BEA-TT French Land Transport Accident Investigation Bureau ACTIVITY REPORT 2011 Ministry of Ecology, Sustainable Development and Energy www.developpement-durable.gouv.fr General Council for the Environment and Sustainable Development French Land Transport Accident Investigation Bureau ACTIVITY REPORT YEAR 2011 French Land Transport Accident Investigation Bureau (BEA-TT) Tour Voltaire 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.developpement-durable.gouv.fr SOMMAIRE GLOSSARY................................................................................................................................7 A REVIEW OF 2011....................................................................................................................9 1 - REMIT AND ORGANISATION OF BEA-TT........................................................................11 1.1 - The reason for technical accident investigations..........................................................11 1.2 - The main stages of the creation of BEA-TT.................................................................11 1.3 - Remits and methods of intervention.............................................................................12 1.4 - Transposition of the European Railway Safety Directive.............................................12 1.5 - Organisation and resources.........................................................................................13 1.6 - Monitoring and reporting of accidents and incidents....................................................13 2 - INVESTIGATIONS CARRIED OUT IN 2011: OVERVIEW.................................................15 2.1 - Investigations carried out in 2011.................................................................................15 2.2 - Causal factors highlighted............................................................................................15 2.3 - Recommendations made..............................................................................................16 2.4 - Follow-up action planned by the recipients..................................................................17 2.5 - Investigations carried out in 2011.................................................................................17 3 - INVESTIGATIONS CARRIED OUT: RAIL TRANSPORT...................................................19 3.1 - Investigations carried out in 2011.................................................................................19 3.2 - Recommendations made..............................................................................................20 3.3 - Follow-up action planned by the recipients..................................................................20 3.4 - Monitoring the implementation of recommendations...................................................21 3.5 - Overall summaries of investigation reports published in 2011.....................................21 4 - INVESTIGATIONS CARRIED OUT: ROAD TRANSPORT.................................................35 4.1 - Investigations carried out in 2011.................................................................................35 4.2 - Recommendations made..............................................................................................36 4.3 - Follow-up action planned by the recipients..................................................................37 4.4 - Overall summaries of investigation reports published in 2011.....................................37 5 - INVESTIGATIONS CARRIED OUT: WATERWAY TRANSPORT.......................................53 5.1 - Investigation carried out in 2011...................................................................................53 5.2 - Recommendations made..............................................................................................53 5.3 - Follow-up action planned by the recipients..................................................................53 5.4 - Overall summary of the investigation report published in 2011...................................54 6 - INVESTIGATIONS CARRIED OUT: GUIDED TRANSPORT.............................................57 6.1 - Investigations carried out in 2011.................................................................................57 6.2 - Recommendations made..............................................................................................58 6.3 - Follow-up action planned by the recipients..................................................................58 6.4 - Overall summaries of investigation reports published in 2011.....................................58 7 - INVESTIGATIONS CARRIED OUT: SKI LIFTS..................................................................67 7.1 - Investigation carried out in 2011...................................................................................67 7.2 - Recommendations made..............................................................................................67 7.3 - Follow-up action planned by the recipients..................................................................67 7.4 - Overall summary of the investigation report published in 2011...................................68 APPENDICES...........................................................................................................................71 Appendix 1: List of accident and incident investigations carried out since 2002.................73 Appendix 2: Investigations opened in 2011..........................................................................79 Appendix 3: Monitoring of the implementation of recommendations issued by BEA-TT in the railway transportation field..........................................................................87 Appendix 4: BEA-TT organisational chart as at 1 September 2012...................................127 Appendix 5: Institutional texts.............................................................................................129 Glossary ➢ CMVOA: French Ministerial Unit for Operational Monitoring and Alerts, Ministry for Ecology, Sustainable Development and Energy ➢ CGEDD: French General Council for the Environment and Sustainable Development ➢ CNO: French Railways National Operations Centre ➢ COGIC: French Operational Centre for Inter-ministerial Crisis Management, Ministry for the Interior ➢ DGITM: French General Directorate for Infrastructure, Transport and the Sea ➢ DSCR: French Road Safety and Traffic Directorate ➢ RO: Rail Operator ➢ EPSF: French Railway Safety Authority ➢ IM: Infrastructure Manager ➢ HGV: Heavy Goods Vehicle ➢ LC: Level Crossing ➢ STRMTG: French Agency for Mechanical Ropeways and Guided Transport Systems ➢ TMD: Transport of Dangerous Substances ➢ LV: Light Vehicle 7 A review of 2011 Sixteen investigations were concluded, with two intermediate reports formulating immediate safety recommendations; 59 recommendations were made, which for the most part were accepted by their recipients; and 17 new investigations were opened – these are the figures that characterise the activity of BEA-TT in 2011. The activity level was particularly sustained, and was higher than in previous years. But apart from these quantitative data, four actions had a particular impact on the work of BEA-TT and mobilised its teams during the past year. Firstly, several inquiries required detailed technical investigations that helped extend the knowledge available. Determining the causes of the braking incident that caused a freight train derailment in Bully-Grenay, analysing the likelihood of trams being derailed on impact with road vehicles, and clarifying the mechanism by which an LPG tanker's outlet cover broke causing a fire on a motorway, were the most significant examples. Secondly, four investigations concluded in 2011 involved tram line operations. Supplementing the three investigations on this mode of transport already completed since 2002, these identified a series of avenues for progress that were discussed at a seminar for the operators involved, which was organised in collaboration with the French Agency for Mechanical Ropeways and Guided Transport Systems (STRMTG). In addition, the overturning of the mini tourist train of Notre-Dame-de-la-Garde, Marseille, in May 2010, following two similar accidents in other cities over the two previous years, stimulated reflection about the specific safety issues relating to the operation of this type of passenger transport. This led to recommendations for a series of actions designed to improve control by both the competent authorities and transport workers. Finally, five investigations were opened between February 2011 and January 2012 into accidents or significant incidents affecting the operation of ski lifts. In addition to the audits conducted by STRMTG, these should provide a perspective on safety management in the sector based on a detailed analysis of concrete events. These various actions illustrate BEA-TT's efforts to fulfil its missions better and better by developing its investigative capacity, structuring the scope of its inquiries and promoting the value of its recommendations to transport and safety professionals. I invite you to read this activity report which gives an account of the investigations carried out in 2011 and the lessons learnt from them. In the name of all the BEA-TT investigators and on my own behalf, I would like to repeat my thanks to everyone who contributes to and supports the work done by