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Annual Report for 2018

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Annual Report for 2018 REPUBLIC OF SERBIA CENTER FOR INVESTIGATION OF ACCIDENTS IN TRANSPORT SECTOR FOR INVESTIGATION OF ACCIDENTS IN RAILWAY TRAFFIC Nemanjina 11, 11000 Belgrade No.: 340-00-9/2019-02-21-1 Date: 25.09.2019. ANNUAL REPORT FOR 2018 Republic of Serbia, Center for Investigation of Accidents in Transport, Sector for Investigation of Accidents in Railway Traffic Center for Investigation of Accidents in Transport (hereinafter referred to as CINS) is independent in its work and performs independent accident investigations. The aim of an investigation is to identify the causes and the possibility of improving safety on the railways and to prevent accidents by issuing safety recommendations. In accordance with the Article 33 of the Law on Investigation of Air, Rail and Water Traffic Accidents (“Official Gazette of RS” No. 66/15 and 83/18) and the Article 23 of the Directive 2004/49/EC of the European Parliament and of the Council of EU (Railway Safety Directive), Center for Investigation of Accidents in Transport drafted and published the Annual Report. Annual report for 2018 consists of: ➢ Information on CINS ➢ Investigative procedure in the field of railway transport ➢ Investigations opened in 2018 ➢ Investigations closed in 2018 ➢ Issued safety recommendations ➢ Measures taken on the basis of the issued safety recommendations Annual Report for 2018 page 2/45 Republic of Serbia, Center for Investigation of Accidents in Transport, Sector for Investigation of Accidents in Railway Traffic Glossary: RS Republic of Serbia CINS Center for Investigation of Accidents in Transport MGSI Ministry of Construction, Transport and Infrastructure IŽS Serbian Railways Infrastructure a.d. Joint-stock company d.o.o. Ltd. US Constitutional Court JŽ Yugoslav Railways ZJŽ Community of Yugoslav Railways EMV Electro motor train DMV Diesel motor train DMK Diesel motor wagon JP Public Enterprise EPS Electrical Power Industry of Serbia TENT Thermo Power Plant “Nikola Tesla” MSK Methanol Acetic Acid Complex Annual Report for 2018 page 3/45 Republic of Serbia, Center for Investigation of Accidents in Transport, Sector for Investigation of Accidents in Railway Traffic С O N T E N T: 1. CINS ..................................................................................................................................... 6 1.1. Legal framework ............................................................................................................ 6 1.2. Role and goal .................................................................................................................. 7 1.3. CINS organization .......................................................................................................... 7 1.4. Organisations competent for the railway system ........................................................... 8 2. INVESTIGATIVE PROCEDURE IN THE FIELD OF RAILWAY TRAFFIC .......... 9 2.1. Accidents and incidents being investigated ................................................................... 9 2.2. Organisations involved in investigation process .......................................................... 10 2.3. CINS’s approach to an investigation ............................................................................ 10 3. INVESTIGATIONS OPENED IN 2018 .......................................................................... 12 3.1. Fire on the train No. 2746 ............................................................................................ 13 3.2. Overtaking of the loc. CEM-7 on the worker- contractor ............................................ 14 3.3. Collision of the trains No. 2990 and 70922 ................................................................. 15 3.4. On the level crossing, overtaking of the train No. 7821 on the bus ............................. 16 4. INVESTIGATION REPORTS FINALIZED IN 2018 ................................................... 18 4.1. Decoupling of train No. 8011 ....................................................................................... 18 4.1.1. Short description of the accident ...................................................................... 18 4.1.2. The causes of incident determined by investigation ........................................ 19 4.1.3. Issued safety recommendations ........................................................................ 20 4.2. On the level crossing, overtaking of the train No. 4905 on the road vehicle ............... 21 4.2.1. Short description of the accident ...................................................................... 21 4.2.2. The causes of accident determined by investigation ........................................ 22 4.2.3. Issued safety recommendations ........................................................................ 22 4.3. Derailment of the shunting composition ...................................................................... 23 4.3.1. Short description of the accident ...................................................................... 23 4.3.2. The causes of accident determined by investigation ........................................ 24 4.3.3. Issued safety recommendations ........................................................................ 24 4.4. On the level crossing, overtaking of the train No. 4905 on the road vehicle ............... 26 4.4.1. Short description of the accident ...................................................................... 26 4.4.2. The causes of accident determined by investigation ........................................ 27 4.4.3. Issued safety recommendations ........................................................................ 27 4.5. Derailment of the train No. 56990 ............................................................................... 29 4.5.1. Short description of the accident ...................................................................... 29 4.5.2. The causes of accident determined by investigation ........................................ 30 4.5.3. Issued safety recommendations ........................................................................ 30 4.6. Derailment of the train No. 53527 ............................................................................... 31 4.6.1. Short description of the accident ...................................................................... 31 4.6.2. The causes of accident determined by investigation ........................................ 32 4.6.3. Issued safety recommendations ........................................................................ 33 Annual Report for 2018 page 4/45 Republic of Serbia, Center for Investigation of Accidents in Transport, Sector for Investigation of Accidents in Railway Traffic 5. SAFETY RECOMMENDATIONS AND MEASURES TAKEN ................................. 35 5.1. Status of safety recommendations from 2017 .............................................................. 36 5.1.1. Investigation Report (ŽS-02/17) 33 No.: 340-8059/2017-16 of 05.01.2018. (accident, derailment of train No. 62946 of 16.08.2017. at 15:30 on the main arterial route: Belgrade Marshalling Yard “А“ - Junction “B“ - Junction “К“ - Resnik, between Junctions “B“ and “К“) ......... 36 5.2. Status of the safety recommendations from 2018 ........................................................ 37 5.2.1. Investigation Report (ŽS-01/17) 33 No.: 340-07684/2017-006 оf 01.03.2018. (incident, decoupling of the train No. 8011 оf 03.08.2017. at 07:55 on the main aretrial route Е 66: Belgrade Center – Pančevo Main station - Vršac – state border - (Stamora Moravita) in the area of the junction and stop Pančevački most) .................... 37 5.2.2. Investigation Report (ŽS-03/17) 33 No.: 340-00-8226/2017-21 оf 16.05.2018. (serious accident, overtaking of the train No. 4905 on the road passenger vehicle of 21.08.2017. at 19:38 on the main arterial route Е 70/Е 85: Belgrade - Mladenovac - Lapovo - Niš - Preševo - state border - (Tabanovce), on the level crossing РВЕ 1, secured with automatic devices on the crossings (half-barriers and road light and sound signaling ) which is located in the area of the switch block 2 of unmanned ТК station Brestovac) ......................................................................................................... 39 5.2.3. Investigation Report (ŽS-05/17) 33 No.: 340-00-10144/2017-20 оf 18.05.2018. (serious accident, overtaking of the train No. 4905 on the road passenger vehicle of 09.10.2017. at 20:26 on the main arterial route Е 70/Е 85: Belgrade - Mladenovac - Lapovo - Niš - Preševo - state border - (Tabanovce), on the level crossing, ensured with the traffic signs on the road and the necessary visibility zone, which is located on the open track between the stations Grdelica and Predejane) ................................ 39 5.2.4. Investigation Report (ŽS-04/17) 33 No.: 340-00-9180/2017-18 оf 22.06.2018. (accident, derailment of the pushed shunting composition of 17.09.2017. at 08:45 on the main arterial route E70/E85: (Belgrade) - Rakovica - Jajinci - Mala Krsna - Velika Plana, between the junction “K1” and station Rakovica) .............................................................................. 41 5.2.5. Investigation Report (ŽS-06/17) 33 No.: 340-00-10982/2017-16 оf 14.08.2018. (accident, derailment of the train No. 56990 оf 03.11.2017. at 15:25 on the local track Markovac - Resavica, between the station Svilajnac and Despotovac) .............................................................. 43 5.2.6. Investigation Report (ŽS-07/17) 33 No.: 340-00-13136/2017-19
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