Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo RJ20 Final PDF /11 15_0 repor File 733 /201 2e t 5 Bjuv.

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1 Occurrence Summary What Location Date of occurrence Location name Bjuv Local time 19:3 Latitude 56:5:9 North Event type Railway vehicle movement events Trains collision Trains collision near miss Longitude 12:54:55 East Description Severely prolonged application time of the brakes on several wagons on a freight train caused this train to overshoot the stopping point, bringing it too close to the set route of a crossing passenger train. Direct Cause descrip The immediate cause of the incident was the abnormal amount of time it took for the brakes to engage, which was due to a constriction of the train pipe main line in wagon 3. Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo RJ2 Final PDF /11 15_ repor File 733 /21 2e t 5 Bjuv. 11:3 pdf 3:46 AM What Title Trains collision near miss, , Bjuv (Sweden) Occurrence type Railway vehicle movement events Trains collision Trains collision near miss Occurrence Class Incident Date of occurrence Local time 19:3 Events Railway vehicle movement events - Trains collision - Trains collision near miss Descriptions ERAIL-REP PUBLIC 1 Wednesday, December 19, 218

2 Description Severely prolonged application time of the brakes on several wagons on a freight train caused this train to overshoot the stopping point, bringing it too close to the set route of a crossing passenger train. Location name Bjuv Railway System type Railway Country Sweden Location type Station Border Country Line type Single track Line number Allowed line speed 13 km/h Km number 59,3 Latitude 56:5:9 North Longitude 12:54:55 East Location description Additional location in Location type details Fixed installations Occurrence details Railway vehicles Movement type Freight train Train number 4466 Sweden Wagons overturned No TX Logistik AB Train speed at mom km/h Passengers onboard No Vehicle description Movement type Passenger train Train number 1859 Sweden Wagons overturned No Arriva Tåg AB Train speed at mom 9 km/h Passengers onboard Yes Vehicle description Other objects involved in the occurrence Other objects Parties involved IM Involved Sweden - Trafikverket (former Banverket) Sweden - TX Logistik AB Sweden - Arriva Tåg AB Fatalities Serious injuries Minor injuries ERAIL-REP PUBLIC 2 Wednesday, December 19, 218

3 Passengers Staff Level crossing users Unauthorised persons Others Total Material consequences Material Damage Estimated total mate < 15 Damage description Images Name Description Type Size Last modified Organization Repository Causation Causes Direct Cause description The immediate cause of the incident was the abnormal amount of time it took for the brakes to engage, which was due to a constriction of the train pipe main line in wagon 3. Underlying and root causes description The constriction occurred because a fixed hose coupling in the main line had been refitted in a way that introduced a twist in the hose which caused it to twist. During assembly, the hose became twisted in a way that affected the flow area. The constriction was not identified by the technical post-inspections, nor by the subsequent brake tests. The underlying cause was that the maintenance contractor had not identified the risk that the hose might become twisted when re-fitting it to the vehicle, this in turn due to a lack of guidance, from the rail-way undertaking () or the entity in charge of maintenance (ECM), regarding the correct procedure for fitting and performing a function check of the hose in question, in conjunction with repairs on the vehi-cle. Neither the ECM nor the had noted this state of affairs. Causation classification Railway vehicle movement events - Trains collision - Trains collision near miss ERAIL-REP PUBLIC 3 Wednesday, December 19, 218

4 Recommendations Recommendation Issuing information Recommendation title R1 Recommendation REC-231 End implementer Other Status Sent to adressee Addressee The ECM Ahus-Alstätter Eisenbahn AG (the certifying body Sconrail also informed) Issue date Recommendation texts Recommendations text Ahus-Alstätter Eisenbahn AG is recommended to ascertain that any maintenance carried out on vehicles, for which they are the entity in charge of maintenance, is carried out in accordance with the pertinent instructions and, if the need is identified, highlight any particular hazards that may be associated with maintenance operations on vehicles or their subsystems (see section 3.2). Implementation information Implementation status Unknown Implementation date NSA Response NIB Comment Causation links Railway vehicle movement events - Trains collision - Trains collision near miss Investigation details Legal Basis Other reason descrip National rules imposed by implementing of the Safety Directive 24/49/EC - in light of Article 19, 2 of SD - (a) the seriousness of the accident or incident Reporting Body National investigatio Occurrence creation :32:39 Investigator in charge NIB INVESTIGATOR Decision to investigate Declaration date Date of IM/ notific ERAIL-REP PUBLIC 4 Wednesday, December 19, 218

5 Report Type Final report Workflow Status Validated Report Version 3 Investigation Status Closed Other Attachments Name Descriptio Type Size Last Organizati Repositor Final Report Name Descriptio Type Size Last Organizati Repositor RJ215_ Final PDF File /11/215 2e report 11:33:46 Bjuv.pdf AM Relevant for sharing Yes Sharing good practice Impact on EU Level Investigation practice Investigation practic ECM Investigation findings Investigation finding Recommendations ERAIL-REP PUBLIC 5 Wednesday, December 19, 218