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5 April 2017, 15:01
Investigators say Peter Rothwell was killed by a tram in Nottingham last August because tram supervisors mistakenly thought he'd moved off the tracks.
Peter Rothwell, who was 51, had been spotted by tram staff nine minutes before he was struck at 10.57pm, according to the Rail Accident Investigation Branch (RAIB).
But a supervisor thought he'd left the tracks, even though RAIB said Mr Rothwell wasn't moving, "lying motionless along the track".
This meant the tram driver wasn't told to slow down or watch for anyone who might be in the way.
The RAIB said, "The driver passed through the section at normal speed and could not see the person in time to stop the tram before striking him."
The tram was travelling at 30mph when it hit Mr Rothwell in the north of the city, between the David Lane and Basford stops.
The RAIB found the misunderstanding happened because the supervisor thought a call taken by a colleague indicated that Mr Rothwell had reached the Basford stop.
The report blamed poor communication between the team, which wasn't helped by the bad audio quality of the call.
It added that the basic principles of safety critical communication weren't followed.
It's not known why Mr Rothwell was on the tracks - but the report said he'd been in the city centre earlier in the evening.
The inquest into his death at Nottingham Coroner's Court has been adjourned until later this year and an investigation by rail regulator the Office of Rail and Road is ongoing.