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Railway Accident Investigation Unit Ireland INVESTIGATION REPORT

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Railway Accident Investigation Unit Ireland INVESTIGATION REPORT Railway Accident Investigation Unit Ireland INVESTIGATION REPORT Operational incidents at Ardrahan on the 23rd October 2015 & Spa on the 28th November 2015 RAIU Report Number: R2016 – 03 Published: 20th October 2016 Operational incidents at Ardrahan, 23rd October 2015 & Spa, 28th November 2015 Report publication This report is published by the Railway Accident Investigation Unit (RAIU). The copyright in the enclosed report remains with the RAIU by virtue of Section 9 of the European Union (Railway Safety) (Reporting and Investigation of Serious Accidents, Accidents and Incidents) Regulations 2014. No person may produce, reproduce or transmit in any form or by any means this report or any part thereof without the express permission of the RAIU. This report may be freely used for educational purposes. For further information, or to contact the RAIU, please see details below: RAIU email: [email protected] 2nd Floor, 2 Leeson Lane website: www.raiu.ie Dublin 2 telephone: + 353 1 604 1241 Ireland fax: + 353 1 604 1351 The original publication details are given below: Title Operational incidents at Ardrahan on the 23rd October 2015 & Spa on the 28th November 2015 Document type Investigation Report Document number 2016-R03 Document issue date 20th October 2016 Where the report has been altered following its original publication, details on the changes are given below: Revision Revision Summary of changes number date Reader guide All dimensions and speeds in this report are given using the International System of Units (SI Units). Where the normal railway practice, in some railway organisations, is to use imperial dimensions; imperial dimensions are used and the SI Unit is also given. All abbreviations and technical terms (which appear in italics the first time they appear in the report) are explained in the glossary. Descriptions and figures may be simplified in order illustrate concepts to non-technical readers. RAIU ii Investigation Report 2016-R003 Operational incidents at Ardrahan, 23rd October 2015 & Spa, 28th November 2015 Report preface The RAIU is an independent investigation unit within the Department of Transport, Tourism and Sport (DTTAS) which conducts investigations into accidents and incidents on the national railway network, the Dublin Area Rapid Transit (DART) network, the LUAS, heritage and industrial railways in Ireland. Investigations are carried out in accordance with the Railway Safety Directive 2004/49/EC, the Railway Safety Act 2005 and Statutory Instrument No. 258 of 2014 European Union (Railway Safety) (Reporting and investigation of serious accidents, accidents and incidents) Regulations 2014. The RAIU investigate all serious accidents. A serious accident means any train collision or derailment of trains, resulting in the death of at least one person or serious injuries to five or more persons or extensive damage to rolling stock, the infrastructure or the environment, and any other similar accident with an obvious impact on railway safety regulation or the management of safety. The RAIU may investigate and report on accidents and incidents which under slightly different conditions might have led to a serious accident. The purpose of RAIU investigations is to make safety recommendations, based on the findings of investigations, in order to prevent accidents and incidents in the future and improve railway safety. It is not the purpose of an RAIU investigation to attribute blame or liability. RAIU iii Investigation Report 2016-R003 Operational incidents at Ardrahan, 23rd October 2015 & Spa, 28th November 2015 Report summary This publication investigates two incidents involving the same Class 2600 rolling stock that occurred within five weeks of each other: On Friday 23rd of October 2015 at 19:50 hrs, the 18:00 hrs passenger service, from Limerick to Galway, was involved in a platform overrun and Signal Passed at Danger (SPAD) without authority at Ardrahan Station (Galway) and travelled through Level Crossing XE156 Ardrahan, with barriers raised and open to road traffic. There was no material damage to infrastructure as a result of the incident at Ardrahan. The units involved showed wheel flats on all wheels that required wheel turning. On Saturday 28th November at 21:16 hrs, the 19:00 hrs passenger service from Ballybrophy to Limerick, passed signal XN159DS at danger without authority and collided with the level crossing gates at Level Crossing XN159 Spa (Castleconnell, Limerick) as they were being opened. The gates at XN159 were beyond repair and required replacement as a result of the collision. The RAIU investigation found that the immediate cause of both overruns was an insufficient rate of adhesion to bring the vehicle to a stop before the relevant signals. As a result of the RAIU investigation one new safety recommendation was made: IÉ-RU should review all traction fleets that do not have sanding capabilities, and fit suitable systems to minimise the risk of low adhesion incidents. RAIU iv Investigation Report 2016-R003 Operational incidents at Ardrahan, 23rd October 2015 & Spa, 28th November 2015 Contents PART 1 - RAIU INVESTIGATION ......................................................................................................................... 1 RAIU decision to investigate................................................................................................................ 1 Introduction to RAIU investigation ....................................................................................................... 1 Scope of investigation ......................................................................................................................... 2 Investigation and evidence .................................................................................................................. 3 Parties and roles involved in the incident ............................................................................................ 3 Parties involved in the incident ....................................................................................................................... 3 Roles involved in the incident ......................................................................................................................... 4 Other parties not directly involved in the occurrences ................................................................................... 5 PART 2 – INCIDENT AT ARDRAHAN ON THE 23RD OCTOBER 2015 ..................................................................... 6 Summary of the incident ...................................................................................................................... 6 General description of the railway ....................................................................................................... 7 Infrastructure .................................................................................................................................................. 7 Signalling and communications ...................................................................................................................... 9 Rolling stock .................................................................................................................................................. 13 Fatalities, injuries and material damage ............................................................................................ 14 Fatalities and injuries .................................................................................................................................... 14 Material damage .......................................................................................................................................... 14 External circumstances ..................................................................................................................... 15 Events before, during and after the incident...................................................................................... 16 Events before the incident ............................................................................................................................ 16 Events during the incident ............................................................................................................................ 17 Events after the incident ............................................................................................................................... 21 Similar occurrences ........................................................................................................................... 22 PART 3 – INCIDENT AT SPA ON THE 28TH NOVEMBER 2015 ............................................................................ 23 Summary of the incident .................................................................................................................... 23 Infrastructure ................................................................................................................................................ 24 Signalling and communications .................................................................................................................... 25 Rolling stock .................................................................................................................................................. 26 Fatalities, injuries & material damage ............................................................................................... 26 Fatalities and injuries ...................................................................................................................................
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