RAIB report into fatality on NET released

On 15th August 2016 a member of the public was hit by Citadis 225 between David Lane and Basford tram stops, tragically suffering fatal injuries. The incident was subject to a full investigation by the RAIB and they have recently released their report which has shown that miscommunication within the control room was the direct cause of the collision happening.

The collision happened at 2257 on 15th August 2016 after a member of the public had alighted from a tram at David Lane tramstop. Once he had got off the tram he walked along the tramway – which is on a reserved section of track adjacent to the Robin Hood mainline railway – and this was reported by a tram driver who had seen him on this section of track nine minutes before he was hit. This was reported to the control room and they immediately implement arrangements to warn tram drivers approaching the area. However after a while a supervisor was of the opinion that the man had left the tramway and stopped warning drivers. Tragically the man had not left the tramway and was in fact lying motionless along the track; the driver of the tram involved in the accident did not see the man in time before striking him.

The misunderstanding in the control room occurred because the supervisor though he understood from a reporting call handled by another supervisor that the member of the public had reached Basford stop. The audio reception of the call was poor and the basic principles of safety critical communication were not followed during the call. There was also no effective exchange of information between the supervisors and the misunderstanding was not detected and challenged by others in the control room.

Since the accident Nottingham Trams Limited have made a number of changes to procedures including a new dedicated procedure for dealing with reports of persons found in an off street section. This now means that if drivers are concerned about the welfare of the person on the tracks they should stop and the control room supervisors should monitor CCTV at both ends of the track where the report has been made and normal working should only be resumed after two trams in either direction have confirmed the area to be clear.

As a result of the changes already made by Nottingham Trams Limited only one recommendation has been made by the RAIB. This states that NTL should undertake a review of its culture change programme to ensure that it addresses the risks associated with the quality of safety critical communications in the control room.

* The full RAIB report can be viewed at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/606486/R062017_170405_David_Lane.pdf.

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