Summary
At around 22:55 hrs on Tuesday 12 March 2019, a passenger was involved in a tram dispatch accident at Ashton-under-Lyne tram stop, on the Manchester Metrolink system, which resulted in him falling from the platform onto the track after the tram departed. The passenger sustained facial injuries from the fall which required treatment in hospital.
The accident happened because the passenger had been leaning on the tram as it departed. He suffered from impaired mobility, making it difficult for him to stand unaided. The tram driver had not observed that the passenger was in close proximity to the tram when he moved the tram away from the tram stop. Once the tram had passed by the passenger and it was no longer supporting him, he fell from the platform onto the track.
The RAIB investigation has also identified two underlying factors. Firstly, the tram operator, Keolis Amey Metrolink (KAM) had not provided instructions to its drivers on the use of the side-view CCTV monitors as a tram is departing from a tram stop. Secondly, KAM had not provided any guidance to its staff on appropriate actions in the event that they encounter an impaired passenger on a tram.
Recommendations
As a result of its investigation, the RAIB has made four recommendations. Three are made to KAM, and cover:
- improving guidance to drivers on the use of the side-view CCTV monitors when departing from tram stops
- improving the visibility of passengers at tram stops
- reviewing the guidance given to staff who may encounter impaired passengers
The fourth recommendation calls for KAM and North West Ambulance Service to jointly develop a communications protocol so that KAM’s control office is informed of any actions of the ambulance service that may be relevant to tram operations.
The investigation also identified two learning points for tram operators. The first of these highlights that it can be difficult for tram drivers to see people at the platform- tram interface in their CCTV monitors during night time operation, and that this should be considered in risk assessment and driver training activities. The second learning point highlights the importance of ensuring that staff travelling on board trams are able to react appropriately to emergencies.
Notes to editors
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The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
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RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
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Newsdate: 28 November 2019
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