A tram’s warning bell was “not loud enough” to alert a pedestrian who was killed at a crossing, an investigation has found.
Carlos Correa, 53, was struck and killed by a tram in Edinburgh as he crossed the tracks in the city’s Saughton area on September 11, 2018.
The off-street crossing had no signs or pedestrian light signals and visibility between the driver and the approaching footpath was blocked at points by trees.
A Rail Accident Investigation Branch (RAIB) probe found bus driver Mr Correa walked on to the tracks when the tram was around 18 metres away, with CCTV indicating he did not look towards it in the last seconds before stepping on to the crossing.
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Investigators found the tram driver sounded the warning bell three times from first spotting Mr Correa.
The report states: “The investigation found that although the tram driver had used the tram’s bell to sound repeated warnings on the approach to the crossing, this audible warning was not sufficiently loud for it to be heard and acted upon by the pedestrian until it was too late.
“During both the tramway’s design and operation, the risks associated with the crossing’s layout, mutual visibility, tram audibility, line speed and braking distance had not been adequately assessed.”
The RAIB recommended Edinburgh Trams Limited improves the audibility of its warning devices, which the firm said it has now done.
It also recommended the company identifies risk factors associated with off-street pedestrian crossings and sets up a process to regularly review the risk control measures.
The RAIB also recommended the Light Rail Safety and Standards Board improves guidance on the audibility of tram warning devices and on the design and layout of tram footpath crossings.
In a statement on behalf of Mr Correa’s family, lawyer Jayne Crawford of Thompsons Solicitors said: “The family, who are still grieving their loss, are shocked by a damning report prepared by the RAIB identifying several areas of failings in respect of public safety.
“Even the most basic risk assessment and investigation would have identified appropriate safety measures, any one of which could have prevented Mr Correa’s death.
“The family welcome the recommendations set out within the RAIB’s report and hope that Edinburgh Trams follow up on the necessary safety measures to ensure such tragic accidents are prevented in the future.”
Ms Crawford added the family hope the report would “expedite” Crown Office investigations into the incident.
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Edinburgh Trams managing director Lea Harrison said providing a safe tramway is “imperative” for the company.
He said: “We have worked closely with the Rail Accident Investigation Branch throughout their investigation, and prior to the publication of today’s report Edinburgh Trams installed a new louder horn system across the fleet.
“Improvements have been made to the crossing at Saughton, including additional signage alerting pedestrians to look both ways for trams and a small fence has been built to guide pedestrians to a safe crossing point.
“Foliage and hedges have also been removed to improve sightlines.
“An off-street crossings review has been completed with all additional measures to be implemented by the end of 2019.”
Edinburgh City Council owns the tram operator and the administration’s transport convener Lesley Macinnes said: “Edinburgh Trams operate a safe and reliable tram service and we will continue to work hand in hand with them to make the system as safe as it can be.”
A Crown Office spokesman said: “The procurator fiscal received a report into the death of a 53-year-old man in Edinburgh on September 11, 2018.
“The investigation, under the direction of the Scottish Fatalities Investigation Unit, is ongoing.”