A tram company has been fined £240,000 for risk assessment failings following the death of a pedestrian.

THE INCIDENT

53-year-old bus driver Carlos Correa Palacio was fatally struck on a tram crossing in Edinburgh, Scotland, on 11 September 2018 while making his way home from work.

The tram driver first saw Carlos 73 metres from the crossing. He continued for another 20 metres before metres sounding his bell and beginning to slow the tram. He sounded the bell three more times over the next 27 metres.

The driver applied the emergency brake approximately 18 metres from the tram crossing, causing the tram warning horn to automatically sound.

Carlos had not been aware of the tram until it was too late to get out of its way.

THE INVESTIGATION

The criminal investigation found Edinburgh Trams Limited had fail to carry out a suitable and sufficient risk assessment of the layout of the crossing, and to ensure that it provided sufficient notice and warning to pedestrians of the crossing itself.

The company failed to assess the loudness of audible warning devices on Edinburgh trams, or the emergency braking distances of trams approaching the crossing in order to identify and implement adequate control measures to address these hazards.

EDINBURGH TRAMS LIMITED’S FAILURE TO ASSESS THE RISKS POSED TO PEDESTRIANS USING THE CROSSING RESULTED IN MR CORREA’S DEATH

The absence of any written risk assessment was made worse by the failure to regularly review which meant the original error went unnoticed. A near miss incident at the same crossing in November 2016 was reported but failed to result in any action in relation to the risk assessment.

Investigators from the Crown Office and Procurator Fiscal Service (COPFS) found there were no issues with the tram drivers driving and that he had responded to the situation in accordance with his training. The tram was in working order and the braking system was functional.

IN COURT

Edinburgh Trams Limited, which operates the tramway system on behalf of the City of Edinburgh Council, admitted breaching of health and safety legislation at Edinburgh Sheriff Court last month.

The advocate depute told the court that there had been no assessment of the foreseeable risk to pedestrians at the Saughton Mains crossing from an approaching tram prior to this incident.

WHAT CAN IOSH MEMBERS LEARN FROM THIS CASE?

Debbie Carroll, who leads on health and safety investigations for the COPFS, said:

'Carlos Correa lost his life in circumstances which could have been avoided had the risks been recognised and appropriate control measures put in place.

'Edinburgh Trams Limited’s failure to assess the risks posed to pedestrians using the crossing resulted in Mr Correa’s death.

'This prosecution should remind duty holders that a failure to manage and implement effective measures can have fatal consequences and they will be held accountable for this failure.'

Comment: "With members of the public in close proximity to the Trams, a full risk assessment should have been carried out, with a further risk assessment on the newly introduced risks. Ignoring the first near miss, is unacceptable in any workplace."

Source: IOSH Magazine