13-05-2025
Edinburgh bus driver was killed at tram crossing because 'bell wasn't loud enough'
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An Edinburgh bus driver was killed by a tram at a crossing because the vehicle's warning bell wasn't loud enough, a judge has concluded.
Sheriff Douglas Keir concluded that Carlos Correa Palacio, 53, might have avoided losing his life in 2018 if the alert was 'audible above background noise'. Sheriff Keir made the observation in a determination published at Edinburgh Sheriff Court on Tuesday.
He had been tasked with investigating the circumstances surrounding the death of Mr Correa in a Fatal Accident Inquiry. The pedestrian died at approximately 1244pm in September 11 2018 when he was using a 'non motorised user' crossing of the city's tramline at a point between the Balgreen and Saughton tram stops.
He struck by the tram as he walked over the crossing, despite the warning horn being sounded three times. The inquiry, which was held earlier this year, heard evidence of how concerns over warning bells on Edinburgh trams being too quiet had been raised prior to the fatal incident.
Tests established that the horns were as loud as similar devices used on Edinburgh's Lothian Buses. The inquiry heard that bosses thought this result meant the issue had been 'put to bed'.
However, investigators tested the bells and horns again after the fatal incident and found they were still too quiet to be heard over background noise. In a written judgement issued on Wednesday, Sheriff Keir wrote that more should have been done to increase the volume of the horns.
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 73 metres from the crossing. This would have allowed him sufficient time to react and step out of the path of the tram.'
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The inquiry had heard how the 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 inquiry heard how the volume of the horns was first flagged up before the line was opened to the public in 2013.
Reports were passed on about how workers on the route were not moving out of the way of the trams despite drivers sounding a warning as their vehicles 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. The horns have since been replaced with louder ones.
The inquiry also heard evidence of how there were also four "near-misses" on the Saughton stretch of the tram track in previous years. The inquiry heard these were incidents in which 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. Edinburgh Trams was fined £240,000 in August 2023 after admitting a health and safety breach at the city's sheriff court.
A investigation into the collision by the Rail Accident Investigation Branch called for louder tram horns and improved visibility at such crossings. On Tuesday, Sheriff Keir also concluded that more could have been done in how the crossing was designed in order to adequately warn pedestrians they were 'entering an area of higher risk.'
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Sheriff Keir wrote: 'The following measures could have been taken:
'Delineation/demarcation of the crossing by marking out the higher risk area in a colour to alert the pedestrian and make it clear that the crossing was not a continuous path. Signage placed on the ground alerting pedestrians who may have been looking down to the fact they were entering an area of higher risk and to look both ways.
'Bollards, chicanes, fencing or pedestrian guard rails installed to slow the pedestrian down and guide them to face oncoming trams before they crossed the track. Additional warning signs to tram drivers to brake could have been introduced to address the hazard of the unresponsive pedestrian.
'Such signage could have been placed on the tramway to alert drivers to the final point at which emergency braking would bring the tram to a stop prior to reaching the mid-point of an NMU crossing.'
Sheriff Keir also mentioned Mr Correa's family in the determination. He added: 'At the outset of the inquiry I extended my condolences to Mr Correa's family.
'I wish to formally repeat my condolences to Mr Correa's family in this determination.'
