DERAILMENTS AT RANDSTADRAIL The Hague, November 2008 (project number M2006RV1129-04) The reports of the Dutch Safety Board are public. All reports are also available on the website of the Dutch Safety Board www.safetyboard.nl DUTCH SAFETY BOARD The Dutch Safety Board has been established with the responsibility to investigate and establish what the causes or probable causes are of individual or categories of incidents in all sectors. The sole aim of such an investigation is to prevent future accidents or incidents and if the results of this should give cause to do so, to attach recommendations to this. The organization consists of a Board with five permanent members and has a number of permanent committees. Specific advi- sory committees are formed for specific investigations. A professional staff supports the Dutch THE Safety Board. Board Rail Committee Chairman: Prof. Pieter van Vollenhoven Chairman: J.A. Hulsenbek Vice chairman J.A. Hulsenbek Vice-chairman: dr. ir. J.P. Visser A.H. Brouwer-Korf1 mr. F.G. Bauduin Prof. F.J.H. Mertens ir. L.H. Haring2 Dr. J.P. Visser drs. R.W.M. van den Heuvel A. van den Berg: did not ir. J.F.M. Kitzen participate in this investigation2 prof. Ir. D.P. Rookmaaker drs. F.R. Smeding drs. W.A. Vriesendorp Additional member: Prof. R.E.C.M. van der Heijden (Road Traffic Committee) General M. Visser Secretary: Project leader: R.H.C. Rumping Visitors address: Anna van Saksenlaan 50 2593 HT The Hague The Netherlands Correspondence address: PO Box 95404 2509 CK The Hague The Netherlands Telephone: +31 (0)70 333 7000 Fax: +31 (0)70 333 7077 Internet: www.safetyboard.nl 1 A.H. Brouwer-Korf joined the Dutch Safety Board on 1 February 2008. 2 Due to their involvement as a supervisory director and employee, respectively, of HTM and pursuant to Sec- tion 15, subsection 2 opening words under c of the Dutch Safety Board Act (Rijkswet Onderzoeksraad voor Veiligheid), Ms A. van den Berg and Mr L.H. Haring did not participate in the investigation into the Randstad- Rail derailments. Ms A. van den Berg left the Dutch Safety Board on 1 December 2007. CONTENTS Considerations................................................................................................................. 5 List of terms and abbreviations ...................................................................................... 12 1 Introduction ........................................................................................................ 19 1.1 Reasons for the investigation ...................................................................................19 1.2 Purpose of the investigation .....................................................................................20 1.3 Scope and method of the investigation ......................................................................21 1.4 Reader’s guide .......................................................................................................21 2 Factual information about RandstadRail ............................................................. 23 2.1 The RandstadRail transport system ...........................................................................23 2.2 The RandstadRail project .........................................................................................24 3 Assessment framework ....................................................................................... 29 3.1 Legislation and regulations ......................................................................................29 3.1.1 Intermunicipal Statutory Regulations Act.........................................................29 3.1.2 2000 Passenger Transport Act .......................................................................29 3.1.3 Railways Act and legislation and regulations governing city trams .......................30 3.1.4 1875 Railways Act ........................................................................................31 3.1.5 Primary and Secondary Railways Service Regulations .......................................32 3.1.6 Secondary and Tram Railways Act ..................................................................33 3.1.7 Dutch Civil Code ..........................................................................................33 3.1.8 General Terms and Conditions governing City and Regional Public Transport Services .....................................................................................................34 3.1.9 Working conditions legislation ........................................................................34 3.2 Standards and guidelines ........................................................................................34 3.2.1 Normative Document for Light Rail Safety .......................................................34 3.2.2 Regulations relating to an Independent Safety Assessor (ISA) ............................35 3.2.3 Technical standards for railways and city trams ................................................35 3.3 Assessment framework for safety management ..........................................................36 4 The parties involved and their responsibilities .................................................... 37 4.1 The Haaglanden Urban District and Rotterdam City Region ...........................................37 4.1.1 Project structure for the realisation of RandstadRail ..........................................38 4.1.2 Role as principal for the realisation of RandstadRail infrastructure ......................40 4.1.3 Role in the purchase and approval of rolling stock ............................................42 4.1.4 Role as principal for transport (concession grantor) ..........................................42 4.1.5 Role as principal for infrastructure management...............................................43 4.1.6 Role of the ISA engaged by the Haaglanden Urban District and Rotterdam City Region .................................................................................................44 4.2 Municipality of The Hague ........................................................................................44 4.2.1 Role as a member municipality of the Haaglanden Urban District ........................44 4.2.2 Role as a contractor for the preparation and construction of RandstadRail infrastructure in Haaglanden jurisdiction .........................................................44 4.2.3 Role as shareholder/owner of HTM .................................................................45 4.3 HTM and RET .........................................................................................................45 4.3.1 Role as railway undertaking (concession holder) ..............................................46 4.3.2 Role as RandstadRail infrastructure manager ...................................................48 4.3.3 Role as supervisors of the construction of railway technology .............................48 4.4 Ministry of Transport, Public Works and Water Management .........................................48 4.4.1 Role as policymaker and provider of funds .......................................................48 4.4.2 Role as permit provider ................................................................................49 4.4.3 Role of the Inspectorate for Transport and Water Management as supervisor .......49 5 Analysis of derailments at RandstadRail ............................................................. 51 5.1 Overview of RandstadRail derailments .......................................................................51 5.2 Derailment on a switch at Forepark ...........................................................................52 5.3 Derailment in a curve at Ternoot ..............................................................................55 5.4 Derailments near The Hague Central Station ..............................................................57 5.5 Derailments on openable switches in The Hague city tram network ...............................59 5.6 From derailments to safety management ...................................................................60 5.6.1 Derailment on a switch near Forepark .............................................................60 5.6.2 Derailment in the curve at Ternoot .................................................................61 3 5.6.3 Derailments near The Hague Central Station....................................................61 5.6.4 Derailments on openable switches ..................................................................62 6 Analysis of RandstadRail safety management ..................................................... 63 6.1 Safety management of HTM .....................................................................................64 6.1.1 Use of insight into risks as the foundation for safety policy ................................65 6.1.2 Demonstrable and realistic safety policy ..........................................................65 6.1.3 Implementation and enforcement of safety policy .............................................66 6.1.4 Management control, involvement and communication ......................................67 6.1.5 Refinement and tightening of safety policy ......................................................69 6.2 Safety management of the municipality of The Hague (RandstadRail Project Bureau).......69 6.2.1 Safety management system ..........................................................................69 6.2.2 Trial operation and transfer ...........................................................................70