Investigation Body for Railway Accidents and Incidents Report - Safety Investigation An Infrabel agent was struck by an SNCB/NMBS-train Neufvilles - 20 November 2017 May 2018
REPORT VERSION TABLE Version number Subject of revision Date 1.0 First version 29/05/2018 2 Any use of this restricted report with a different aim than of accident prevention - for example in order to attribute liability - individual or collective blaim in particular - would be a complete distortion of the aims of this report, the methods used to assemble it, the selection of facts collected, the nature of questions posed and the ideas organising it, to which the notion of liability is unknown. The conclusions which could be deduced from this would therefore be abusive in the literal sense of the term. In case of contradiction between certain words and terms, it is necessary to refer to the French version.
1. SUMMARY At approximately 10:45 a.m. on Monday 20 November 2017, a team of 4 agents from the infrastructure manager (I-AM directorate), having completed their work of lubricating railroad switches and ES inspections, were making their way back to their vehicle, walking in a line along the tracks of line 96, at a short distance of the Neufvilles unmanned stopping point. At approximately 10:45 a.m., the passenger train E15809, an empty train with two Desiro electrically-powered rail cars, was travelling towards its departure station (Mons-Aviation) along line 96. The route of train E15809 takes the secondary track, through railroad switches 09AE and 09BE. As the train was proceeding along the secondary track and approaching the agents, the driver initiated an emergency brake procedure. The first agent was within the track gauge and was hit by the train. The driver made an alarm call using the GSM-R. 3
2. BASIC INFORMATION 2.1. NATURE OF THE EVENT An Infrabel agent was struck by an SNCB/NMBS-train. 2.2. DATE AND TIME OF THE EVENT Monday 20/11/2017 around 10:50 a.m.. 2.3. PLACE OF THE EVENT Neufvilles, Line 96, Kilometre marker 40220. The accident occurred as the train was going along the secondary track at a place called "Neufvilles- Garage". Location of the accident (source: Infrabel). 4
2.4. TRAIN The SNCB/NMBS-train is an empty passenger train with the number E15809. It consists of two electrically-powered rail cars of the AM 08 Desiro -type (nos. 08078 + 08550). The route of the train E15809 connects the station of Braine-le-Comte to that of Mons-Aviation. Rail car of train E15809 stopped on the secondary track. 5
2.5. VICTIM The seriously injured agent was transported to hospital. 2.6. CONSEQUENCES No material damages to rolling stock or infrastructure. Several trains were delayed. 2.7. WEATHER CONDITIONS Rain with slight breeze Temperature: 10 C. 2.8. TYPE OF EVENT AND SAFETY INVESTIGATION The on-duty investigator was notified of the accident by Traffic Control and drove to the site of the accident. The accident does not meet the criteria for classification as a serious accident 1. According to subparagraph 2 of article 111 1 of the law of the 30 August 2013 relating to the Rail Code, the Investigation Body (IB) can investigate accidents and incidents that, in slightly different circumstances, would have caused serious accidents. The IB decided to launch a limited investigation. 6 1 Article 3 of the law of the 30 August 2013, relating to the Rail Code: 1 "Accident": an unforeseen, adverse or unintentional event, or a specific sequence of events of the same nature, with negative consequences: accidents are disaggregated in the following types: collisions, derailments, accidents at level crossings, accidents involving persons caused by rolling stock or vehicles moving on a railroad, fires and other incidents; 2 "Serious accident": any train collision or train derailment causing at least one fatality or seriously injuring at least five persons, or causing significant damage to the rolling stock, the infrastructure or the environment, or any similar accident that has clear consequences on rail safety regulations or management; the term significant damage is used to describe damage that can be immediately assessed by an investigation body to total at least 2 million euros;
3. ANALYSIS 3.1. WORK AND MOVEMENT OF THE INFRABEL TEAM OF AGENTS On the day of the accident, a team of agents from the infrastructure manager (IO-AM directorate) was conducting lubricating work on the railroad switches and ES inspections. The inspection and integrated lubrication of switches and crossings are routinely carried out on all operating switches and crossings of the Infrabel network 2. Inspection and lubricating work must occur at any moment when there is no rolling stock on or in the direction of the switches and crossings. The purpose of lubrication operations is to reduce friction between metal parts and prevent rust from developing. The team has the skills required for the rail signalling specialisations. According to a guideline governing the organisation of this work and the make-up of teams, the team includes the following members 2 : 1 team leader: Track Work (primary) technician or Track Maintenance technician who coordinates activities and records anomalies in the relevant inspection log; 1 specialised track maintenance agent or a track adjuster, for the completion of the checklist relating to operations conducted on railroad switches; 1 specialised maintenance agent or one experienced track maintenance agent for the completion of the checklist relating to the Track; 1 or 2 persons in charge of scraping and lubricating side plates, waste disposal and, as necessary, the removal of excess railway ballast for the completion of the checklist relating to Lubrication; a sentry or several sentries required for protection purposes depending on the chosen protection method and the geographic location. However, the Maintenance Manager must take into account the fact that the number of members in the team significantly impacts the protection method. Having consulted the Signalling and Track engineers and the local track technical manager, the Maintenance Manager may derogate from the guideline when deciding on the make-up of the team (RGPS Book 576, Part III, Title IV, Chap. I, Section 2). In accordance with the guideline, the chosen protection method is the presence of a sentry. On the day of the accident, the team consisted of 4 agents, one of whom was tasked with sentry duty during operations. The team conducted the lubrication work on the railroad switches and ES verifications on the switches and crossing of the line 96 ( Braine-le-Comte side with respect to the Neufvilles unmanned stopping point). 7 2 see circular letter 18 I-AM/2015: Integrated inspection and lubricating of switches and crossings.
Shortly before 10:30 a.m., having completed their work, the team members made their way back to the company car (parked in rue Reine de Hongrie see 2.3). For this purpose, the team had to walk along line 96. In accordance with the requirements (RGE 811), Personnel proceeding along tracks must take the service path along the tracks, clear of the danger zone [ ] Unless otherwise authorised for maintenance purposes, personnel must always stay on the indicated tracks and paths Figure showing the danger zone (source: Infrabel Security booklet). The term danger zone is used to describe an area in which: a worker is exposed to the risk of being hit or crushed by a moving railway vehicle; or of losing his/her balance because of the blast of air caused by the passing of a vehicle at high speed. Line 96 features a reference speed of 160 km/h: the safety distance is of 1.5m. According to the General Operating Rules (Book 811 1.4.3.1 Traffic rules): Personnel proceeding along tracks must take the service path along the tracks, clear of the danger zone. Personnel members are not authorised to walk on or between the tracks unless this is absolutely necessary, and in this respect, they must comply with applicable safety regulations; Unless otherwise authorised for maintenance purposes, personnel must always stay on the indicated tracks and paths. An agent is authorised to walk outside the danger zone along a secondary track. However, in certain sections of the path along the Neufvilles-Garage secondary track, vegetation at ground level hinders progress along the path. 8
Photo of the train E15809 stopped on the secondary track after the accident, showing the area where the agents were walking. The General Operating Rules (Personnel protection) also provide the following rules in terms of personnel alertness when walking along the tracks: members of personnel must remain alert to the sound signals emitted by traction units; when members of personnel have heard a sound signal, they confirm to the driver that it has been understood by stopping and turning towards the train, and by stepping aside if necessary. According to their testimonies, the agents did not hear the sound signal of the traction unit. Still according to the General Operating Rules (Book 811 1.4.1): Any person present on or around railroad tracks must wear a high visibility yellow or orange vest or clothing. This is a high visibility vest or jacket with reflective stripes, worn alone or combined with an orange armband. When present on or around railroad tracks, personnel always wears the same equipment: If they are part of Infrabel personnel, they wear a yellow high visibility vest. The 4 agents were wearing yellow high visibility vests, in accordance with applicable regulations. 9
3.2. ANALYSIS OF THE DATA RECORDED ON BOARD THE TRAIN Note: a one-hour time difference is to be taken into account for the data. 9:30 a.m. on the graphs is 10:30 a.m. in reality. u Passage of the train at signal M-E.27 v Service braking initiated by the driver w Emergency braking initiated by the driver 10
The analysis of the data recorded on board the train indicates that: the driver slowed the train down, as expected, as the train was nearing signal M-E.27; the speed of the train at signal M-E.27 was of 38 km/h (less than the imposed 40 km/h); brakes (dynamic braking) were activated at the level of the railroad switches leading to the secondary track; service brakes were activated just after the dynamic braking; emergency braking was initiated 3 seconds later. The analysis of the data recorded on board the train reveals that the driver did not sound the horn ( sound alert in the graphs) during the trip. According to his testimony, the driver thought he had sounded his horn. Driver regulations (HTL II.A.11): The use of the horn is required: case n 4 of the table 5.3 Warning persons on or in the vicinity of the track being used or the adjacent track. 11
3.3. ROUTE OF THE TRAIN Shortly before 10:30 a.m., the passenger train E15809, an empty train with two Desiro electrically-powered rail cars, was travelling towards its departure station (Mons-Aviation) along line 96. Route of train E15809 The route of train E15809 takes it through railroad switch 09AE (left position) and 09BE (left position) where it is directed onto the secondary track ("Neufvilles-Garage"). The train E15809 travels on the secondary track to prevent rust from developing on the secondary track. A rails covered in rust situation can occur if the service track remains unused for 72 hours. When a rail is covered in rust, this situation 3 : jeopardises the detection of motion by the track circuits or by insulated rails (e.g. block sections, itineraries, areas of automatic level crossing passenger announcements...); and may cause: o the early opening of an itinerary; o the late closing and/or the early opening of an automatic level crossing; o the undue opening of an occupied section or of an occupied track portion. For the purpose of preventing such a situation from occurring: the capacity manager (I-TMS) establishes regular train routes so as to prevent, on the primary tracks and their connection, any track circuit or insulated rail to remain unused for more than 72 hours; for the purpose of local and daily operations, the traffic control agent ensures that there is sufficient circulation frequency on all of the switches and crossings in his/her area of operations. According to their testimony, the agents were not aware that a train would take that route on the day of the accident. 12 3 Cf. General Operating Rules 731.1 2.1
4. CONCLUSIONS Having completed their lubricating and ES inspection work on the switches and crossings of line 96 between Neufvilles and Jurbise, a team of 4 agents of Infrastructure Manager Infrabel was returning to their service vehicle. The 4 agents were walking in a line along the Neufvilles-Garage secondary track, outside the danger zone. However, in certain sections of the path along this secondary track, vegetation at ground level hinders progress along the path. At the same moment SNCB/NMBS-train E15809, an empty passenger train, was travelling along line 96 towards its departure station (Mons-Aviation). The train and the team of 4 agents were going in the same direction. The route of the train takes the Neufvilles-Garage secondary track. To prevent rust from developing on the rails, the infrastructure manager must ensure that a train travels on the service tracks once every 72 hours. The designated route forces the train to take the switches leading to the secondary track at a maximum speed of 40 km/h. The analysis of the data recorded on board the train confirms that the driver reduced the speed of the train down to 38 km/h at the signal in rear of the railroad switch and that he failed to use his horn to warn people walking next to the railroad track he was travelling along. The train continued to decrease its speed when passing the railroad switches. Going in the same direction as the train, the agents did not see the train travelling down the track next to which they were walking. The first agent of the line, unaware of the presence of the train, was hit by the train. 5. MEASURES TAKEN Following the accident, the infrastructure manager and the railway undertaking had a meeting to discuss the situation. Several measures were taken in the wake of the accident: by the railway undertaking: reminding all the drivers of the importance of using a horn when personnel is in the vicinity of the tracks. by the infrastructure manager: o reminding all those concerned of the importance of maintenance work on service paths along the tracks. These operations were scheduled in Neufvilles; o reminding the agents of proper practices to observe when a train is passing, by sharing testimonies during a safety conference/agent training session; o reminding the agents of proper practices to observe when a train is passing, by sharing a Safety Flash; o transmission to the Infrabel Occupational Safety committees of the comprehensive report relating to the serious work accident and the Safety Flash; o discussion relating to the accident at the Infrabel Occupational Safety Desk; o discussion relating to the accident on the Infrabel Entrepreneurs platform. 13
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