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.
Response to recommendations:
- RAIB will periodically update the status of recommendations as reported to us by the relevant safety authority or public body
- RAIB may add comment, particularly if we have concerns regarding these responses.