Transport Accident and Incident Investigataion BureauTransport Accident and Incident Investigataion Bureau
 
 
 
 

Investigation report No.1/2009 of serious railway accident

Two freight train collision on 20 December 2008 in Ventspils station

 

            Serious railway accident (hereinafter - accident) occurred 20 December 2008 at 9.29 a.m. in the Ventspils station park „station Ventspils-II” (hereinafter - Ventspils-II).

            At 9.29 a.m. freight train No.2445 (locomotive 2TE10M-3453 and 59 loaded wagons) entered Ventspils-II railway track No.2 from Elkskenes station side, which at that time was occupied with standing freight train No.1703 (locomotive 2TE10M-3422 and 61 loaded wagons). As a result locomotive of train No.2445 collided with last wagon of train No.1703.

            As result of collision the crew (2 people) of locomotive of train No.2445 died, locomotive of train No.2445 and its first two wagons, 8 wagons of train No1703 loaded with fuel and six wagons standing on the way No.3 burst into flames. As result of fire the locomotive of train No.2445 was completely damaged (not repairable), 21 wagons damaged (13 wagons not repairable) and completely destroyed freight (fuel) from three wagons.

            After collision the rolling stock of train No.2445 cover around 40m until complete stop place. Last three wagons of train No.1703 were released from rolling stock to the direction of railway track No.1 and five wagons derailed with two wheel pairs. Also locomotive of train No.2445 and four wagons derailed - in movement direction from twentieth to twenty third (two with two wheel pairs and two with all wheel pairs).

            Five meters behind exit signal light P2 of railway track No.2 to direction of accident site (48 meters before collision place) traces of sand feed were detected, which testifies about possible sudden use of brakes before the collision or about the work of automatic brakes.

            Human remains of machinist were found in the diesel room of lead section „A” of locomotive above compressor KT7, human remains of machinist assistant - outside locomotive on the left side of train movement direction at the fuel tank of section „B”.

            In the cabin of train locomotive was guard, which sustained light bruise and left cabin of locomotive on his own.

            As result of collision and fire locomotive of train No.2445 was completely damaged, speed measuring tape was burnt, speed measuring instrument melted due to high temperature, control devices of locomotive and control devices of alertness were completely damaged and to detect its condition until the moment of collision is not possible. The scheme of train collision is shown in Picture 1.

            Infrastructure manager for the prevention of the consequences of accident involved fire-fighting train of Ventspils station and assistance train of Jelgava station. The quenching of fire was lead by Ventspils brigade of State Fire and rescue service.

            Train traffic along railway track No.5 resumed at 23.30 20 December 2008. Prevention of the consequences of accident were completed at 14.10 21 December 2008, but the works for reconstruction of infrastructure were completed at 12.00 24 December 2008.

 

 

            Direct cause of accident

 

            The direct cause of accident was human mistake: crew of the locomotive of the train No.2445 had lost vigilance and did not control the train, as a result of which the train passed by entrance signal light N of Ventspils-II with restrictive signal and collided with freight train No.1703 standing on the railway track No.2.

 

 

            Contributing factors

 

-         from experts opinion can be concluded, that crew of locomotive of train No.2445 had lost vigilance and leading the train disregarded communication regulation – did not repeat mutually signals of traffic lights;

-         Ventspils-II stationmaster did not warn machinist of train No.2445 about holdup at the entry traffic lights;

-         Ventspils – Jelgava section railway traffic controller due to intensive train traffic, did not have complete information about occupation railway track in Ventspils-II;

-         Ventspils – Jelgava section railway traffic controller did not manage to take rapidly  the right decision, when Ventspils-II station master on duty on the telephone asked the help to resolve the nonstandard situation occurred;

-         due to uncoordinated conduct of Ventspils Nafta-Austrumu park station master on duty  occurred situation that two trains from opposite directions were approaching Ventspils-II, but only one railway track was free;

-         Ventspils-II station master on duty was new employee and the accident day for her was only seventh day without any assistance, therefore she did not have enough skills how to act in nonstandard situations;

-         Railway section Ventspils-Tukums-II is not equipped with uninterrupted type automatic locomotive signalling devices, therefore in this section train driver’s vigilance control devices operates only in time mode, but is not connected with signals of traffic lights.

 

 

Safety recommendations

 

Recommendation 2009-1

 

            For infrastructure manager – State Joint Stock company „Latvijas dzelzceļš” should consider possibility to ensure main lines (1520 mm) railway infrastructure with automatic locomotive signalling (coding of rail circuit) devices.

 

 

Recommendation 2009-2

 

            For railway operators – should consider possibility to equip locomotives of freight and passenger train main lines (1520 mm) with  train drivers vigilance control devices, which operates not only periodically requesting the confirmation of train driver, but also stops the train, if it has passed the restrictive signal, but which operation should allow:

 

  • to control continuously the capacity for work of train driver;
  • to stop the train, if the speed would not be in due time reduced when approaching the traffic lights with restrictive signal.

 

 

Recommendation 2009-3

 

            For „LDZ Cargo” Ltd. and other operators - should carry out the audit of its safety management system with purpose to improve efficiency of this system, paying particular attention to observation and control of the mutual communication regulation of train drivers and their assistants.

 

 

Recommendation 2009-4

 

            For infrastructure manager – State Joint Stock Company „Latvijas dzelzceļš” should update procedure how station master on duty or railway traffic controller delivers in time information, using radio communication, to train driver concerning the holdup of train at traffic lights, unexpected stop or in other nonstandard cases.