Edinburgh sheriff concludes inquiry into fatal tram accident by making no recommendations

About this case:

• Citation:
  [2025] FAI 22
• Judgment:
  External link
• Court:
  Sheriff Court
• Judge:
  Sheriff D R G Keir

Carlos Correa died aged 53 on 11 September 2018 while crossing the Edinburgh tramline at a point between the Balgreen and Saughton tram stops. The Crown invited the court to make a finding that Edinburgh Trams Ltd had failed to carry out location-specific risk assessments at non-motorised user crossings but declined to submit that recommendations should be made in light of the response to the accident.

The inquiry was conducted by Sheriff Douglas Keir at Edinburgh Sheriff Court. Goddard KC represented the Crown and Gray KC appeared for Edinburgh Trams Ltd. Representations were also made on behalf of the Office of Rail and Road, the Rail Accident Investigations Branch, and the UK Tram and Light Rail Safety and Standards Board.

Below minimum standards

On 11 September 2018 Mr Correa left his home in Eskbank, Edinburgh, in the morning to commence his shift as a bus driver at 0956 hours. At around 1203 hours he alighted from a bus at Stenhouse Grove and walked to an NMU crossing of the tramline at an off-street section of the Edinburgh tramway near the Saughton tram stop. There, he was struck by the front nearside of a tram travelling at around 53 kilometres per hour.

The driver of the tram sounded the tram’s bell four times beginning from 53 metres away from the crossing and applied the emergency brake which automatically sounded the warning horn. Mr Correa only looked up moments before he was struck by the tram. An off-duty doctor aboard the tram provided assistance to Mr Correa at the scene and paramedics attended shortly after, however Mr Correa entered cardiac arrest and was pronounced dead at the scene at approximately 1244 hours.

Investigations established that there were no defects with the tram and that ETL had recorded five incidents in the vicinity of Saughton involving use of a tram’s emergency brake. The RAIB advised that the warning horn on the Edinburgh tram was below minimum safety standards in its report pm the accident, and in August 2023 ETL pled guilty at Edinburgh Sheriff Court to a contravention of the Health and Safety at Work etc. Act 1974.

By November 2019 ETL had fitted new, louder tram horns to all trams and carried out a full review of all risk assessments for NMU crossings. The Crown did not invite the court to make any formal recommendations standing the detailed recommendations made by the RAIB and the subsequent changes made by both ETL and the wider tram industry to implement those recommendations. This position was adopted by the other participants in the inquiry.

Comprehensive recommendations

In his determination, Sheriff Keir said of the RAIB report: “Adopting the approach taken by Sheriff Principals Turnbull and Pyle at previous Inquiries, my assessment of the evidence before this Inquiry, and of the submissions made by the participants, is that there is no credible evidence to suggest that the RAIB investigation into the accident was incomplete, flawed or deficient. This Inquiry had the benefit of hearing evidence from the RAIB lead inspector for the accident, Simon Kay. He gave his evidence in a measured, detailed and professional manner. It is significant  to note that his evidence was not challenged.”

He continued: “While ETL highlighted other evidence that suggested other possible reasons why Mr Correa might not have responded to the approaching tram, I do not consider that this amounted to a challenge to the RAIB investigation and, in any event, I prefer the evidence given by Mr Kay which was based on a comprehensive investigation into the accident. Accordingly, I am satisfied that there is no basis upon which the RAIB’s findings and conclusions should not be adopted in full.”

Considering any precautions that might have prevented Mr Correa’s death, Sheriff Keir said: “There was no dispute that there were a number of precautions which could reasonably have been taken which might realistically have avoided the accident that resulted in Mr Correa’s death. The bedrock for identifying those precautions should have been ETL’s risk assessment process and the specific measures that could reasonably have been taken would have been identified by carrying out a suitable and sufficient risk assessment of the layout of the crossing to ensure that it provided sufficient notice and warning to pedestrians of the crossing itself.”

In terms of recommendations, he concluded: “I am satisfied that [the RAIB’s] comprehensive and wide-ranging recommendations have been fully implemented and have led to significant improvements both at ETL and within the UK tram industry more broadly. I am further satisfied that all of the measures taken since this accident adequately address the concerns identified during the investigation and subsequently raised at this Inquiry. The fact that there have been no reported collisions or near-misses involving trams and pedestrians at NMU crossings on the Edinburgh tramway since these measures have been implemented fortifies this conclusion.”

Sheriff Keir therefore declined to make recommendations, and concluded the inquiry by repeating his condolences to Mr Correa’s family