Concerns raised over tram warning bells before death

Concerns over warning bells on Edinburgh trams being too quiet had been raised prior to a tram hitting and killing a pedestrian in 2018, a fatal accident inquiry has heard.

Carlos Correa Palacio, 53, was struck by the tram on 11 September 2018 as he walked over a crossing, despite the warning horn being sounded three times.

Edinburgh Trams previously believed that, as the noise level was the same as a bus horn, the issue had been "put to bed".

But investigators tested the bells and horns again after the incident and found they were still too quiet to be heard over background noise.

Mr Correa, a father-of-three, had just finished a shift as a bus driver for Lothian Buses when he was crossing the tram line and was struck by the vehicle.

The volume of the horns was first flagged up before the line was opened to the public in 2014, with workers on the route not moving out of the way despite drivers sounding a warning as the trams approached.

This prompted the test against the noise of a bus horn, which found they were near identical. Edinburgh Trams then considered the matter resolved.

After the accident investigators ruled both the horns and bells could not be heard at the distance required for the tram to carry out an emergency stop, and were too quiet.

They have since been replaced with louder ones.

Other failings found by the inquiry included overgrown vegetation hindering the tram driver's line of sight - a concern that had been raised by a cyclist around a year before the death of Mr Correa.

Managers decided that the tree should be removed but it was only cut back and had regrown by the time of the accident.

The inquiry heard of four "near-misses" on the Saughton stretch of the tram track in previous years, where pedestrians or cyclists started using a crossing despite the tram approaching.

On each occasion the driver had to use the emergency brake to avoid hitting the person.

Sarah Singh, the head of service delivery at Edinburgh Trams, told the inquiry each incident would have been reviewed by the senior management team but no changes were made to reduce risk at these crossings.

Mr Correra appeared to walk straight on to the crossing without hesitation, mirroring a previous fatality in Nottingham in 2012.

Following that accident industry wide recommendations had been issued for how pedestrian crossings could be made safer.

However there was no evidence any recommendations had been implemented in Edinburgh.

Michael Powell, who was the safety and standards manager for Edinburgh Trams, told the inquiry he didn't realise it was his responsibility to risk assess the crossing prior to the route opening in 2014.

That meant no risk assessment was carried out at the crossing.

Mr Powell, who held the role between 2013 and 2019, added he had only been working in the tram industry for a few months at the time and would have expected more experienced colleagues to flag up any issues.

He said it had been an "incredibly busy" time ahead of the launch and the focus was on risk in the city centre and not on outer sections of the route.

Mr Powell told the inquiry: "There was a general feeling that any accident would be in town because it has been so long since there were trams on Princes Street."

He added that he was "overwhelmed" before the line opened and that paperwork by colleagues was being "rushed" ahead of the line opening.

Mr Powell felt he was "clearly overstretched" as a result.

Safety measures have since been implemented such as bollards being introduced at the crossing and a warning to check for trams being painted on the ground.

Oral evidence to the inquiry has concluded with written evidence due to be submitted by 24 April. A determination is due by the end of May.

Edinburgh Trams was fined £240,000 in August 2023 after admitting a health and safety breach.