Accident Involving a Rail Grinding Train in Stavoren, the Netherlands, on 25 July 2010
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Accident involving a rail grinding train in Stavoren, the Netherlands, on 25 July 2010 The Dutch Safety Board telephone +31(0)70 333 70 00 • e-mail [email protected] • website www.safetyboard.nl visiting address Anna van Saksenlaan 50 • 2593 HT The Hague postal address PO Box 95404 • 2509 CK The Hague • The Netherlands Accident involving a rail grinding train in Stavoren, the Netherlands on 25 July 2010 The Hague, September 2011 The Dutch Safety Board’s reports are in the public domain. All reports are also available on the Dutch Safety Board’s website, www.safetyboard.nl THE DUTCH SAFETY BOARD The Dutch Safety Board has been set up to carry out the task of investigating and determining the causes or probable causes of individual or categories of incidents in all sectors. The objective of these investigations is solely to prevent future accidents or incidents and, when the results give cause to do so, issue recommendations. The organisation consists of a Board with five permanent members and a professional bureau. The Dutch Safety Board appoints guidance committees for specific investigations. Dutch Safety Board Guidance Committees Chairman: T.H.J. Joustra J.P. Visser Vice-chairman: A.H. Brouwer-Korf A.H. Brouwer-Korf F.J.H. Mertens F.G. Bauduin J.P. Visser W.A.G. Döbken I.A. Hansen B.B.M. Ernens General secretary: M. Visser Project manager: R.J.H. Damstra Visiting address: Anna van Saksenlaan 50 Postal address: PO Box 95404 2593 HT The Hague, 2509 CK The Hague The Netherlands Telephone: +31 (0)70 333 7000 Fax: +31 (0)70 333 7077 Internet: www.safetyboard.nl This report is published in the Dutch and the English language. In the event of conflict in interpretation, the original Dutch text will be binding. 2 TabLE OF COntEnts LIST OF ABBREVIATIONS ................................................................................................. 4 COnsidERatiON ............................................................................................................. 6 1. INTRODUCTION ........................................................................................................ 13 1.1 Reason for the investigation .....................................................................................13 1.2 Purpose and research questions ...............................................................................13 1.3 Scope of the investigation ........................................................................................14 1.4 Reading guide ........................................................................................................14 2. THE TRAIN ACCIDENT ............................................................................................... 15 2.1 Relevant facts ........................................................................................................15 2.2 Circumstances ........................................................................................................16 2.3 Consequences ........................................................................................................19 2.4 What took place before the train accident occurred .....................................................19 3. REFERENCE FRAMEWORK ......................................................................................... 23 3.1 Laws and regulations ...............................................................................................23 3.2 Sector regulations...................................................................................................28 3.3 Safety management ................................................................................................29 4. PARTIES AND RESPONSIBILITIES ............................................................................ 31 4.1 Companies .............................................................................................................31 4.2 Umbrella organisations ............................................................................................34 4.3 Government bodies .................................................................................................35 5. ANALYSIS.................................................................................................................. 36 5.1 Research questions .................................................................................................36 5.2 Research question 1: Immediate causes and underlying factors ....................................36 5.3 Research question 2: Scope of the issues ..................................................................42 5.4 Research question 3a: Risk analyses ........................................................................ 44 5.5 Research question 3b: Controlling the risks ................................................................46 5.6 Research question 3c: Lessons learned from previous (near) accidents..........................51 5.7 Research question 3d: Contractual agreements ..........................................................53 5.8 Research question 4: Government supervision ...........................................................56 5.9 Research question 5: Measures taken by the parties involved .......................................58 6. CONCLUSIONS .......................................................................................................... 62 7. RECOMMENDATIONS ................................................................................................. 65 Appendices: Appendix 1: Explanation of the investigation .........................................................................66 Appendix 2: Responses received following review of the report ...............................................70 Appendix 3: Explanatory notes on the facts relevant to the investigation .................................71 Appendix 4: Explanatory notes on self-propelled maintenance machines passing signals set at danger ...........................................................................................................76 Appendix 5: Explanatory notes on the compatibility of ATB versions ........................................77 Appendix 6: Explanatory notes on using approach markers ....................................................79 3 LIST OF ABBREVIATIONS ALARP As Low As Reasonably Practicable ARR Automatic Trip Registration ATB Automatic Train Protection System ATB-EG Automatic Train Protection System – First Generation ATB-NG Automatic Train Protection System – New Generation ATB-VV Automatic Train Protection System – Improved Version ATB-E Automatic Train Protection System - Basic AV General Regulations BVS Operating Regulations for Rail Signal Systems EC European Community ERTMS European Rail Traffic Management System ERA European Railway Agency EU European Union IenM Ministry of Infrastructure and the Environment IVW Transport, Public Works and Water Management Inspectorate LWB Workplace Safety Leader NSA National Safety Authority NVW Safety at Work Standards Framework OBE Overview of Routes and Railway Yards OVS Railway Companies Safety Consultation OVV Dutch Safety Board PCA Railway Contractor RI&E Risk Inventory and Evaluation RKS Rail Vehicle Inspection Regulations RvT V Dutch Transport Safety Board SMS Safety Management System SPAD Signal Passed at Danger TPRB Locally operated all-relay interlocking system VenW Ministry of Transport, Public Works and Water Management V&G-O Health and Safety Plan – Design Phase V&G-U Health and Safety Plan – Construction Phase VVW Safety at Work Regulations WBI Workplace Safety Instructions WTB Work Train Supervisor WTI Work Train Instructions 4 Explanation of terms, including technical terms Appendices 5 and 6 contain the definitions of a number of terms, including technical terms, appearing in this report. Name of the responsible ministry The Railway Sector formed part of the portfolio of the Ministry of Transport, Public Works and Water Management until 14 October 2010. Since that date the Railway Sector has been incorporated in the portfolio of the new Ministry of Infrastructure and the Environment (IenM). This report uses the name of the ministry that applied at the time of the accident, which is the Ministry of Transport, Public Works and Water Management (VenW). 5 COnsidERatiON ACCIDENT Relevant facts On Sunday evening, 25 July 2010 at approximately 11.30 p.m. a rail grinding train travelling at high speed ploughed through a buffer stop located at the end of the railway track at Stavoren Station. The train then crashed into a parked tanker and drove straight through a shop. The train was en route to Stavoren because it was scheduled to grind the rails of the track section located between Sneek and Stavoren later that night. The accident occurred while the rail grinding train was transferred to Stavoren Station. This was considered a regular train run and the track was in service. The intention was to take the track section out of service after the train had arrived and to subsequently commence the rail grinding activities. Consequences The crew on board the train consisted of four people, two of whom were slightly injured. Since there was no one near the station at the time of the accident, there were no other casualties. However, the rail grinding train was severely damaged and the tanker and the shop premises were completely destroyed. The material damage incurred as a result of the accident is estimated to be over EUR 20 million. Companies involved The rail grinding activities