Man killed after tram horn was too quiet - inquiry

A bus driver was killed by a tram at a crossing because the vehicle's warning bell was not loud enough, a judge has concluded.

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.

Sheriff Douglas Keir concluded that Mr Correa's death might have avoided if the alert was "audible above background noise."

Horns on Edinburgh trams have since been replaced and the judge concluded no further action was needed to improve the safety of pedestrian crossings.

Earlier this year, the inquiry heard how Mr Palacio was struck by the tram as he walked over the crossing between the Balgreen and Saughton tram stops.

He had just finished a shift as a bus driver for Lothian Buses.

CCTV showed how the dad-of-three appeared to be unaware of the approaching tram despite the driver sounding the horn and bell up to three times.

In a written judgement, Sheriff Keir wrote that more should have been done to increase the volume of the horns before Mr Correa's death.

He added: "ETL (Edinburgh Trams Limited) could have taken steps to increase the audibility of the tram warning devices, in particular that of the horn, and thereafter used the warning horn as the primary mode of warning in off-street areas, as envisaged by the applicable industry guidance.

"Had the warning horn been sufficiently audible above the background noise and been used in the off-street area, it might realistically have alerted Mr Correa at the point of first sighting at 73m from the crossing.

"This would have allowed him sufficient time to react and step out of the path of the tram."

Edinburgh Trams was fined £240,000 in August 2023 after admitting a health and safety breach at the city's sheriff court.

A rail accident investigation board ruled both the horns and bells were too quiet and could not be heard at the distance required for the tram to carry out an emergency stop.

This led to the horns on all trams being replaced with louder ones.

Concerns over the low volume of warning bells on Edinburgh trams were first flagged up before the line was opened to the public in 2014.

Workers on the route had failed to move 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.

The inquiry also heard evidence of how there were also four "near-misses" on the Saughton stretch of the tram track in previous years.

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

On Tuesday, Sheriff Keir said that more could have been done when the crossing was built in order to adequately warn pedestrians they were "entering an area of higher risk."

The crossing where the incident happened has since been redesigned.

The judge concluded by giving his condolences to Mr Correa's family.