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Reports Igation Bureau BEA-TT French Land Trans- port Accident Invest- reports igation Bureau 2007 ACTIVITY REPORT French Departmental Council for the Environment and Sustainable Development September 2008 French Land Transport Accident Investigation Bureau 2007 ACTIVITY REPORT French Land Transport Accident Investigation Bureau (BEA-TT) Tour Pascal B 92055 La Défense Cedex Tél : 33 (0)1 40 81 21 83 – Fax : 33 (0)1 40 81 21 50 email : [email protected] web : http:/www.bea-tt.equipement.gouv.fr 1 CONTENTS Glossary........................................................................................... 5 A review of 2007................................................................................ 7 1 Remit and organisation of the BEA-TT......................................... 11 1.1 The reasons behind technical accident investigations............................................................ 11 1.2 The main stages in the creation of the BEA-TT..................................................................... 11 1.3 Remits and methods of intervention....................................................................................... 12 1.4 Transposition of the rail safety directive................................................................................ 12 1.5 Organisation and resources.....................................................................................................13 1.6 Monitoring and reporting accidents and incidents..................................................................14 2 The investigations conducted in 2007 : overview.......................... 15 2.1 Investigations conducted in 20007......................................................................................... 15 2.2 Causal factors identified......................................................................................................... 15 2.3 Recommendations made.........................................................................................................15 2.4 Actions taken following the recommendations...................................................................... 16 2.5 Investigations opened in 2007................................................................................................ 16 3 The investigations conducted : rail and guided transport............. 19 3.1 Investigations conducted in 2007........................................................................................... 19 3.2 Recommendations made.........................................................................................................19 3.3 Actions taken or planned by the recipients.............................................................................20 3.4 Global summary of the investigation reports..........................................................................20 4 The investigations conducted : road transport............................. 21 4.1 Investigations conducted in 2007........................................................................................... 21 4.2 Recommendations made.........................................................................................................21 4.3 Actions taken further to the recommendations.......................................................................22 4.4 Global summary of the 2007 investigation reports.................................................................22 5 The investigations conducted : waterways....................................23 5.1 Investigations conducted in 2007........................................................................................... 23 5.2 Recommendations made.........................................................................................................23 5.3 Actions taken further to the recommendations.......................................................................24 5.4 Global summary of the 2007 investigation reports.................................................................24 6 Studies and feedback.................................................................. 25 6.1 Database of reported events....................................................................................................25 6.2 Study of spontaneous fires involving coaches........................................................................26 3 ANNEXES....................................................................................... 27 Annex 1 : Rail and guided transport : global summary of investigation reports...........................29 Annex 2 : Road transport : global summary of the investigation report........................................39 Annex 3 : Waterways : global summary of the investigation reports............................................47 Annex 4 : Investigations into accidents and incidents occurring from 2002 onwards.................. 53 Annex 5 : Follow-up to the implementation of BEA-TT recommendations in the railway sector ....................................................................................................................................................... 57 Annex 6 : Study of spontaneous fires in heavy goods vehicle in 2007......................................... 83 Annex 7 : Road accidents listed in the BEA-TT database.............................................................85 Annex 8 : Organisation chart of the BEA-TT in 2007.................................................................. 87 Annex 9 : Legislation covering the BEA-TT.................................................................................89 4 Glossary CGPC : French Departmental Council for Bridges and Highways (now the CGEDD) CMVOA : French Ministerial Unit for Operational Monitoring and Alerts CGEDD : French Departmental Council for the Environment and Sustainable Development CNO : French National Operations Centre COGIC :French Operational Centre for Inter-ministerial Crisis Management DDE : French Departmental Public Works Directorate DRE : French Regional Public Works Directorate DSCR : French Road Safety and Traffic Directorate EPSF : French Railway Safety Authority INRETS : French National Institute for Transport and Safety Research HGV : Heavy Goods Vehicle LV : Light Vehicle RH : Road Haulage SDIS : French Departmental Fire and Rescue Services SIC : French Information and Communication Service STRMTG : French National Agency for Ropeway and Guided Transport Safety TDS : Transport of Dangerous Substances 5 A review of 2007 For the BEA-TT, 2007 was the third year of full service since it was founded in 2004. The year was marked firstly by a notable rise in its main activity, namely conducting technical investigations into accidents and incidents. This rise meets high and perhaps lasting expectations from the public and media that the causes of accidents will be determined and prevention increased. Twelve investigations were concluded in the publication of the investigation report in 2007 as compared to ten in 2006. The most significant increase was in workload: nineteen new investigations were opened in 2007, as compared to fifteen in 2006 and nine in 2005. The most serious accident to be investigated was the Polish coach crash in Laffrey, the stretch of road between Gap and Grenoble, on 22 July 2007, in which 26 people lost their lives. The BEA-TT also continued to study spontaneous fires involving heavy vehicles (coaches and heavy goods vehicles) and to use its road database in 2007. The reports are uploaded onto the BEA-TT website www.bea-tt.equipe- ment.gouv.fr. At the close of 2007, 32 published reports were accessible on this site, which was visited by 13,508 Internet users in 2007 (9,068 in 2006) of whom 21% were foreigners in more than seventy countries. Experiences in 2007 also confirmed the importance of international aspects in BEA-TT activity. It was ascertained that companies established outside of France were amongst the transport operators that were directly involved in the three most ser- ious rail accidents and the four most serious road accidents which were subject to investigation. This situation calls for active international cooperation, which the BEA-TT endeavours to implement whenever possible. This is especially relev- ant to the rail sector, for which there are or soon will be counterpart bodies to the BEA-TT in the majority of European countries, whereas this is not yet the case for road transport. A cooperation agreement was therefore reached with the British Rail Acci- dent Investigation Branch (RAIB) in 2006 in order to clarify the methods of co- operation in the event of an investigation involving the Channel Tunnel. This agreement is also being used for the ongoing investigation into the Zoufftgen rail crash with our Luxembourgian colleagues. In addition the BEA-TT regularly takes part in meetings of the network of 7 rail investigation bodies led by the European Railway Agency (ERA), and in follow- up seminars to the SafetyNet project undertaken by the European Commission on road safety. In 2007 it also contributed to the safety training workshops organised by France in Estonia and Bosnia in the framework of railway-related projects with these countries. In this climate of increased activity, the resources of the BEA-TT have also grown. In 2007, its authorised workforce rose from ten to twelve with the addition of two investigators, one of whom joined the rail and guided transport team, and the second the roadway team. At the close of 2007, the BEA-TT had two senior managers, six permanent
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