Investigation Body for Railway Accidents and Incidents

November 2015

RESTRICTED SAFETY INVESTIGATION REPORT

Sideswipe collision between two passenger trainsin Arlon on 15 September 2010

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Any use of this restricted report with a different aim than of accident prevention - for example in order to attribute liability - individual or collective blame in particular - would be a complete distortion of the aims of this report, the methods used to assemble it, the selection of facts col-lected, 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 nec-essary to refer to the French version.

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On Wednesday 15 September 2010, a sideswipe collision took place between the train entering and the train leaving Arlon station. The incident was made possible by the unauthorised departure of a passenger train following an incorrect mental representation by the driver. No serious injury or fatality occurred. Normal traffic resumed at the station on 16 September at 16:39, several trains were cancelled, others were partially cancelled.

On Wednesday 15 September 2010, the passenger train E5937, composed of a double motor coach of type AM961, was travelling on line 162 from Luxembourg to Arlon.At 17:53, the train pulled into the station with around 1 minute delay and stopped on track III.After a change of end, the passenger train was to depart in the direction of Luxembourg station.

The driver had to change cabin to be able to depart in the direction of Luxembourg and carry out various operations linked to this change of direction, including changing the position of the reverser to allow the conductor to close the door at the time of departure.

The time allowed for the change of driver’s cab is 6 minutes.

On 16 September 2010, the SNCB/NMBS carried out a simulation of the time necessary to carry out the operations: the time recorded was 5 minutes and 20 seconds. According to the service in charge of SNCB/NMBS drivers, this time cannot be reduced further without risking putting pressure on operators on the ground. The arrival with one minute delay to the planned timetable leaves 5 minutes for the driver to change end, or about 20 seconds less than the time calculated.

Before the departure of a passenger train, various operations must be carried out. According to the RSEIF/VVESI2, the railway undertaking should determine the procedures to be applied by their personnel and potentially equip their stock with provisions for:

• attracting the attention of passengers before the closing of the doors;• carrying out and monitoring the closing and locking of the doors;• carrying out and monitoring the removal of the retractable steps;• checking that no passengers are stuck in the doors or on the steps and if so then intervening

safely.

According to the railway undertaking’s procedures, operations are carried out by the train manager/conductor:

•Around twenty seconds before the theoretical time of departure, the conductor blows his whistle;

•he then climbs aboard to close all the doors, except his own;• he steps back down onto the platform to operate a box which signals the end of disem-

barkation and boarding operations simultaneously. From this moment, the signal box can change the signal for the driver at any time3;

•he goes back on board, in theory waits for the first half turn of the wheels before closing “his” door.

1 AM 96 : 96 type motor coach2 RSEIF/VVESI Safety Rules for Railway Infrastructure Operation3 The command for opening the signal by the signal box is not conditioned by the disembarkation and boarding operations.

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Considering the imminence of departure, passengers are no longer allowed to board, including by this final open door. When departing from tracks equipped with IOT4 (completed operations indicator), the informa-tion on completed operations (OT) is given using light units.

The light units:• are composed of a box with a ring of six white or yellow lights arranged around a red light;• are normally switched off;• are normally operated using one of the command boxes placed at intervals on the platform.

The red light goes on after the command box operation.

White or yellow lights:• replace the red light on the double condition:

• that an interval of 10 seconds, in the present case, has passed since the command box operation;

• that the departure signal or marker authorises departure in major movement or that, when the distance announced in major movement by the following signal is insuffi-cient, the departure signal authorises the departure in minor movement;

• are extinguished when the departure signal or marker changes to danger.

Illumination of the white or yellow lights involves OT information.

Several raised IOTs are situated on the platform of track III including one at the end of the plat-form. A ground mounted IOT is placed after the platform on track III.

In general the track exits possess large signals at danger on each of the tracks.In the present case, leaving tracks III and IV in the direction of Luxembourg is done via the simplified signals ey.III and ey.IV which are both coupled to the main stop signal EY.96 on a portal structure.

The signal ey.III is a simplified ground mounted stop signal to the left of the track. It is not equipped with any equipment on the ground.

This configuration5 would be due to a lack of space to install a main stop signal on each of the tracks.

4 IOT : information d’opération terminée (completed operation indicator)5 This configuration existed in several places on the network in accordance with regulations.

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The simplified stop signal may have two functions:

Stop Passage allowed

Passage prohibited Passage in major or minor movement allowed without change of type or regime

The signal EY.96 is a main stop signal in operation and is placed on a portal structure situated at BK 198208, with a crocodile.

The various IOTs found on the platform are coupled functionally to the small simplified stop signal ey.III.

The small simplified stop signal is functionally coupled to the signal EY.96.

The IOT lamp switches on via a relay. Without stimulation, there is no contact and the lamp remains switched off. The logic of coupling the IOT to the signal was verified by Infrabel via the electrical diagram. The tests confirm that it is not possible to illuminate the white lights of the indicator without the EY.96 signals and ey.III being on passage allowed.

At the time of the events, the Arlon control room was equipped with an optical control panel (OCP) which shows the information on the condition of the outdoor components (points, sig-nals, occupation of the tracks, etc.), on the journey routes made by the convoys and their posi-tion, by indicating the schedule, the occupation and release of routes. In the absence of com-mand of aspects of the track circuit, the signals and track switches are turned off.

There is no recording of the routes scheduled by the signaller. The off-status images of the track circuits, signals and track switches are the standard form. When the signaller presses the push button on the schedule he wants to create, the route lights up on the OCP6. The signals included in the route light up in red. The route is provisionally immobilised. A push selection button is necessary to record the command requiring control of the points in the correct position in order to carry out the route.

At this moment and when the conditions for coupling are fulfilled, the signals are controlled on opening. The signals included in the route light up in white.According to a photo taken by the infrastructure manager on the day of the accident, no route was lit up for the train leaving Arlon station (E5919). The lamps of the signal EY.96 were extin-guished.

This is in accordance with the logic of the system. The interlocking of the route of the train (E5888) which was entering the station via track IV prevented the opening of the signals ey.III and EY.96.Therefore, we can conclude that the signal EY.96 was closed.

6 TCO : tableau de contrôle optique (optical control panel)

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The departure of passenger trains with a conductor is dependent on the following conditions:• receipt by the driver of the “Terminated Operations” (OT) information;• compliance by the driver with information given by the signals, by an overrunning order

or by one of the authorisations provided for.

The “Completed Operations” information (OT) alone received by the driver does not constitute an order to depart.

In the present case, the signal EY.96 at danger means that the coupled small signal ey.III is also at danger and that the white lamps on the IOT rosette are switched off.

A reconstruction took place several days after the accident under the closest possible conditions to the evening of the accident. The following remarks were made:

• the aspect of the first raised IOT facing the driver is visible but the sun could disrupt this visibility. When the sun is in a low position it gives the impression that certain lamps on the rosette are illuminated.

• the aspect of the simplified stop signal ey.III was not visible in the area of AM departure when the train is at a standstill.

• the visibility of the main stop signal EY.96 is disrupted by the catenaries up to more or less 50 metres before the said signal.

The driver of the passenger train confirmed having seen the door light illuminated as well as the white lamps of the IOT rosette; he started the train. He began adjusting the service radio, that he hadn’t had the time to restart before. The driver was experienced with a valid licence and various certificates.

According to our hypothesis, the door light being illuminated influenced the driver’s impression of the situation. According to the “normal” mode (frequent), the door light illuminates when the lights on the IOT rosette are illuminated. The influence of the sun on the rosette lights and the non-visibility of the simplified stop signal from the driver’s cab in the train stopped at the sta-tion, supported the driver’s incorrect mental image.

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When he raised his head, he saw the ground signal was at danger (red) followed by a main sig-nal at danger. According to the study of the Teloc strip, the driver travelled 146 metres before engaging the emergency brake. The speed of the passenger train was then around 22km/h. The train came to a stop between the simplified ground mounted signal and the main stop signal. Despite the emergency brake, the train was in the gauge of the adjacent track.

7 Photo from the extract of the SNCB/NMBS report in Annex 1

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The passenger train (E5888) entered Arlon station. The train was switched over to track IV. It was running at around 40km/h. The driver of the train saw the train in the track gauge and engaged the emergency brake. The cornering of the two trains was inevitable, the speed of the train at the moment of impact was around 36km/h. The train driver launched the radio alarm and called Traffic Control.

There were no serious injuries or fatalities.An advanced medical post was put in place in the concourse of Arlon station and was visited by 63 people.

Eight people were transferred to hospitals in the region for various tests.In total 22 passengers and a train driver suffered bruises in the accident.

The material damage to the infrastructure was light and caused by the derailment of one of the motor coaches: a few railway sleepers had to be replaced, as well as some cables.

The leading car AM 502 of the train, which was entering Arlon station, was damaged in the collision.Following the impact, there was a rupture to the coupling between the two motor coach-es that made up the train.

The leading car AM506 of the train leaving Arlon station was damaged in the collision.The two axles on the first bogie derailed.

Following the accident, railway circulation was suspended between 15 and 16 September at Arlon station. Normal traffic resumed on 16 September at 16:39.Several trains were cancelled, others were partially cancelled.

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MESURES TAKEN

INFRABELThe stop signal ey.III seems to have been hit prior to the accident, having been pushed back-wards and turning the light beam towards the catenary.This impact had not been reported and the technical services were not aware of it.

The simplified ground mounted signals on tracks III and IV were replaced by new signals with the optimal orientation re-established.The signal ey.III will be raised to the edge of the gauge and the shape of the track will be re-viewed so that visibility is not compromised (for example in case of heavy snow).

So as to improve visibility of the IOT, Infrabel decided to replace the IOT with more efficient IOTs with LED lights.

When block 96 was taken over in EBP by block 74 in Libramont on 01/04/2013, the simplified stop signals ey.III and ey.IV were replaced by two main stop signals equipped with the TBL1+ system.

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SNCB It was decided that the time allocated for carrying out the change of direction at Arlon station should be extended by 1 minute.Drivers were reminded to depart only after finalising the operations for changing direction.

Regular reminders are given to drivers to emphasise the risk of overrunning a signal at the origi-nating station.In addition, driver support by management personnel has been strengthened and monitored to ensure that they correctly apply regulations. Specific checks of drivers by the hierarchy are also monitored. The objective of checks is regu-larly updated. Any overrunning of a signal is analysed to determine the causes and, if need be, the necessary corrective measures are taken (reminder to drivers, request to alter signals, etc.).

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ANNEX: INFLUENCE OF THE SUN ON IOT

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Investigation Body for Railway Accidents and Incidents

http://www.mobilit.belgium.be