing this check because of a modification to the tram’s CCTV system. The travel officer and other staff at the tram stop were unable to stop the tram departing, and the tram driver remained unaware of the pushchair until he arrived at the next tram stop.
Inadequate risk assessment by Nottingham Trams is the probable underlying cause for its staff placing inappropriate reliance on the doors closed indication, being unaware of the importance of the final door visual check, and the way in which the tram CCTV arrangements were modified. The incident also showed that training of travel officers was inadequate.
The RAIB investigation has resulted in two recommendations, both addressed to Nottingham Trams, and one learning point. The first recommendation seeks improved arrangements for preventing trap and drag events. The second requires improvements to Nottingham Trams’ risk assessment processes. The learning point reminds all tram drivers that they must carry out a thorough final door visual check, and not rely solely on doors closed indications, when deciding whether it is safe for their tram to depart.
Simon French, Chief Inspector of Rail Accidents said:
“Since it was set up in 2005, RAIB has investigated 13 events in which door systems have not detected objects trapped in the closed and locked doors of a departing train or tram. In many cases, a limb or item of clothing has been caught in the doors and the people involved have been injured. This incident was different - it was just an empty pushchair that was pulled along outside a tram from one tram stop to the next. However, it is easy to imagine how serious the consequences might have been if there had been a child in the pushchair.
“Our investigation found that the tramway operator did not fully understand the hazards at the platform-tram interface, and the measures needed to control those hazards. The tram, delivered in 2014, had originally been designed with exterior cameras that gave the driver views from front and back platform-side cameras along the whole length of the tram until after moving off. This had been modified by the tram operator in such a way that the rear CCTV camera view was not available to the driver once the doors closed (and this was how the rest of the trams in Nottingham had operated since the tramway opened in 2004). This modification reduced the quality of the view of the platform-tram interface, and could encourage an incomplete check when making the final decision to move off.
“Once again our investigators encountered a driver who thought that door safety systems would always prevent him taking power if any object was trapped in the closed doors; he was unaware that small objects may not be detected by the door safety system. Worryingly, this misconception was shared by other, more senior members of staff at Nottingham Trams. An incident at Bury on the Manchester Metrolink system described in our safety digest D08/2018, demonstrates that the same belief exists on other tram systems.
“This incident reinforces that absolute importance of the final safety check after the doors are detected as closed and before a tram or train continues with its journey. I must stress that this important safety message applies equally to trams and trains.
“We are recommending that Nottingham Trams takes action to improve safety around the platform-tram interface, as well as reviewing its general assessment of the risk from tram operations. This operator, and others in the UK tram industry, need to be aware of the hazards associated with passengers getting on and off trams, and the ways in which safety can be improved in this area.”
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: 10 September 2018