Transport Accident and Incident Investigataion BureauTransport Accident and Incident Investigataion Bureau
 
 
 
 

Investigation report No.1/2010 of railway accident

Collision of a freight train with a railway crane occurred on 16/12/2009

 

The accident occurred on Wednesday 16 December 2009 at about 12:20 hrs in the railway line Indra – state boarder (kilometre 446 picket 2).

The railway crane was unloading and fitting up stairs on the newly constructed railway road embankment. The parts of railway crane were turned towards railway in the direction of rolling stock on the parallel line. The working place wasn’t fenced and signalmen weren’t appointed, that is why no one noticed the freight train approaching on the parallel line. Noticing the railway crane, the train driver applied breaking, but it was too late and he couldn’t avoid collision.

As the result of collision serious damage was done to diesel-electric locomotive, seven empty tanks, and little damages main road, and newly contracted road in the accident place. The railway crane was totally damaged and isn’t repairable. Railcar and rail-platform got little damages.

The elimination of accident consequences was done by infrastructure manager. Environment wasn’t polluted, because rail tanks were empty, and the fuel tanks of locomotive and railway crane weren’t damaged at all. The train traffic was closed for almost 8 Hrs. There were no fatalities and injured persons in this accident.

Direct Cause of the Accident

The direct cause of the accident was the failure of “RKF Transceltnieks” Ltd to cordon off the work site and to assign signalmen, as a result of which a railway crane collided with a freight train.

Underling Causes

Representatives of “RKF Transceltnieks” Ltd, who drew up and handed in the project application, had not provided the necessary safety measures at the work site.

Engine drivers were not warned about the assignment of a railway crane to the railway section under construction; engine drivers had become accustomed to ongoing repairs to the railway section, which had continued for a long period of time, and thus were not on alert.

The foreman of “RKF Transceltnieks” Ltd did not inform the infrastructure management company’s railway technician about the commencement of construction work on the given railway section.

Root Causes

“RKF Transceltnieks” Ltd does not adhere to the requirements of the existing traffic safety internal monitoring system regarding the planning and enforcement of safety rules, regular job planning and the monitoring of work progress.

The existing regulations do not provide that the infrastructure management company’s station duty officer must inform the infrastructure management company’s railway technician about the commencement of work by a third party on a railway section.

Description of measures taken or being planned

After the accident, the State Railway Technical Inspectorate carried out unscheduled technical inspections at “RKF Transceltnieks” Ltd and “LDZ infrastruktūra” Ltd. More than 40 violations and shortcomings were established at “RKF Transceltnieks” Ltd, which dealt with a faulty system of internal monitoring of traffic safety (Recommendation No. 2010-1).

“Latvijas dzelzceļš” State Joint Stock Company – the railway infrastructure management company – plans to issue new instructions, “On the Procedure of Distribution and Use of Technological Slots in Train Schedule for the Performance of Repairs and Construction Work on the Railway, Engineering and Technical Facilities, Overhead Lines, and Signalling, Centralisation and Interlocking Equipment”.

The State Railway Technical Inspectorate has suggested amendments to the Cabinet of Ministers Regulation No 616 of 23 August 2005, “Procedures for Issuing, Suspending or Revoking a Safety Permit”, in order to step up the requirements of the system of internal monitoring of traffic safety for commercial undertakings that apply for safety permits.

Safety Recommendations

Recommendation 2010-1

“RKF Transceltnieks” Ltd must examine the suggested system of internal monitoring of traffic safety and make sure that it is efficient, that the procedures provided therein ensure that relevant safety requirements are properly observed in order to guarantee safety of its operations and perform regular monitoring of work progress, carry out internal checks and document them, as well as organise regular technical and qualification-raising courses for its employees.

Recommendation 2010-2

The infrastructure management company – “Latvijas dzelzceļš” State Joint Stock Company – must introduce requirements (criteria) for the applications for railway repairs and construction work in order to ensure that permits for technological slots meet traffic safety requirements.

Recommendation 2010-3

The infrastructure management company – “Latvijas dzelzceļš” State Joint Stock Company – must introduce a new provision in its internal regulations, that the infrastructure management company’s station duty officer must inform the infrastructure management company’s railway technician about work to be performed by third parties at the station or railway sections between stations.

Recommendation 2010-4

“LDZ infrastruktūra” Ltd, the chief contractor of the infrastructure management company – “Latvijas dzelzceļš” State Joint Stock Company – must provide in railway repairs and construction contracts that the infrastructure management company and the chief contractor must ensure that subcontractors adhere to train traffic safety requirements in performing their work.