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IC4 Train Set Passed Signal at Danger at Marslev

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IC4 Train Set Passed Signal at Danger at Marslev 30.08.2013 REPORT IC4 train set passed signal at danger at Marslev HCLJ 611-2011-23. Incident SPAD Train operation Date: 07.11.2011 Time: 15:17 Place: Marslev Infrastructure manager: Rail Net Denmark Railway undertaking: DSB (Banedanmark) Personal injury: None Through independent surveys, the Accident Investigation Board in Denmark will make recommendations to prevent accidents and incidents in rail and aviation in the future. The Accident Investigation Board in Denmark does not place blame and liability. The Danish edition is the current version. Page 2 of 46 1 Summary .................................................................................................................................................... 3 2 Facts ........................................................................................................................................................... 4 2.1 Description of the accident......................................................................................................................... 4 2.1.1 Date, time and location of the incident ...................................................................................................... 4 2.1.2 Description of the events and the accident site .......................................................................................... 4 2.1.3 The accomplishment of the investigation .................................................................................................. 4 2.2 The settings ................................................................................................................................................ 5 2.2.1 Involved staff and contractors and other parties and witnesses ................................................................. 5 2.2.2 The trains and their composition ................................................................................................................ 6 2.2.3 Signals and interlockings ........................................................................................................................... 7 2.2.4 Works carried out at or in the vicinity of the site ....................................................................................... 8 2.3 Fatalities, injuries and other damage .......................................................................................................... 8 2.3.1 Passengers, staff and other involved parties............................................................................................... 8 2.3.2 Rolling stock, infrastructure and the environment ..................................................................................... 8 2.4 External circumstances .............................................................................................................................. 8 2.4.1 Weather conditions .................................................................................................................................... 8 2.4.2 Geographical references ............................................................................................................................. 8 3 Investigations ........................................................................................................................................... 10 3.1 Summary of testimonies ........................................................................................................................... 10 3.2 The safety management system ............................................................................................................... 10 3.3 Safety regulations ..................................................................................................................................... 11 3.4 Functioning of rolling stock ..................................................................................................................... 12 3.4.1 Adhesion/friction in general ..................................................................................................................... 12 3.4.2 Quality of wheels/material ....................................................................................................................... 12 3.4.3 Brakes in general ...................................................................................................................................... 13 3.4.4 Authorisation of IC4 train sets in general ................................................................................................ 15 3.4.5 Standards for testing brake systems under slippery conditions ................................................................ 19 3.4.6 Authorisation of MG 5627 as an individual train set ............................................................................... 19 3.4.7 Data recording .......................................................................................................................................... 20 3.4.8 Other investigations ................................................................................................................................. 25 3.4.9 Test of brake computers ........................................................................................................................... 28 3.5 Traffic safety ............................................................................................................................................ 30 3.6 Man-machine-organisation interface ....................................................................................................... 31 3.7 Occurrences of a similar character ........................................................................................................... 33 4 Analyses and conclusions ........................................................................................................................ 36 4.1 Final account of the event chain............................................................................................................... 36 4.2 Analysis (discussion) ............................................................................................................................... 37 4.3 Conclusions .............................................................................................................................................. 40 4.4 Additional observations ........................................................................................................................... 40 5 Measures already taken ............................................................................................................................ 42 6 Safety recommendations .......................................................................................................................... 43 7 Definitions and explanations .................................................................................................................... 44 Page 3 of 46 1 Summary On Monday 7 November 2011, L 47 passed an AM signal (automatic block signal) at danger at Marslev by 651 metres. The train which was a single-operated IC4 train set used approx. 2,800 metres to brake from a speed of 180 km/h to a standstill. The train stopped 374 metres behind the freight train ahead of it. Shortly after the incident, the Accident Investigation Board was notified about three other incidents where the engine driver had experienced problems or irregularities with a train of that type. The investigations showed that the brake system generally worked according to applicable standards, but that applicable standards did not cover all conditions that were expectable in daily operation (very low adhesion). The investigations also showed that the functionality of the brake system during brake applications under very low-adhesion conditions led to the wheels blocking and the distance travelled not being recorded correctly. Several physical and software-related (parametric) faults were found in the brake system in connection with the further investigations. Tests of brake computers and the Wheel Slide Protection (WSP) system showed that the WSP system was not able to identify the actual speed (bring the reference speed back up to the actual speed) when the brakes were applied under low-adhesion conditions and thus prevent the wheels from blocking, and that the train was not able to identify the distance actually travelled and the actual speed of the train.. Against this background, the Accident Investigation Board made the following recommendations: . The European Rail Agency (ERA) must ensure that applicable international standards for approval of brake systems for rolling stock are revised so that the accumulated functionality of the brake system is documented in all applications of the rolling stock, including under adhesion conditions that must be regarded as probable in daily operation. The Danish Transport Authority (Trafikstyrelsen) must ensure that applicable national standards for approval of brake systems for rolling stock are revised so that the accumulated functionality of the brake system is documented in all applications and under all operating conditions and adhesion conditions that must be regarded as probable in daily operation. The Danish Transport Authority must ensure that the braking power is documented in all applications of the rolling stock, including the adhesion conditions which may be expected to prevail in daily operation . The Danish Transport Authority must ensure that the IC4 train
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