Collision A shunting locomotive with 6 wagons collided into 48 wagons loaded with timber

Transcription

1 -5532 Occurrence Summary What Location Date of occurrence Location name Kouvola marshalling yard Local time 21:46 Latitude 60:52:06 North Event type Railway vehicle movement events Trains collision Trains collision with an obstacle Longitude 26:44:32 East Description Direct Cause descrip Collision A shunting locomotive with 6 wagons collided into 48 wagons loaded with timber The root cause of the accident was the failure to notify the change of destination track for the wagons in the shunting unit. The shunting movement that ended in the collision was performed at too high a speed. When it was noticed that the destination track was occupied, nothing could be done to prevent the collision. Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo R201 PDF / File 106 /201 Final 8 Repo 2:12: rt.pdf 37 R201 PDF / File 6 /201 CON 8 CLUS 2:12: IONS 52.pdf R201 PDF / File 6 /201 SAFE 8 TY 2:13: REC 10 OMM END ATIO NS.p df ERAIL-REP PUBLIC 1 Wednesday, April 17, 2019

2 -5532 R201 PDF / File 6 /201 Data 8 Sum 9:12: mary 36.pdf AM What Title Trains collision with an obstacle, , Kouvola marshalling yard (Finland) Occurrence type Railway vehicle movement events Trains collision Trains collision with an obstacle Occurrence Class Accident Date of occurrence Local time 21:46 Events Railway vehicle movement events - Trains collision - Trains collision with an obstacle Descriptions Description Collision A shunting locomotive with 6 wagons collided into 48 wagons loaded with timber Location name Kouvola marshalling yard Railway System type Railway Country Finland Location type Marshalling yard Border Country Line type Multiple track Line number 412 Allowed line speed 20 km/h Km number Latitude 60:52:06 North Longitude 26:44:32 East Location description Additional location in Location type details Fixed installations ERAIL-REP PUBLIC 2 Wednesday, April 17, 2019

3 -5532 Occurrence details Railway vehicles Movement type Shunting operation Train number RU Finland Wagons overturned No VR Group Ltd Train speed at mom 26 km/h Passengers onboard No Vehicle description Shunting unit 6403, a Dr14 diesel-hydraulic locomotive and 6 wagons Other objects involved in the occurrence Other objects Other object - Other objects (48 wagons loaded with timber) Parties involved IM Involved Finland - Finnish Rail Administration RU Finland - VR Group Ltd Passengers Staff Level crossing users Unauthorised persons Others Total Fatalities Serious injuries Minor injuries Material consequences Material Damage Rolling stock Estimated total mate < Damage description Images 1 hopper wagon was seriously damaged, 1 container wagon and 1 container wagon were slightly damaged. A 20-foot tank container that was loaded on container wagon was seriously damaged. Name Description Type Size Last modified Organization Repository P j image/jpeg /12/2017 pg 11:06:09 AM P j image/jpeg /12/2017 pg 11:06:49 AM P j image/jpeg /12/2017 pg 11:07:09 AM ERAIL-REP PUBLIC 3 Wednesday, April 17, 2019

4 -5532 Causation Causes Direct Cause description The root cause of the accident was the failure to notify the change of destination track for the wagons in the shunting unit. The shunting movement that ended in the collision was performed at too high a speed. When it was noticed that the destination track was occupied, nothing could be done to prevent the collision. Underlying and root causes description Upon entering the railway yard, the crew of the shunting unit did not notice that the destination track was occupied. This was partly due to the difficulty in identifying the tracks in the dark railway yard. The shunting foreman acting as an observer in the wagon did not have a radio control unit. With a radio control unit, he might have been able to perform emergency braking a little faster, but this would not have prevented the collision. In addition, braking would have been faster if the shunting foreman on the locomotive had performed emergency braking with the locomotive s emergency stop button rather than by radio control. The investigation revealed that, in the radio control system used in locomotives of this kind, there is a two-second delay in all commands. In addition, there is no separate emergency stop button on the radio control unit. There was a major difference in the level of experience between the shunting foremen working on the shunting unit. They were working in the shunting unit as shunting foremen of the same level, but the shunting foreman with three months of experience would have needed the guidance of a more experienced colleague and advice on the correct and safe way to perform shunting work. It was observed that rolling stock training for shunting foremen at the training institution was too focused on rolling stock for passenger transport. In addition, there is currently no way of engaging in supervised practice in using radio control and communication devices at the training institution. Forthis reason, the correct procedures may remain unclear. This can be seen, for example, in the use of incorrect communication tools in shunting work. Work guidance forms a major part of the training of shunting foremen. This is mainly done as part of normal work in the railway yard. A single trainee can have several work guidance instructors; in this case, they had nine. Work guidance may be insufficient due to lack of time, and there is no guarantee that all of the issues are covered when there are several occupational instructors. It was observed that the verification of skills at the end of the training, i.e. the documentation of the skills demonstration, was restricted to pass/fail, which gives no indication of the employee's ability to work independently. There are no written instructions on performing and reporting track changes. Furthermore, there is no verification that such procedures have been completed. Lack of an operational model and assignment of responsibility pose a serious safety risk in railway yards. Because a number of shunting operators work in the yards, they must have consistent practices. Radio-controlled locomotives are involved in collisions and near-miss situations, some of which are not reported to superiors. This is due to the sanction procedure used by the investigated railway operator. The investigation revealed that there may be large differences between the practices described in the safety management system and those used in practice. Official supervision is insufficient to ascertain whether an enterprise is operating in the manner described in the safety management system. Causation classification Railway vehicle movement events - Trains collision - Trains collision with an obstacle ERAIL-REP PUBLIC 4 Wednesday, April 17, 2019

5 Switches and crossings 1 - Working conditions 1 - Risk assessment 2 - Management Commitment and safety culture 2 - Ambient conditions 1 - Risk assessment 2 - Control and communications systems (onboard train control systems etc) 1 - Design 1 - Risk assessment 2 - Documentation 3 - Regulatory Framework 3 - Managing traffic 1 - Procedures 1 - Management Commitment and safety culture 2 - Monitoring 3 - Information 4 - Documentation 5 - Regulatory Framework 6 - Structure and responsibility 2 - Communication 1 - Monitoring 2 - Regulatory Framework 3 - Supervision 1 - Management Commitment and safety culture 4 - Train driving 1 - Training / Experience 1 - Management Commitment and safety culture 2 - Competence management Railway vehicle movement 3 - Documentation events - Trains collision - Trains collision with an obstacle 2 - Supervision 1 - Management Commitment and safety culture 2 - Organisational learning 3 - Risk assessment ERAIL-REP PUBLIC 5 Wednesday, April 17, 2019

6 -5532 s title 2018-S14 Development of work guidance monitoring REC End implementer NSA Status Sent to adressee Addressee NSA texts s text When approving safety management systems and persons who are responsible for the verification of personnel skills, the Finnish Transport Safety Agency makes sure that their skills verification methods are sufficient and skills verification is reported accordingly. Under implementation According to Finnish Transport Safety Agency, they use EU-level criteria when auditing safety management systems. Procedures have not been changed due to recommendation. Investigation showed, that procedures are not sufficient to ensure competencies of trainees. Not yet implemented. title 2018-S15 Development of teaching tools REC End implementer Other (Trainin institutions) Status Sent to adressee Addressee NSA texts s text Training institutions in the railway sector include simulator training in the training programme for shunting foremen. ERAIL-REP PUBLIC 6 Wednesday, April 17, 2019

7 -5532 Under implementation KRAO has started together with the simulator suppliers to study the alternatives to add the remote radio control to the simulators in use. The study is unfinished and the possible decisions on the extension of the properties of the simulators also to operate with the remote radio control will be made during the year Not yet implemented. title 2018-S16 Instruction on track changes in railway yards REC End implementer IM Status Sent to adressee Addressee NSA texts s text The Finnish Transport Agency draw up written instructions for track changes in railway yards and ensure that the operators in the yards act according to the instructions. Under implementation Finnish Transport Agency is developing new tools for rail yard traffic control. These tools will be commissioned by the end of Finnish Transport Agency will also check it's existing instructions related to track changes and update them if it is necessary. Not yet implemented. ERAIL-REP PUBLIC 7 Wednesday, April 17, 2019

8 -5532 title 2018-S17 Emergency braking by radio control REC End implementer NSA Status Sent to adressee Addressee NSA texts s text The Finnish Transport Safety Agency (Trafi) require that the radio control units used for shunting work have a separate, non-delayed emergency stop button. Under implementation According to Finnish Transport Safety Agency adding an emergency-stop button to existing rolling stock would be time consuming and expensive. Because of these reasons Finnish Transport Safety Agency can not require this kind of feature. SIAF has information, that there are radio-control systems in use in Finland that fullfill the recommendantion. Not yet implemented. title 2018-S18 Monitoring of the practical implementation of safety management systems REC End implementer NSA Status Sent to adressee Addressee NSA texts s text The Finnish Transport Safety Agency begin monitoring the practical implementation of safety management systems. ERAIL-REP PUBLIC 8 Wednesday, April 17, 2019

9 -5532 Under implementation Procedures have not been changed due to recommendation. Finnish Transport Safety Agency aims to monitor the practical implementation of safety management systems thru it's audits. According to Finnish Transport Safety Agency, in-field monitoring with current resources is not efficient in monitoring the practical implementation of safety management systems in everyday work. Efficient monitoring would require a considerable increase in resources. Not yet implemented. title 2018-S19 Use of emergency service routes during emergency calls REC End implementer Government Rescuing services Status Sent to adressee Addressee Emergency Response Centre texts s text The Emergency Response Centre add numbered emergency service routes for railwayyards to its system, and emergency duty officers be instructed to locate the accident site primarily through such routes. Unknown ERAIL-REP PUBLIC 9 Wednesday, April 17, 2019

10 -5532 title S194 Track numbering in railway yards REC End implementer IM Status Sent to adressee Addressee NSA texts s text Railway yard tracks should be equipped with number plates. Under implementation Finnish Transport Agency is studying best procedures to display track information so, that it is available to all operators in operative situations. Not yet implemented. Causation links Railway vehicle movement events - Trains collision - Trains collision with an obstacle Subsystem - Infrastructure - Switches and crossings Causal factors - Working conditions Systemic factors - Risk assessment Systemic factors - Management Commitment and safety culture Causal factors - Ambient conditions Systemic factors - Risk assessment Subsystem - Rolling stock - Locomotives and traction units - Control and communications systems (onboard train control systems etc) Causal factors - Design Systemic factors - Risk assessment Systemic factors - Documentation Systemic factors - Regulatory Framework Subsystem - Operation - Operation and traffic management - Managing traffic Causal factors - Procedures Systemic factors - Management Commitment and safety culture ERAIL-REP PUBLIC 10 Wednesday, April 17, 2019

11 -5532 Systemic factors - Monitoring Systemic factors - Information Systemic factors - Documentation Systemic factors - Regulatory Framework Systemic factors - Structure and responsibility Causal factors - Communication Railway Subsystem vehicle Causal movement - Systemic Operation factors - factors events Procedures - Operation - Monitoring Trains and collision traffic - management Trains collision - Managing with obstacle traffic Systemic factors - Regulatory Framework Causal factors - Supervision Systemic factors - Management Commitment and safety culture Subsystem - Operation - Operation and traffic management - Train driving Causal factors - Training / Experience Systemic factors - Management Commitment and safety culture Systemic factors - Competence management Systemic factors - Documentation Causal factors - Supervision Systemic factors - Management Commitment and safety culture Systemic factors - Organisational learning Systemic factors - Risk assessment Investigation details Legal Basis Other reason descrip National rules imposed by implementing of the Safety Directive 2004/49/EC - in light of Article 19, 2 of SD - (a) the seriousness of the accident or incident National investigatio R Occurrence creation :32:34 Investigator in charge EVARTTIO Decision to investigate Declaration date Date of IM/RU notific Report Type Final report Workflow Status Validated Report Version 3 Investigation Status Closed ERAIL-REP PUBLIC 11 Wednesday, April 17, 2019

12 -5532 Other Attachments Name Descriptio Type Size Last Organizati Repositor R PDF File /11/2018 CONCLUS 2:12:52 IONS.pdf R PDF File /11/2018 SAFETY 2:13:10 RECOMME NDATION S.pdf R PDF File /11/2018 SUMMARY 2:13:22.pdf R PDF File /12/2018 DataSum 9:12:36 mary.pdf AM Final Report Name Descriptio Type Size Last Organizati Repositor R PDF File /11/2018 Final 2:12:37 Report.pdf Relevant for sharing Sharing good practice Impact on EU Level Investigation practice Investigation findings s Yes No Was there any issue with a TSI component? Could the results of the investigation have any impact on railway safety at EU-Level? the collection of evidence the reconstruction of the occurrence (e.g. video, simulation, practical tests) the analysis has involved investigation of SMS the analysis has involved investigation of human performance / human factor SMS issues human performance / human factor issues Investigation practic Investigation finding ERAIL-REP PUBLIC 12 Wednesday, April 17, 2019