Date of occurrence Location name O Porriño (Pontevedra) Local time 09:25 Latitude Railway vehicle movement events Train derailment.

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1 -5165 Occurrence Summary What Location Date of occurrence Location name O Porriño (Pontevedra) Local time 09:25 Latitude Event type Railway vehicle movement events Train derailment Longitude Description Passenger train derailment and collision, at the entrance of Porriño station Direct Cause descrip The derailment was caused by an excess of speed of the train when passing the diverted switch at the entrance of Porriño station. Previous signals had ordered the train to slow down, but the driver didn t comply with those orders, although he confirmed reception. Evidence and tests have ruled out any failure in signals, brakes or visibility, so most likely cause was a human error in signals interpretation. However, this is not concluding, because of the lack of recordings in cabin and direct witnesses (driver himself and train guard were among the fatalities). Some hints point to a possible distraction (previous incompliance of a speed limit, possible presence of the train guard in the cabin). Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo 1903 Full PDF / final File 3286 / repor 9 9-IF- t 1:41: CIAF (Spa 04.pdf nish PM versi on) 0 What Title Train derailment, , O Porriño (Pontevedra) (Spain) Occurrence type Railway vehicle movement events Train derailment Occurrence Class Serious accident Date of occurrence Local time 09:25 Events Railway vehicle movement events - Train derailment Railway vehicle movement events - Trains collision - Trains collision with an obstacle ERAIL-REP PUBLIC 1 Sunday, April 21, 2019

2 -5165 Descriptions Description Passenger train derailment and collision, at the entrance of Porriño station Location name O Porriño (Pontevedra) Railway System type Railway Country Spain Location type Station Border Country Line type Single track Line number 810 Allowed line speed Km number 151,9 Latitude Longitude Location description Additional location in Location type details Fixed installations Occurrence details Railway vehicles Movement type Regional passenger train Train number RU Train speed at mom Vehicle description Spain RENFE Other objects involved in the occurrence Other objects Parties involved IM Involved Spain - ADIF RU Wagons overturned Passengers onboard Spain - RENFE Passengers Staff Level crossing users Unauthorised persons Others Total Fatalities Serious injuries Minor injuries ERAIL-REP PUBLIC 2 Sunday, April 21, 2019

3 -5165 Material consequences Material Damage Estimated total mate < Damage description Images Name Description Type Size Last modified Organization Repository 0 Causation Causes Direct Cause description The derailment was caused by an excess of speed of the train when passing the diverted switch at the entrance of Porriño station. Previous signals had ordered the train to slow down, but the driver didn t comply with those orders, although he confirmed reception. Evidence and tests have ruled out any failure in signals, brakes or visibility, so most likely cause was a human error in signals interpretation. However, this is not concluding, because of the lack of recordings in cabin and direct witnesses (driver himself and train guard were among the fatalities). Some hints point to a possible distraction (previous incompliance of a speed limit, possible presence of the train guard in the cabin). Underlying and root causes description Routine habits and low frequency of travelling could have influenced the driver s behaviour. The driver only drove this section once every 3-4 weeks, in a different country with different rules and signals. Moreover, those times he drove, situation was always the same: 25 km with no stops nor diversions, with several speed restrictions that didn t apply to this train ( simply go ahead ). This, combined with the low frequency of travelling, could have led to a poor consolidation of knowledge about line, a wrong risk perception and a possible habit-based driving, prone to a lower level of attention to signals. Moreover, signals beacons that warned to slow down were positioned amidst other beacons with trivial messages (speed restrictions that didn t apply to this train), so (in the described situation of lower level of attention) they could have been confused with those trivial warnings (although this beacons arrangement was not against rules, it has been modified). This combination of factors (possible habit-based driving + possible distraction + sub-optimal beacons arrangement) could have caused the wrong response to the instructions of the signals. On other matters, the train was diverted by the IM for checking a track circuit, according to a usual practice. However, this procedure is not properly defined in the SMS and it has traceability issues. Risk management in this situations has to be solved. Causation classification Railway vehicle movement events - Train derailment Railway vehicle movement events - Trains collision - Trains collision with an obstacle ERAIL-REP PUBLIC 3 Sunday, April 21, 2019

4 -5165 s title 41/16-1: prevent 'habit-based' driving REC End implementer RU texts s text Prevent habit-based driving through drivers training contents. title 41/16-2: line knowledge improving by increasing travel frequency REC End implementer RU texts s text Increase the frequency of service of the allocated drivers, and the number of accompanied travels, in order to consolidate line knowledge. ERAIL-REP PUBLIC 4 Sunday, April 21, 2019

5 -5165 title 41/16-3: Risk Assessment updating. REC End implementer RU texts s text Update the Risk Assessment of this service, considering the findings of this investigation and newest regulatory framework. title 41/16-4: create guides for a correct risk assessment. REC End implementer NSA texts s text Elaborate guides for correct risk assessment (by RUs) in international services, specially considering human factor and findings of this investigation. ERAIL-REP PUBLIC 5 Sunday, April 21, 2019

6 -5165 title 41/16-5: create an adequate procedure for checking of track circuits by using trains. REC End implementer IM texts s text Elaborate an adequate procedure for track circuits checkings with RU s trains, with coordination protocols, clear responsibility allocation and traceability. ERAIL-REP PUBLIC 6 Sunday, April 21, 2019

7 -5165 title 41/16-6: cabin audio recording and front cameras for investigation purposes. REC End implementer RU texts s text Study the options for installation of cabin audio recording and front cameras, for investigation purposes. Causation links Railway vehicle movement events - Train derailment Railway vehicle movement events - Trains collision - Trains collision with an obstacle Investigation details Legal Basis Other reason descrip National rules imposed by implementing of the Safety Directive 2004/49/EC - in light of Article 19, 1 of SD National investigatio Occurrence creation :23:24 Investigator in charge Decision to investigate Declaration date Date of IM/RU notific Report Type Final report Workflow Status Waiting for validation ERAIL-REP PUBLIC 7 Sunday, April 21, 2019

8 -5165 Report Version 3 Investigation Status Open Other Attachments Name Descriptio Type Size Last Organizati Repositor 0 Final Report Name Descriptio Type Size Last Organizati Repositor Full final PDF File /16/ IF- report 1:41:04 CIAF.pdf (Spanish PM version) ERAIL-REP PUBLIC 8 Sunday, April 21, 2019

AS STANDARD

AS STANDARD AS 1319-1994 STANDARD SAFETY SIGNS FOR THE OCCUPATIONAL ENVIRONMENT COMPLIES WI TH THE ST ANDARDS AUST RAL I A COMMITTEE INDU ST RI AL WARNI NG SIG N S Safety Signs are crucial in any work environment.