Montpellier english summary
At 11:14 3 September 2012, tram No. 2095 travelling on Montpellier tram line 2 made an emergency stop between the “Comédie” and “Corum” stations that caused a 73 year-old passenger moving inside the tram to fall and hit his head violently on the lower part of a handrail. He died despite resuscitation attempts firstly by passengers, then by the emergency services after the tram was brought to the “Beaux-Arts” station.
The casualty fell as a direct result of the emergency braking triggered by the VACMA automatic vigilance system that the driver must activate regularly to confirm that he or she has not fallen ill or died, thereby not activating it within the prescribed time.
Three factors contributed to this accident :
- the design of the tram, which does not modulate its emergency braking performance according to the system which triggers it and applies the brakes sharply, generating a serious risk of falls in the event of a failure in activating the vigilance system although, in such cases, there is generally no confirmed imminent risk of collision with a third party ;
- the ergonomics of the vigilance system alarm signal, the sound of which is less loud and with a softer tone than that of other equipment that the driver was used to operating and only allows the driver a short reaction time before triggering the emergency braking.
- the attention of the driver was diverted by two pedestrians walking on the platform, which is likely to be the cause of the failure to activate the VACMA system, the design and adjustment of which requires frequent operation on French trams, within the prescribed time.
This analysis led BEA-TT to make three recommendations and three calls for action on the following matters :
- vigilance system and the ergonomics of its alarm signal ;
- adaptation of the emergency braking performance of trams ;
- management of accident situations.
It should be noted that the VACMA system with which most French trams are equipped is currently being analyzed with regard to the driver health risks it may generate. This aspect does not fall within the competences of BEA-TT and was not therefore taken into account in this technical inspection report.