Recommendation: 2020001-01

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Ref # 2020001-01
Status Open / In progress
Occurrence Passenger trap-and-drag on Luas tram at Heuston Stop, 26th March 2019
Occurrence Date 26 March 2019

Basis for Recommendation

Transdev’s suite of documents (SM017 Driver Training Plan, SM 018 Competency Assessment, SM 019 Competence Assessment, TSI Manual, etc) are not robust in ensuring that drivers are not relying on the tram’s doors closed and locked indications (interlock systems) as an assurance that nothing is trapped in the doors; and, requiring a thorough final visual door check (using CCTV if appropriate) is essential after obtaining doors closed and locked indications and before moving the tram to confirm that nothing outside the tram is trapped in the doors; as a result, the RAIU make the following safety recommendation:

Recommendation

Transdev should update their suite of documents for driver training (SM 017 Driver Training Plan), operations (TSI Manual) and competence assessment (SM 018 & SM 019 Competence Assessment) to include a requirement for drivers to conduct a thorough final visual check (using CCTV and mirrors) after obtaining doors closed and locked indications
and before moving the tram to confirm that nothing is trapped in the doors.