The investigation of the rail traffic accident which occurred in Kouvola, Finland, on 21 September 2017 is complete – safety recommendations for the prevention of similar incidents
The safety investigation of the collision of a shunting unit with a timber train standing in the Kouvola railway yard on 21 September 2017 has been completed. As a result of the accident, one person was injured and around 11,000 litres of hydrogen peroxide solution leaked into the soil. In addition, significant material and financial damage was caused.
The shunting unit collided with loaded timber wagons standing in the eastern railway yard in Kouvola. The shunting unit consisted of a diesel locomotive, four empty hopper wagons and two container wagons loaded with hydrogen peroxide. In the collision, the central buffer coupling of a hopper wagon struck a tank container on a container wagon, from which the hydrogen peroxide solution poured out. The collision caused a short circuit, which cut the power from the overhead conductor at the Kouvola railway yard. To determine the environmental impact of the accident, a groundwater pipeline was commissioned by the South East Finland ELY Centre and installed on the northern side of the site of the accident. No deviations have so far been detected in the samples taken from the pipeline.
The root cause of the accident was the failure to notify the change of destination track for the wagons in the shunting unit. The crew of the shunting unit was acting according to its shunting instructions and moving wagons to the eastern end of an empty track. The shunting unit was not notified of a track change following the cancellation of the departure of a timber train on the track on the same afternoon. The investigation revealed that there are no written instructions on making and reporting track changes, and no responsibility is assigned for them.
The shunting movement that led to the collision was performed at too high a speed, which meant that nothing could be done to prevent the collision after realising that the destination track was wrong. Braking would have been faster if emergency braking had been performed with the emergency stop button of the locomotive rather than by radio control. There is no separate emergency stop button on the radio control unit. In addition, a two-second delay was detected in the radio control system used in these locomotives.
The investigation also involved a review of the training and guidance of shunting foremen. It was found that theoretical training was too narrowly focused on passenger rolling stock. In addition, there is currently no way of engaging in supervised practice in using radio control and communication devices at the training institution. The correct procedures may remain unclear. Work guidance is mainly provided as part of normal work in the railway yard. Work guidance may be insufficient due to lack of time, and it is not ensured that all of the issues are covered. It was observed that the verification of skills at the end of the training, i.e. the documentation of the skills demonstration, was restricted to pass/fail, which gives no indication of the employee's ability to work independently.
The investigation also found that radio-controlled locomotives are involved in collisions and near-miss situations, some of which are not reported to superiors. This is due to the sanction procedure used by the investigated railway operator. The investigation revealed that there may be large differences between the practices described in the safety management system and those used in practice. Official supervision is insufficient to ascertain whether an enterprise is operating in the manner described in the safety management system. The initiation of rescue operations was slowed by problems in locating the site of the accident. The work was affected by the fact that no addresses had been entered for the yard in the emergency centre system. The rescue operation went smoothly once the rescue services had found their way to the scene of the accident.
Recommendations for improving rail traffic safety
The Safety Investigation Authority recommends that the Finnish Transport Safety Agency (Trafi) When approving safety management systems and persons who are responsible for the verification of personnel skills, the Finnish Transport Safety Agency ensures that their skill verification methods are sufficient and that skill verification is reported accordingly. The work guidance instructor must document the competencies of the trainee after each shift. Likewise, the trainee must evaluate the outcome of his or her training. The employer must arrange sufficient time for the instructor and trainee to perform evaluations directly after each shift. Work guidance forms a major part of the training of shunting foremen. Trainee competencies are not sufficiently ensured, because the monitoring of work guidance does not give a true picture of the competencies of trainees.
Secondly, the Safety Investigation Authority recommends that training institutions in the railway sector include simulator training in training programmes for shunting foremen. The simulator should allow the use of different types of radio control units. Practice with different types of communication equipment should be enabled. KRAO's training does not include the possibility of practical training in the use of radio control or communication equipment. Guided training on a simulator would improve the preparedness of trainees for work.
Thirdly, the Safety Investigation Authority recommends that the Finnish Transport Agency draw up written instructions for track changes in railway yards and ensure that the operators in the yards act according to the instructions. In addition to the correct working practices, the instructions should include the correct responsible persons and verification of critical functions. Track changes are a daily activity in railway yards. If they are not done correctly and information is not passed onto the relevant parties, there is a high risk of accidents.
The Safety Investigation Authority recommends that the Finnish Transport Safety Agency (Trafi) require that the radio control units used for shunting work have a separate non-delayed emergency stop button. As a direct measure, the instruction should be given to use the emergency brake using an emergency stop button on the locomotive. The radio control system of the locomotives responds slowly to the driver's commands. There is no separate emergency stop button on the radio control. The delay in the radio control system slows the start of emergency braking in critical situations.
In addition, the Safety Investigation Authority recommends that the Finnish Transport Safety Agency begin monitoring the practical implementation of safety management systems. Supervision should mainly be performed by interviewing randomly selected employees engaged in practical work, and comparing the information received from them with the content of the company's safety management system. Near misses and minor collisions, which are not revealed, occur in the case of radio-controlled locomotives. Users do not dare to report such incidents, due to fear of sanctions. There is no way of learning from near misses and collisions involving radio-controlled locomotives, which hampers the development of the safety of radio-controlled work. In the railway sector, safety management systems remain at the level of target setting, because their implementation is virtually unsupervised by public authorities. In addition, there is little self-supervision.
The Safety Investigation Authority recommends that the Finnish Transport Safety Agency ensure the implementation of the above-mentioned recommendations.
The Safety Investigation Authority recommends that the Emergency Response Centre add numbered emergency service routes to its system, and that emergency duty officers be instructed to locate the accident site primarily through such routes. In order to be able to use emergency service routes in the event of an accident, it should be ensured that they are marked individually in railway yards and that workers in the railway yards know where they are.
Emergency service routes are marked in the rescue plans for VAK railway yards (transport of dangerous goods), along which routes into the area are planned in case accidents occur. However, these routes are largely unknown to the Emergency Response Centre Administration, and this could hamper and delay access to the accident site.
In addition to the new safety recommendations, the Safety Investigation Authority will open Recommendation C10/2003R, intended for the Finnish Transport Agency, in the ‘Unimplemented’ status in the investigation report. According to the recommendation, tracks in railway yards should be equipped with number plates. Several railway yards have not been equipped with clearly visible track numbers at the ends of tracks. Identifying the destination track can be difficult and it may come as a surprise that the track is reserved. Track numbers can be installed in the electrical track portal crossing the railway yard, for example.
Esko Värttiö, Chief Rail Safety Investigator, tel. +358 295 150 708