Occurrence Summary What Location Date of occurrence 24-07-13 Location name Near Santiago de Compostela Local time 20:41 station (La Coruña) Latitude 42:51:35 North Event type Railway vehicle movement events Longitude 8:31:43 West Train derailment Description The accident took place on 24 July 2013, at 20:41 pm, in the PK 84 +413 of 082 Bifurcación Coto da Torre Bifurcación A Grandeira aguja km 85.0 railway line, nearby Santiago de Compostela station. The long distance passenger train Alvia 150/151 of Renfe Operadora, class S-730, consisting of 13 vehicles, running from Madrid-Chamartín station to Ferrol station (A Coruña), after making a passenger stop in Ourense, changed its train driver and resumed its route with four minutes of delay and kept running through 082 railway line (known as Ourense-Santiago railway line). The train ran the first 78 km of the line at a speed of about 200 km/h, with the ASFA Digital system in service, finding all signals it passed through stating clear line. Approximately 6.000 m (PK 78 +280) before the start of the curve at Bifurcación A Grandeira (located at PK 84 +228, speed limited to 80 km/h), the train driver answered a service phone call, made by the ticket inspector that was on board, using the company mobile phone. The train kept on running at track 1 and passed through the Bifurcación A Grandeira s caution signal E'7 (PK 80 +619), stating clear line, at a speed close to 200 km/h, train driver still talking through the mobile phone, which probably made him to divert his attention and not start braking at the precise time to adapt the train s speed to the one that was prescribed for the curve of radius 402 m (starting at PK 84 +228). When the train was very close to the home signal E7 (PK 84 +176), which also stated clear line, the last sound of the telephone conversation was recorded (one hundred seconds had passed since its beginning) and the emergency brake application was made then, passing through the signal at 195 km / h. Train 150/151 is already very close to the beginning of the curve (PK 84 +228), derailing within it after 185 meters from its starting point ( PK 84 +413), traveling at 179 km/h. All the thirteen cars derailed and were out of track 1. The first three were about 10 m separated from the following two and these were 30 m apart from the rest. Rear technical end coach (CET) caught fire and one of the cars of the last group (the eighth) flew off over a concrete wall. Direct Cause descrip ERAIL-REP PUBLIC 1 Sunday, May 13, 2018
The cause of the accident was the train s speeding (traveling at 179 km / h) at the curve for entering to Bifurcación A Grandeira ( Angrois curve, speed limited to 80 km / h), when the train driver didn t comply with what is laid down on the train 150/151 s Route Book and on the Table of Maximum Speeds book for line 082. It s pointed, as a contributing cause, the lack of attention of the train driver as he answered a service phone call from the train s ticket inspector which led to the application of the brake in an inadequate manner to reduce the speed before reaching that curve. Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo IF_2 appli 2861 7/24 Softe 4071 catio 2767 /201 co 3_20 n/pdf 4 0514 8:28: _CIA 23 F.pdf AM IF_2 Tran appli 2616 11/7 Softe 4071 slatio catio 806 /201 co 3_ER n n/pdf 4 A_20 provi 12:3 14_0 ded 9:36 070_ by PM EN.p df the Tran slatio n Cent re for the bodi es of the EU What Title Train derailment, 24/07/2013, Near Santiago de Compostela station (La Coruña) (Spain) Occurrence type Railway vehicle movement events Train derailment Occurrence Class Serious accident Date of occurrence 24-07-13 Local time 20:41 Events Railway vehicle movement events - Train derailment Descriptions ERAIL-REP PUBLIC 2 Sunday, May 13, 2018
Description The accident took place on 24 July 2013, at 20:41 pm, in the PK 84 +413 of 082 Bifurcación Coto da Torre Bifurcación A Grandeira aguja km 85.0 railway line, nearby Santiago de Compostela station. The long distance passenger train Alvia 150/151 of Renfe Operadora, class S-730, consisting of 13 vehicles, running from Madrid-Chamartín station to Ferrol station (A Coruña), after making a passenger stop in Ourense, changed its train driver and resumed its route with four minutes of delay and kept running through 082 railway line (known as Ourense-Santiago railway line). The train ran the first 78 km of the line at a speed of about 200 km/h, with the ASFA Digital system in service, finding all signals it passed through stating clear line. Approximately 6.000 m (PK 78 +280) before the start of the curve at Bifurcación A Grandeira (located at PK 84 +228, speed limited to 80 km/h), the train driver answered a service phone call, made by the ticket inspector that was on board, using the company mobile phone. The train kept on running at track 1 and passed through the Bifurcación A Grandeira s caution signal E'7 (PK 80 +619), stating clear line, at a speed close to 200 km/h, train driver still talking through the mobile phone, which probably made him to divert his attention and not start braking at the precise time to adapt the train s speed to the one that was prescribed for the curve of radius 402 m (starting at PK 84 +228). When the train was very close to the home signal E7 (PK 84 +176), which also stated clear line, the last sound of the telephone conversation was recorded (one hundred seconds had passed since its beginning) and the emergency brake application was made then, passing through the signal at 195 km / h. Train 150/151 is already very close to the beginning of the curve (PK 84 +228), derailing within it after 185 meters from its starting point ( PK 84 +413), traveling at 179 km/h. All the thirteen cars derailed and were out of track 1. The first three were about 10 m separated from the following two and these were 30 m apart from the rest. Rear technical end coach (CET) caught fire and one of the cars of the last group (the eighth) flew off over a concrete wall. Location name Near Santiago de Compostela station (La Coruña) Railway System type Railway Country Spain Location type Line Border Country Line type Double track Line number 082 Bifurcación Coto da Torre - Bifurcación A Grandeira Ag, km 85,0 Allowed line speed Km number 84+413 Latitude 42:51:35 North Longitude 8:31:43 West Location description Additional location in ERAIL-REP PUBLIC 3 Sunday, May 13, 2018
Location type details Plain track Fixed installations Occurrence details Railway vehicles Movement type Long distance passenger Train number Alvia 150/151 train RU Spain Wagons overturned Yes RENFE-Operadora Train speed at mom 179 km/h Passengers onboard Yes Vehicle description Other objects involved in the occurrence Other objects Parties involved IM Involved Spain - ADIF RU Spain - RENFE-Operadora Passengers Staff Level crossing users Unauthorised persons Others Total Fatalities Serious injuries Minor injuries 78 73 79 2 0 0 0 0 0 0 0 0 0 0 0 80 73 79 Material consequences Material Damage Estimated total mate 150 000-2 000 000 Damage description Images Name Description Type Size Last modified Organization Repository 0 ERAIL-REP PUBLIC 4 Sunday, May 13, 2018
Causation Causes Direct Cause description The cause of the accident was the train s speeding (traveling at 179 km / h) at the curve for entering to Bifurcación A Grandeira ( Angrois curve, speed limited to 80 km / h), when the train driver didn t comply with what is laid down on the train 150/151 s Route Book and on the Table of Maximum Speeds book for line 082. It s pointed, as a contributing cause, the lack of attention of the train driver as he answered a service phone call from the train s ticket inspector which led to the application of the brake in an inadequate manner to reduce the speed before reaching that curve. Underlying and root causes description Causation classification Railway vehicle movement events - Train derailment 1 - Operation 1 - Train driving s 54/13-1 Speed restriction signals - Signpost REC-000275 End implementer IM To regulate that all speed reductions from a certain range are signposted on the track with fixed speed restriction signals. ERAIL-REP PUBLIC 5 Sunday, May 13, 2018
54/13-2 Speeding - ASFA balises for braking REC-000276 End implementer IM For these situations (significant reductions of speed), to manage the progressive introduction of balises that could help controlling the speed of the trains, so, in case of exceeding the speed limit of the next rail section, the train could be braked. For achieving this, to boost the necessary technological developments of the ASFA Digital system. 54/13-3.1 Procedures within Renfe Operadora s SMS: effective preventive management of deficiencies REC-000277 End implementer RU ERAIL-REP PUBLIC 6 Sunday, May 13, 2018
To reinforce the procedures within the Renfe Operadora s safety management system (SMS) for the safety-related deficiencies that are detected in any level to be extended to the functionally established channels for their analysis and consideration, thus ensuring their effective preventive management. 54/13-3.2 Procedures within RUs SMS: effective preventive management of deficiencies REC-000278 End implementer NSA The National Railway Safety Authority (NSA) shall ensure the extension of the recommendation 54/13-3.1 to the other railway undertakers. ERAIL-REP PUBLIC 7 Sunday, May 13, 2018
54/13-4 Joint Committees for safety of rail traffic REC-000279 End implementer NSA The National Railway Safety Authority (NSA) shall analyze restoring the Joint Committees for the safety of rail traffic where risks situations arising from driving-vehicle-track interaction could be assessed, which will be attended by representatives of Adif and the railway undertakers and supervised by the NSA. 54/13-5 Risk analysis - hazards interaction different subsystems REC-000280 End implementer NSA ERAIL-REP PUBLIC 8 Sunday, May 13, 2018
In the process of putting into service new railway lines and bypasses, to include an specific risk analysis that shows the identification and management of potential hazards arising from the interaction of the different subsystems, under normal and deteriorated conditions of operation, and their linkages with train drivers and operations staff that take part in the running of a train from the beginning to the end of a railway line or bypass, and its connection with the existing network. To analyze the feasibility of its implementation in the different stages of construction process also. To promote, in the lines already in service and in those cases where is justified, putting into practice the aforementioned risk analysis. 54/13-6 Regulate communications with train drivers - Avoid distractions REC-000281 End implementer NSA To include in the regulation, and hand it on to the RUs for its inclusion in their SMS, the appropriate arrangements for the communications with the train drivers being on the train cab to be carried out in a safe way in order to avoid likely distractions. ERAIL-REP PUBLIC 9 Sunday, May 13, 2018
54/13-7.1 Renfe Operadora impelmentation audio and video recording system into cabs REC-000282 End implementer RU To foster the progressive implementation of an audio recording system into the driving cabs. To analyze the feasibility of also install a video recording system. 54/13-7.2 RUs impelmentation audio and video recording system into cabs REC-000283 End implementer NSA The National Railway Safety Authority (NSA) shall ensure the extension of the recommendation 54/13-7.1 to the other railway undertakers. ERAIL-REP PUBLIC 10 Sunday, May 13, 2018
Causation links Railway vehicle movement events - Train derailment Subsystem - Operation Subsystem - Operation - Operation and traffic management - Train driving Investigation details Legal Basis Other reason descrip National rules imposed by implementing of the Safety Directive 2004/49/EC - in light of Article 19, 1 of SD Reporting Body National investigatio 54/13 Occurrence creation 01-08-13 10:36:30 Investigator in charge Decision to investigate 25-07-13 Declaration date Date of IM/RU notific Report Type Final report Workflow Validated Report Version 4 Investigation Closed Other Attachments Name Descriptio Type Size Last Organizati Repositor IF_24071 Translatio applicatio 2616806 11/7/2014 Softeco 3_ERA_20 n n/pdf 12:39:36 14_0070_ provided PM EN.pdf by the Translatio n Centre for the bodies of the EU Final Report Name Descriptio Type Size Last Organizati Repositor IF_24071 applicatio 28612767 7/24/2014 Softeco 3_200514 n/pdf 8:28:23 _CIAF.pdf AM ERAIL-REP PUBLIC 11 Sunday, May 13, 2018