Date of occurrence Location name Cata Rupea Local time 16:45 Latitude 46:03:20 North

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1 -5099 Occurrence Summary What Location Date of occurrence Location name Cata Rupea Local time 16:45 Latitude 46:03:20 North Event type Rolling stock events Fire in RS Longitude 25:16:43 East Description the electric locomotive EA no.557 that hauled the passenger train no.3536 caught fire Direct Cause descrip Direct cause The fire happened because the mechanical interaction between the windings of the rotor and of those of the stator, because the detachment of the band from the rotor winding, leading to a serious local heating and appearance of sparks, it generating the ignition of the electrical insulation of the power supply cables from the traction engine no.4, of the gangway of the ventilation duct and the fire propagation at the other components. Contributing factors deterioration of the band of the rotor winding because its aging; keeping in service of the locomotive EA 557, after reaching the norms of time/km for the performance of the planed repairs. Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo Micro PDF /14 soft File 48 /201 Word 7 - RI 10:2 Cata 0:04 - AM Rupe a CR trans mis_ 1_.p df 0 ERAIL-REP PUBLIC 1 Friday, March 15, 2019

2 -5099 What Title Fire in RS, , Cata Rupea (Romania) Occurrence type Rolling stock events Fire in RS Occurrence Class Accident Date of occurrence Local time 16:45 Events Rolling stock events - Fire in RS Descriptions Language English Translation provider Information providers own translation Description the electric locomotive EA no.557 that hauled the passenger train no.3536 caught fire Location name Cata Rupea Railway System type Railway Country Romania Location type Line Border Country Line type Double track Line number Allowed line speed Km number Latitude 46:03:20 North Longitude 25:16:43 East Location description open line between Cata and Rupea railway station Additional location in in the center of Romanian railway network, on the Brasov railway county Location type details Fixed installations Occurrence details Railway vehicles Movement type Passenger train Train number 3536 RU Romania Wagons overturned No National Company for Passenger Railway Transport "CFR-Calatori" S.A. Train speed at mom Passengers onboard Yes Vehicle description electric locomotive Co-Co 5100KW Other objects involved in the occurrence Other objects Parties involved ERAIL-REP PUBLIC 2 Friday, March 15, 2019

3 -5099 IM Involved Romania - National Railway Company "CFR" S.A. RU Romania - National Company for Passenger Railway Transport "CFR-Calatori" S.A. 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 the locomotive damaged Images Name Description Type Size Last modified Organization Repository 0 Causation Causes Language English Translation provider Information providers own translation Direct Cause description Direct cause The fire happened because the mechanical interaction between the windings of the rotor and of those of the stator, because the detachment of the band from the rotor winding, leading to a serious local heating and appearance of sparks, it generating the ignition of the electrical insulation of the power supply cables from the traction engine no.4, of the gangway of the ventilation duct and the fire propagation at the other components. Contributing factors deterioration of the band of the rotor winding because its aging; keeping in service of the locomotive EA 557, after reaching the norms of time/km for the performance of the planed repairs. Underlying and root causes description ERAIL-REP PUBLIC 3 Friday, March 15, 2019

4 -5099 Underlying causes Infringement of the provisions of the Railway Norm :2011 "Railway vehicles. Types of revisions and planned repairs. Norms of time and run km for the performance of the inspections and planned repairs", approved through the Order of the Minister of Transports and Infrastructure no.315/2011, amended through the Order of Minister of Transports and Infrastructure no.1359/2012, respectively: chapter 3 Norms for the performance of inspections and planned repairs of the railway vehicles and their periodicity, sub-point 3.1, that is the locomotive EA 557 was not withdrawn from running when it reached the norm of time or km stipulated for the performance of the planned repairs; chapter 3 Norms for the performance of the inspections and planned repairs of the railway vehicles and their cycle, Table 3.1, letter A, position no.1, that is the cycle of the planned repairs for the locomotive EA 557 was not met. Root causes infringement of the requirements from the operational procedure PO Planning of inspections and repairs for locomotives, multiple units and electrical multiple units got by SNTFC CFR Calatori SA chapter Organization of the planning of the scheduled repairs, point Sequence and periodicity of the inspections and scheduled repairs - Annex no. 1 code F-PO point A.1 concerning the Norm of time or km run for the performance of the planned repairs; lack of some real provisions for keeping under control of the risks generated by the danger represented by Non-meeting with the cycle of inspections and repairs at the rolling stock. Language Romanian Translation provider Original version Direct Cause description Cauza directa Incendiul s-a produs datorita interac?iunii mecanice dintre înfa?urarile rotorului?i ale statorului ca urmare a desprinderii bandajului înfa?urarii rotorice, ce a avut ca efect o puternica încalzire locala?i apari?ia de scântei fapt ce a produs aprinderea izola?iei electrice a cablurilor de alimentare ale motorului de trac?iune nr.4, a burdufului de la canalul de ventila?ie?i extinderea incendiului la celelalte componente. Factorii care au contribuit deteriorarea bandajului înfa?urarilor bobinajului rotoric ca urmare a îmbatrânirii acestuia; men?inerea în serviciu a locomotivei EA 557, dupa atingerea normelor de timp/kilometri pentru efectuarea repara?iilor planificate. Underlying and root causes description ERAIL-REP PUBLIC 4 Friday, March 15, 2019

5 -5099 Cauze subiacente Nerespectarea prevederilor Normativului feroviar :2011 "Vehicule de cale ferata. Tipuri de revizii?i repara?ii planificate. Normele de timp sau normele de kilometri parcur?i pentru efectuarea reviziilor?i repara?iilor planificate", aprobat prin Ordinul Ministrului Transporturilor?i Infrastructurii nr.315/2011 modificat?i completat prin Ordinul MTI nr.1359/2012, respectiv: capitolul 3 Norme pentru efectuarea reviziilor?i repara?iilor planificate ale vehiculelor feroviare?i periodicitatea acestora (ciclul), subpunctul 3.1, în sensul ca locomotiva EA 557 nu a fost retrasa din circula?ie la atingerea normei de timp sau kilometri prevazuta pentru efectuarea repara?iilor planificate; capitolul 3 Norme pentru efectuarea reviziilor?i repara?iilor planificate ale vehiculelor feroviare?i periodicitatea acestora (ciclul), Tabelul 3.1, lit. A, pozi?ia nr.1, în sensul ca nu a fost respectat ciclul de repara?ii planificate pentru locomotiva EA 557. Cauze primare nerespectarea cerin?elor prevazute în procedura opera?ionala PO Planificarea reviziilor?i repara?iilor pentru locomotive, automotoare?i rame electrice apar?inând SNTFC CFR Calatori SA capitolul Organizarea activita?ii de planificare a repara?iilor programate, punct Succesiunea?i periodicitatea reviziilor?i repara?iilor programate - Anexa nr. 1 cod F-PO punctul A.1 referitor la Norma de timp sau de kilometri parcur?i pentru efectuarea repara?iilor planificate; absen?a unor prevederi concrete pentru?inerea sub control a riscurilor generate de pericolul reprezentat de Nerespectarea ciclului de revizii?i repara?ii material rulant. Causation classification Rolling stock events - Fire in RS 1 - Locomotives and traction units 2 - Maintenance of rolling stock Recommendations Recommendation Issuing information Recommendation title About the accident happened on the 14th of June 2016, in the running of the passenger train Regio... Recommendation REC End implementer RU Status Sent to adressee Addressee NSA Issue date Recommendation texts Language English Translation provider Information providers own translation Recommendations text ERAIL-REP PUBLIC 5 Friday, March 15, 2019

6 -5099 About the accident happened on the 14th of June 2016, in the running of the passenger train Regio no.3536, one found out that the fire burst into the locomotive EA 557 was because the failure of the traction engine no.4, whose technical condition had to be kept under control for inspections and specific works of maintenance, performed during the planned repairs. During the investigation, one found out that the locomotive EA 557 was kept in service after reaching the norms of time and km for the performance of the planned repairs, infringing the provisions of the Order of Minister of Transports and Infrastructure MTI no.1359/2012 for the amendment of the Railway Norm "Railway vehicles. Types of inspections and planned repairs. Norms of time and run km for the performance of the inspections and planned repairs", approved through the Order of the Minister of Transports and Infrastructure no.315/2011, it being a factor that contributed to the accident occurrence. Taking into account that this factor was generated by deviations from the regulations in force, as well as that the oversight of the economic operators from the railway field is in charge of Safety Authority ASFR, the investigation commission does not consider necessary to issue some safety recommendations. 1. Concerning the safety management system of the railway passenger undertaking, one found out some deficiencies in the drawing up and application of some procedures, as they are pointed out in chapter C.5.2. Safety management system from this report, therefore the investigation commission recommends Romanian Railway Safety Authority ASFR to ask railway passenger undertaking SNTFC CFR Calatori SA the revision of the operational procedures Management of the risks associated to the railway safety and Planning of the inspections and repairs at the locomotives, multiple units and electrical multiple units got by SNTFC CFR Calatori, so these ensure the identification of risks associated to the railway safety, as well as that the maintenance and operation of the locomotives are made in accordance with the specific legislation. Language Romanian Translation provider Original version Recommendations text ERAIL-REP PUBLIC 6 Friday, March 15, 2019

7 -5099 În cazul accidentului feroviar produs la data de în circula?ia trenului de calatori Regio nr.3536 s-a constatat ca incendiul produs la locomotiva EA 557 s-a datorat defectarii motorului de trac?iune nr.4, a carui stare tehnica trebuia?inuta sub control prin verificari?i lucrari specifice de mentenan?a ce se executa cu ocazia repara?iilor planificate. În cursul ac?iunii de investigare s-a constatat faptul ca locomotiva EA 557 a fost men?inuta în serviciu dupa atingerea normelor de timp?i kilometrii pentru efectuarea repara?iilor planificate, contrar prevederilor Ordinului MTI nr.1359/2012 pentru modificarea?i completarea Normativului feroviar "Vehicule de cale ferata. Tipuri de revizii?i repara?ii planificate. Normele de timp sau normele de kilometri parcur?i pentru efectuarea reviziilor?i repara?iilor planificate", aprobat prin Ordinul ministrului transporturilor si infrastructurii nr. 315/2011, ceea ce a constituit un factor care a contribuit la producerea accidentului feroviar. Având în vedere ca acest factor a fost generat de abateri de la reglementarile în vigoare, precum?i faptul ca, supravegherea operatorilor economici din sistemul de transport feroviar este atribu?ia?i raspunderea Autorita?ii de Siguran?a Feroviara Româna ASFR, comisia de investigare nu considera necesara emiterea unor recomandari de siguran?a. 1. Referitor la sistemul de management al siguran?ei operatorului de transport feroviar de calatori s-au constatat deficien?e la întocmirea respectiv punerea în aplicare a unor proceduri a?a cum sunt ele semnalate în capitolul C.5.2. Sistemul de management al siguran?ei din prezentul raport, fapt pentru care comisia de investigare recomanda Autorita?ii de Siguran?a Feroviara Româna ASFR sa solicite operatorului de transport feroviar de calatori SNTFC CFR Calatori SA revizuirea procedurilor opera?ionale Managementul Riscurilor asociate siguran?ei feroviare?i Planificarea reviziilor?i repara?iilor la locomotive, automotoare?i rame electrice apar?inând SNTFC CFR Calatori, astfel încât acestea sa garanteze identificarea riscurilor asociate siguran?ei feroviare precum?i faptul ca între?inerea?i exploatarea locomotivelor este efectuata în conformitate cu legisla?ia în domeniu. Implementation information Implementation status Implementation date NSA Response NIB Comment Causation links Rolling stock events - Fire in RS Subsystem - Rolling stock - Locomotives and traction units Causal factors - Maintenance - Maintenance of rolling stock ERAIL-REP PUBLIC 7 Friday, March 15, 2019

8 -5099 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 206 Occurrence creation :08:17 Investigator in charge Decision to investigate Declaration date Date of IM/RU notific Report Type Final report Workflow Status Validated Report Version 2 Investigation Status Closed Other Attachments Name Descriptio Type Size Last Organizati Repositor 0 Final Report Name Descriptio Type Size Last Organizati Repositor Microsoft PDF File /14/2017 Word - RI 10:20:04 Cata - AM Rupea CR transmis_ 1_.pdf ERAIL-REP PUBLIC 8 Friday, March 15, 2019

Date of occurrence Location name Aninoasa Local time 06:00 Latitude 44:58:12 North

Date of occurrence Location name Aninoasa Local time 06:00 Latitude 44:58:12 North -4980 Occurrence Summary What Location Date of occurrence 23-01-16 Location name Aninoasa Local time 06:00 Latitude 44:58:12 North Event type Rolling stock events Fire in RS Longitude 25:26:16 East Description