R2017-02 Collision between shunting unit and wagons standing on the tracks at Kouvola on 21 September 2017

A shunting unit consisting of diesel locomotives, four empty hopper wagons and two container wagons loaded with tank containers containing hydrogen peroxide, on a container car collided with timber wagons standing in the eastern up yard at Kouvola at 9.47 pm on 21 September 2017.

The timber train had arrived in Kouvola on 19 September and was supposed to continue its journey to Kuusankoski on the same day. However, the final leg of the journey was cancelled. The intention was to move the wagons to their destination station on the afternoon of 21 September, but the train was cancelled and the wagons were left to await a further transfer to track 843 of the railway yard on the night between 21 and 22 September.

Two shunting foremen were working in the shunting unit, taking turns to drive the locomotive by remote control. The shunting order being used gave instructions for the six wagons to be taken from Soramäki to the vacant track 843 at its eastern end. From Soramäki, route for the shunting unit was made to shunting signal 0823 in the direction of track 225.

The transfer to track 843 was accomplished as a pushing movement. The shunting foreman in the locomotive drove the locomotive by radio control and the shunting foreman on the wagon controlled the shunting movement via a radio telephone connection. After the signal had changed, the shunting foreman driving the locomotive used radio control to set a maximum speed request for the system of 35 km/h. As he saw the shunting unit turn towards the track with the standing timber wagon after the switch, the shunting foreman on the wagon shouted the signal red into the radio telephone. The shunting foreman driving the locomotive performed an emergency brake with the radio control. Despite the braking, the speed did not drop by much before the collision. The shunting foreman on the wagon jumped off the wagon before the collision. The shunting unit collided with the timber wagons at a speed of 26 km/h. In the collision, the central buffer coupling of a hopper wagon struck a tank container on a container wagon, upon which the hydrogen peroxide in the tank container poured out. The collision caused a short circuit, which cut the power from the overhead contact wire in the Kouvola entry railway yard.

An emergency call about the accident was recorded at 9.50.32 pm. The caller stated that the location was the entry railway yard and that the rescue department would know the place. No actual street address was given. The emergency duty officer created an assignment code for an accident of medium severity involving dangerous goods at the Kouvola railway station. Rescue Department units moved into the vicinity of the railway station. The on-call fire chief requested a precise address from the traffic controller, but the traffic controller was unaware of the accident at that point. The units moved towards the scene of the accident on the basis of the address details. The on-call fire chief requested the disruption of traffic and power in the railway yard, and raised the assignment code to high severity. Units were added to the assignment and the on-call officer at the Kymenlaakso Rescue Department was alerted. A situation centre was established at the Kotka Fire Station.

Two sectors were formed at the accident site. The first sector was for chemical diving, leak management and fluid pumping. The second was for isolating the accident area, investigating the nearby area, monitoring the spread of the vapour cloud and cooperating with the police. The rescue department contacted a company which manufactures hydrogen peroxide, which provided suitable pumping gear. The hydrogen peroxide left in the tank was pumped into containers brought from the company.

The shunting foreman on wagon in the shunting unit during the accident was injured. The first hopper wagon viewed from the locomotive was the worst damaged in the accident. The last hopper wagon of

the shunting unit, the second container wagon and the tank containers on the second container car were damaged. In addition to the wagons on the shunting unit, the first wagon of the timber wagons was damaged. Of the track equipment, one sleeper and an overhead contact wire were damaged. As a result of the accident, around 11,000 litres of 40.1% hydrogen peroxide solution poured into the ground. The accident caused EUR 110,500 in costs. 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 accident caused delays for the Allegro train from St. Petersburg to Helsinki and ten freight trains travelling in the Kouvola area.

The chain of events leading to the accident originated in the cancellation of the transfer of timber wagons on the afternoon of 21 September. The root cause of the accident was the failure to notify the change of destination track for the wagons in the shunting unit. Upon entering the railway yard, the crew of the shunting unit did not notice that the destination track was occupied. This was partly due to the difficulty in identifying the tracks in the dark railway yard. The shunting movement that ended in the collision was performed at too great a speed. When it was noticed that the destination track was occupied, nothing could be done to prevent the collision. The shunting foreman acting as an observer in the wagon did not have a radio control unit. With a radio control unit, he might have been able to perform emergency braking a little faster, but this would not have prevented the collision. If the shunting movement had been performed at the permissible speed of 20 km/h, this would have left more time for braking after the danger of collision had been detected. In such a case, both the collision speed and damage would have been reduced. In addition, braking would have been faster if the shunting foreman on the locomotive had performed emergency braking with the locomotive’s emergency stop button rather than by radio control. The investigation revealed that, in the radio control system used in locomotives of this kind, there is a two-second delay in all commands. In addition, there is no separate emergency stop button on the radio control unit.

There was a major difference in the level of experience between the shunting foremen working on the shunting unit. They were working in the shunting unit as shunting foremen of the same level, but the shunting foreman with three months of experience would have needed the guidance of a more experienced colleague and advice on the correct and safe way to perform shunting work.

It was observed that rolling stock training for shunting foremen at the training institution was too focused on rolling stock for passenger transport. In addition, there is currently no way of engaging in supervised practice in using radio control and communication devices at the training institution. For this reason, the correct procedures may remain unclear. This can be seen, for example, in the use of incorrect communication tools in shunting work.

Work guidance forms a major part of the training of shunting foremen. This is mainly done as part of normal work in the railway yard. A single trainee can have several work guidance instructors; in this case, they had nine. Work guidance may be insufficient due to lack of time, and there is no guarantee that all of the issues are covered when there are several occupational instructors. 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.

There are no written instructions on performing and reporting track changes. Furthermore, there is no verification that such procedures have been completed. Lack of an operational model and assignment of responsibility pose a serious safety risk in railway yards. Because a number of shunting operators work in the yards, they must have consistent practices.

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. No addresses had been entered for the yard in the emergency centre system. The railway yard employees had not been instructed on the use of emergency service routes when making an emergency call. Even the Emergency Response Centre was unaware of the emergency service routes and had no instructions to ask the caller about them.

In order to avoid similar accidents in the future, the Safety Investigation Authority recommends that the Finnish Transport Safety Agency (Trafi) ensure the implementation of the following recommendations:

1. When approving safety management systems and persons who are responsible for the verification of personnel skills, the Finnish Transport Safety Agency ensures that their skills verification methods are sufficient and that skills verification is reported accordingly. Finnish Transport Safety Agency should provide instructions to training institutions in the railway sector on the creation of evaluation reports, and monitor their use.

2. Training institutions in the railway sector include simulator training in the training programme for shunting foremen.

3. 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.

4. The Finnish Transport Safety Agency require that the radio control units used for shunting work have a separate non-delayed emergency stop button.

5. The Finnish Transport Safety Agency begin monitoring the practical implementation of safety management systems.

The Safety Investigation Authority also recommends the following:

6. The Emergency Response Centre add numbered emergency service routes for railway yards to its system, and emergency duty officers be instructed to locate the accident site primarily through such routes.

Additionally, the Safety Investigation Authority will open a recommendation in the investigation report C10/2003R, which is intended for the Finnish Transport Agency and is currently in the ‘“Not to be implemented" status:

Railway yard tracks should be equipped with number plates.

R2017-02 safety recommendations (pdf, 0.38 Mt) R2017-02 conclutions (pdf, 0.47 Mt) R2017-02 report (in Finnish) (pdf, 3.76 Mt) Data summary (pdf, 0.01 Mt)

 
Published 1.6.2018