Report of the railway accidents

investigated in 2016

Tallinn 2017

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Public railways in the Republic of Estonia

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Preface to the report

The railway accident investigation unit of the Ministry of Economic Affairs and

Communications was established in Estonia on 31 March 2004 in order to begin

conducting railway accident safety investigations pursuant to the European

Parliament and Council Railway Safety Directive 2004/49/EC. A multimodal Safety

Investigation Bureau was formed at the same ministry on 1 January 2012.

The existing Estonian classification of cases affecting railway safety (accident,

serious accident and incident) matches that of the Railway Safety Directive

2004/49/EC. There were no serious accidents in the reporting year. The Safety

Investigation Bureau is obligated to conduct a safety investigation under the

circumstances stated in the Railways Act.

The legislation of the Republic of Estonia specifies the guidelines for conducting

safety investigations which are in accordance with the requirements set out for

European Union member states by the Safety Directive. Safety investigations are

independent from other investigations of given cases and their aim is increasing

railway safety and decreasing the number of railway accidents.

Due to sudden temperature changes that took place at the end of 2015 / beginning of

2016 there were several track breakages; the Safety Investigation Bureau examined

the circumstances of these and drew up their position. No safety investigation was

launched about these cases.

For several years now, the Safety Investigation Bureau’s investigator of railway

accidents has been participating in Central European and Nordic regional railway

accident investigation working groups.

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Contents

Public railways in the Republic of Estonia 2

PREFACE 3

CONTENTS 4

1 INTRODUCTION TO THE INVESTIGATION BODY 5

1.1 Legal basis 5

1.2 Role and aim 8

1.3 Organisation 11

1.4 Organisational flow 11

2 INVESTIGATION PROCESSES 14

2.1 Cases to be investigated 14

2.2 Institutions involved in investigations 15

2.3 Investigation process and approach of the Investigation Body 16

3 SAFETY INVESTIGATIONS 19

3.1 Overview of completed investigations 19

3.2 Safety Investigations completed and commenced in 2016 20

3.3 Surveys completed in 2016 20

3.4 Summary of the safety surveys completed in 2016 21

3.5 Comments on investigations 24

3.6 Accidents and incidents investigated during the past five years

(2012-2016) 25

4 RECOMMENDATIONS 27

4.1 Short review and presentation of recommendations 27

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1. Introduction to the Investigation Body

1. Legal basis

Legal basis for investigating railway accidents in Estonia was created by The

Railways Act which came into force on 31 March 2004. At the same time, the

European Parliament and Council Directive 2004/49/EC on Railway Safety came into

force in the European Union member states. At this point the cooperation between

the investigation unit created at the Ministry of Economic Affairs and Communications

and the European Union Agency for Railways was not sufficiently defined. For

example, there was no obligation to forward information or investigation reports about

the cases investigated to the Agency. An amendment in legislation on 2 March 2007

aligned the cooperation between the investigation unit and the European Union

Agency for Railways with the concept of the Directive.

Before 1 January 2012, in chronological order of their formation, a Unit for

Investigation of aviation accidents, a Unit for Investigations of railway accidents and a

Unit for Investigation of maritime accidents were operating at the Crisis Regulation

Department of the Ministry of Economic Affairs and Communications. In order to

improve the management of safety investigations of all three modes of transport and

coordinate the work, necessary amendments were made to the Aviation Act, Maritime

Safety Act and Railways Act and as a result a new structural unit was formed -

Estonian Safety Investigation Bureau (ESIB).

The independence and procedures of the safety investigations of the Estonian Safety

Investigation Bureau, which is a structural unit of the Ministry of Economic Affairs and

Communications, have been specified by the 1 April 2014 wording of the Railways

Act. According to Subsection 42 (1) of the Act, the ESIB conducts safety

investigations of accidents, serious accidents and incidents. The ESIB is independent

in conducting safety investigations and is guided only by law and other legislation

and any international treaties that are binding in Estonia. There is no supervisory

control of the ESIB’s investigative activities. Independence of the Safety Investigation

Bureau is also ensured by organisational measures. Subsection 48 (2) of the Aviation

Act provides that the director of the ESIB is appointed and relieved of its duties by the

Government of the Republic on the recommendation of the relevant ministry. The

ESIB officials are appointed and relieved of their duties by the director of ESIB. The

Safety Investigation Bureau has an independent budget that has been approved by

the Parliament of the Republic of Estonia in the State Budget Act of 2016 with item

code 20SE07004.

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The ESIB’s activities and connection with the ministry are specified by the Safety

Investigation Bureau Statutes which require that the ESIB is accountable to the

Secretary General and the Minister when using the Ministry’s ancillary services. The

Statutes specify that the Ministry does not have the right to give orders or tasks to the

ESIB which hinder the independence of safety investigation. Neither does the

Ministry have the right to demand information from the ESIB that compromises the

independence of safety investigation and may hinder any existing or future safety

investigations. When using the Ministry’s ancillary services ESIB is guided by the

statutes of the departments providing the ancillary services and the rules regulating

the ancillary services. The Statutes of the Safety Investigation Bureau which were

approved by the Ministry of Economic Affairs and Communications Directive in 2014

form one part of the legal framework affecting the safety investigations of railway

accidents.

The Safety Investigation Bureau is a permanent structural unit of the ministry with

special rights. The tasks of the investigator-in-charge are performed by the official

responsible for conducting railway safety investigations. The ESIB is functionally

independent from the safety authority and the railways regulating authority. Its

organisation, legal structure and decision making process are independent of any

railway infrastructure managers, railway undertakings, tax collection authorities,

distribution authorities and notified bodies or any other party whose interests might

conflict with the tasks given to the ESIB. By fulfilling the aforementioned conditions,

the ESIB has ensured that its independence is pursuant to Article 21 of the Directive

on Railway Safety 2004/49/EC.

The framework for the investigations of railway accidents and incidents is provided by

Article 4 of the Railways Act “Railway traffic and safety” and related legislation. The

most important sections covering the legal nature of safety investigations are Section

42 of the Railways Act “Safety investigations of accidents, serious accidents and

incidents” and Section 43 “Safety Investigation Reports“. The subject of the safety

investigation is specified by Section 40 “Cases affecting railway safety”. There are

two regulations directly linked to the processes of safety investigation, these are

“Safety investigation procedures” and “Procedures for providing written notification of

accidents, serious accidents and incidents and format of written notifications and

reports”. Legislation provides delegation authority for enforcing the directives.

Subsection 42 (3¹) of the Railways Act provides that the railway infrastructure

managers or railway infrastructure possessors and railway undertakings have the

task of immediately notifying the Safety Investigation Bureau of an accident, serious

accident or incident. Notifying the Safety Investigation Bureau of these occurrences

has been specified by The Ministry of Economic Affairs and Communications

“Procedures for notifying of accidents, serious accidents and incidents and the format

of the written notices and reports”. Pursuant to Subsection 2 (1) of the Directive the

immediate first notification of the occurrence will be made by the infrastructure

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manager to the ESIB via means of public communication. The same infrastructure

manager presents a notification to the ESIB within three working days of the

occurrence in specified format. Pursuant to Subsection 2 (2) of the Directive the

same infrastructure managers make an immediate notification of an incident via

email. A written report of an incident must be presented within three working days

only if the ESIB requests additional information.

Subsection 42 (2) of the Railways Act provides the ESIB’s right to involve experts to

clarify circumstances which require specialist knowledge and form committees. The

experts involved in a safety investigation and the committee take part in the

investigation under the supervision of the official conducting it. Authorities and third

parties involved in a safety investigation are obliged to offer necessary assistance to

ESIB within their competence and produce any information they hold related to the

incident.

The Safety Investigation Bureau may issue a safety alert during the investigation. A

safety alert is issued when circumstances and facts come to light during the

investigation of the incident that are important to more than one railway infrastructure

manager or railway undertaking, one or more European Union member states. The

safety alert includes only facts and descriptions but no recommendations or

assessments and is issued to those concerned and the European Union Agency for

Railways. Issuing a safety alert is legally provided by Subsection 42 (11²) of the

Railways Act.

The Safety Investigation Bureau must conduct the safety investigation of an accident,

serious accident or an incident in the shortest possible time and publish a report of its

results pursuant to Subsection 43 (1) of the Railways Act - “Safety Investigation

Reports”. The investigation report is published without delay and no later than within

12 months of the occurrence. The report is forwarded to all those involved such as

the railway infrastructure managers, railway undertakings, the safety investigation

body of another European Union member state, victims and their families, owners

and manufacturers of damaged property, Rescue Board, representatives of the

employees and passengers and the European Union Agency for Railways.

Estonian Technical Regulatory Authority, other authorities, businesses or

organisations that were subject to the ESIB’s recommendations, submit a report to

the ESIB on the status of the proceedings and results by the 1st April of the following

year.

A Ministry of Economic Affairs and Communications Directive No 72 “Safety

Investigation Procedures” that came into force on 6 April 2014 covers the multimodal

ESIB’s all three areas of transport. The Directive specifies the objective of a safety

investigation which is to determine the causes of the occurrence and making safety

recommendations to avoid similar occurrences in the future. The Directive

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determines areas of a safety investigation and its coordinator, defines the start of a

safety investigation and notification, formation of a safety investigation committee

and its division of work, procedures for a safety investigation, issuing a safety alert,

the conditions and format of the safety investigation report, closing the safety

investigation, principles of the proceedings of the safety recommendations and

proposals and the format of the report, reopening of the safety investigation and

procedures for registration of the cases being investigated.

The format of railway reports is specified in the annexes of the Directive is in

accordance with the Railway Safety Directive 2004/49/EC annex 5 and the ERA

“Guidance on Safety Recommendations in terms of Article 25 Directive 2004/49/EC”.

1.2 Role and aim

The role of the multimodal Safety Investigation Bureau in increasing the safety of the

Estonian transport system is primarily conducting safety investigations of maritime-

and aviation accidents and incidents as well as railway accidents and incidents via

the proceedings of the results of the investigations by those involved. The aim of the

safety investigations of accidents and incidents is to determine their causes and

circumstances. They discover any connections with traffic safety and make

recommendations for increasing traffic safety. It is the task of the Safety Investigation

Bureau to participate in formulation of legislation related to its areas of activity and if

necessary, make recommendations for amending this legislation. The ESIB also

participates in formulation and implementation of projects, policies, strategies and

development plans related to its areas of activity, and participate in the preparation

and implementation of international projects.

The statute has defined the following obligations for the Safety Investigation Bureau:

1) Complete all its tasks in a timely manner and to a high standard.

2) Ensure the confidentiality of the professional information pursuant to legislation.

3) Utilize any assets and resources that it has been allocated purposefully and

rationally.

4) Ensure it does not violate the principle of independence and confidentiality of the

safety investigation, forward to other structural units of the Ministry information

that is necessary for them to perform their tasks.

The objective of the safety investigations of railway accidents, serious accidents and

incidents is to determine the causes and make recommendations to prevent such

occurrences in the future and not to appoint blame or liability. The objective of the

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safety investigation has been provided by Subsection 42 (3) of the Railways Act and

Section 1 of the Minister’s Directive “Safety Investigation Procedures”.

In order to achieve its role and aim the ESIB has the right to

1) Access documents and information necessary for fulfilling the tasks assigned

to the Safety Investigation Bureau from ministers, secretaries general and

deputy secretaries general, other departments, government authorities within

the jurisdiction of the Ministry and legal persons governed by private law which

are subject to the Ministry’s founding, membership, stockholder or shareholder

rights.

2) Engage employees of other departments in resolving issues within the Safety

Investigation Bureau remit.

3) Receive relevant ancillary services from the Ministry’s departments.

4) Work in cooperation with other government and local authorities and legal

persons governed by private law and make recommendations to form

committees and working groups within its areas of activity.

5) Within limits of its competence, communicate information to other authorities

and persons.

6) Make proposals for contracts required for fulfilling its tasks.

7) Get further training to improve the professional level of the Safety Investigation

Bureau employees.

8) Receive necessary office equipment, resources and literature and technical

and information support.

9) To enter into collaboration agreements with other ministries, government

departments and experts.

While fulfilling its main objective The Safety Investigation Bureau

1) Works in cooperation with other government departments, local government

units, foundations, non-profit associations, business and consumer

organisations, businesses, private persons and respective authorities of other

countries and international organisations.

2) Represents the state in the international organisations related to its areas of

activity.

3) Takes part in fulfilling any duties of the Republic of Estonia pursuant to the

international agreements relating to the ESIB areas of activity.

4) Prepares the draft budget for ESIB and the report on the execution of the

previous year's budget.

5) Develops and implements its development plan and work schedules.

6) Monitors, analyses and assesses the situation in its areas of activity and

informs relevant bodies, Ministry’s departments and other authorities and

businesses of its conclusions.

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7) Performs tests and expert analysis on machinery, engines, equipment, its

details and assemblies and other devices to assess their compliance with

requirements to clarify the circumstances of a case under investigation.

8) Makes recommendations and takes decisions within its jurisdiction provided by

law.

9) Ensures the confidentiality of information containing business and technical

details and personal data if legislation does not provide that it should be

published.

10) Implements measures for witness protection.

11) Performs the duties assigned by legislation as a chief or authorised

administrator of the database of cases investigated.

12) Preserves the items, equipment, assemblies and details in its possession that

are relevant to ascertaining the causes of the occurrence.

13) Organises information days about safety and development activities.

14) Possesses, uses and disposes of public property in its possession in cases

provided by and in accordance with legislation.

15) Advises individuals in matters relating to the Safety Investigation Bureau’s

areas of activity.

16) Performs other tasks assigned by legislation.

The following rights have been established to define the jurisdiction of the official

appointed by the Safety Investigation Bureau to conduct the safety investigation of a

railway accident or incident:

1) Immediate access to the rolling stock, railway infrastructure and traffic control

and signalling devices involved in an accident, serious accident or incident.

2) Restrict unauthorised access to the scene of the accident and prohibit

handling, removing or destroying items from the scene of the accident.

3) Ensure immediate inventory of all evidence and controlled removal of the

wreck, rolling stock, infrastructure equipment or components for investigation

or analysis.

4) Immediate access to the on-board and other recording equipment and their

recordings and to subject them to their control.

5) Immediately receive into their disposal autopsy reports of the casualties and

the results of the analysis of any samples taken from the deceased.

6) Question witnesses and persons who might have important information

regarding the safety investigation and demand confirmation or provision of

information necessary for the safety investigation.

7) Access to all relevant information and documents independently or in

cooperation with the authority conducting the preliminary criminal

investigation.

8) Immediate access to the testimony of persons associated with the occurrence

and to the analysis results of any samples taken from these persons.

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1.3 Organisation

The Safety Investigation Bureau is a structural unit of the Ministry of Economic Affairs

and Communications. The ESIB has a special organisational status and can

therefore perform specific tasks. All other structural units of the Ministry are called

departments and as a rule, do not have any legislative provisions specific to their

work alone. For its work, the ESIB utilizes the Ministry’s ancillary services but is

independent in conducting safety investigations and making any decisions

associated with these. Cooperation with other structural units of the Ministry is in

accordance with the Ministry’s work schedule.

The letterhead, website, logo and a budget that has been approved by the

Parliament all reflect the ESIB’s distinctive organisational nature. Every ESIB official

has a certificate of employment; by presenting this the officials can carry out the

tasks based on the special rights granted to them by legislation.

In 2016 four officials worked at the Safety Investigation Bureau - a director, an

aviation accident investigation expert, a chief specialist in marine accident

investigation and a chief specialist in railway accident investigation.

Only the Safety Investigation Bureau has jurisdiction to make the decision whether to

begin or not a safety investigation of an accident or an incident. The time allowed for

a safety investigation is 12 months during which an investigation report must be

completed. The report is signed by the investigator-in-charge or the members of the

committee, if there is one, and the director of the ESIB. The report is published on the

ESIB website and forwarded to those concerned. Should the safety investigation last

longer than expected an interim report is published after 12 months.

1.4 Organisational flow

Due to singularity of its tasks which require special rights the Safety Investigation

Bureau is more separate and legally independent than the other departments of the

Ministry and any units they incorporate. The Safety Investigation Bureau’s work is

directed and supervised by the Director of the ESIB. Structurally the ESIB forms a

single unit. All ESIB officials are permanent staff members and each one is

responsible for the accurate, lawful and timely completion of the duties assigned to

them.

Each of the Safety Investigation Bureau officials is responsible for conducting safety

investigations of accidents and incidents of only the transport sector that has been

assigned to them. An official conducting safety investigations of accidents within their

area is independent in their activities. If necessary, they will use the officials of other

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areas of transport as assistants in their investigation. If one of the officials is away the

others will cover his work to a certain extent. The Safety Investigation Bureau has a

24-hour telephone service in which the officials are involved in.

Figure 1 The Safety Investigation Bureau in the organisational structure of the

Ministry

Safety investigations of marine-, aviation- and railway accidents in Estonia are

conducted only by the Safety Investigation Bureau. Other investigations and

proceedings related to the accidents and incidents that are being conducted by law

enforcement, surveillance authorities or other authorities, institutions or undertakings

are not related to the safety investigations conducted by the Safety Investigation

Bureau. The timings for these might coincide but the content and results of the safety

investigation do not depend on the content or results of the other investigations.

Estonian Technical Regulatory Authority performs the function of the railway safety

authority as well as regulatory tasks in Estonia. Estonian Technical Regulatory

Authority is an independent in the administration area of the Ministry of Economic

Affairs and Communications with a separate budget, structure and management.

All railway infrastructure managers and rail operators and other undertakings that

manage or own other railway infrastructure or rolling stock are independent

manufacturing enterprises acting as legal persons. The Ministry of Economic Affairs

and Communications is a shareholder for three of them. These are the railway

infrastructure manager Estonian Railways Ltd, railway undertakings AS EVR Cargo

and AS Eesti Liinirongid (Elron). The Estonian state does not participate in the

ownership of the rest of the infrastructure and freight companies. The relationship

Estonian Technical Regulatory Authority

Ministry of Economic Affairs and Communications

Safety Investigation Bureau

Investigation of

marine accidents

Investigation of

railway accidents

Investigation of

aviation

accidents

Department

of Ministry

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between the Safety Investigation Bureau and railway undertakings is regulated by

legal acts and directives.

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2 Investigation processes

2.1 Cases to be investigated

In launching a safety investigation, the Safety Investigation Bureau is guided by the

obligation to investigate as provided by the Railways Act. In Estonia, the classification

of occurrences affecting railway safety is identical to that presented in the Railway

Safety Directive 2004/49/EC; these are an accident, a serious accident and an

incident. Obligation to investigate in the Estonian judicial area is identical to that

provided by the Safety Directive. Estonian legislation uses the same phraseology,

terminology and standards as the Safety Directive.

The Safety Investigation Bureau is obligated to begin a safety investigation in case of

a serious accident. The ESIB has a right to begin a safety investigation if the

circumstances of an accident or incident or similar circumstances might have caused

a serious accident, including significant physical harm to five or more people, at least

one death, also technical failure in the subsystem of the Trans-European

conventional or high-speed rail system or interoperability constituent. In such cases

the Safety Investigation Bureau considers the severity of the case, including from the

pan-European perspective and other important circumstances. The decision of the

Safety Investigation Bureau is based on its previous experience but in its assessment

of a case it also considers applications submitted by a safety investigation body of

another European Union member states, the Technical Regulatory Authority and

infrastructure managers and railway undertakings.

During the reporting year, the Safety Investigation Bureau developed an internal

appendix to The Safety Investigation Manual “ESIB handbook” which lists the

characteristics of a railway accident or incident for making the decision to begin a

safety investigation or formulating an opinion. The ESIB formulates its opinion

depending on whether circumstances come to light which indicate a high potential of

risk of the occurrence, presence of fatalities, breakdown of railway infrastructure

manager equipment, obvious mistake or oversight, when assessing the

circumstances of similar cases, collision with a group of people, depending on the

number of injuries and fatalities.

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2.2 Institutions involved in investigations

Principles of involvement in safety investigations are specified in the Railways Act

and the Directive about the procedures for safety investigations. The principles of

involvement are compulsory to all parties. Infrastructure managers as well as third

parties are obliged to provide assistance to the Safety Investigation Bureau. They are

obliged to present any relevant information in their possession if requested by the

ESIB. If invited by the ESIB, a person is obliged to appear and give testimony about

circumstances known to them. If necessary, the investigator-in-charge works in

cooperation with state and local authorities, undertakings and other persons to utilise

any information or materials they hold in the process of the investigation. If

necessary, the Safety Investigation Bureau may request help from a safety

investigation authority of another country or the European Union Agency for Railways

for their expert knowledge, to perform technical inspections and analysis and give

assessments.

In the spring of 2015, a cooperation agreement was signed between the Police and

Border Guard Board, the Office of the Prosecutor General, the Rescue Board, the

Emergency Centre, and the Safety Investigation Bureau. The purpose of the

agreement was to ensure the coordinated activities of the various authorities when

fulfilling the duties assigned to them by legislation. If criminal proceedings are

initiated in addition to a safety investigation in relation to an accident or an incident,

all parties ensure that the proceedings do not hinder each other. The Emergency

Centre sends a SMS to the Safety Investigation Bureau’s 24-hour helpline. Whenever

possible, the police and the Rescue Board offer their skills in ensuring safety at the

scene as well as conducting investigations after the rescue operations have finished.

All parties allow access to evidence and factual information, except where it is

forbidden by law. It is the decision of the prosecutor’s office whether to share data

collected as part of criminal proceedings. Ensuring access and disclosure of

evidence shall not hinder the safety investigation or criminal proceedings. If

necessary, the parties consult each other and where possible, exchange information.

The parties work in cooperation but the safety investigation and criminal proceedings

are kept separate.

Supported by current legislation, pragmatic cooperation methods have evolved

between the Safety Investigation Bureau and various businesses, authorities,

institutions and private individuals. For example, in order to ascertain weather

conditions, information is obtained from the Estonian Meteorological and Hydrological

Institute, information about casualties from hospitals, etc. The Safety Investigation

Bureau has signed cooperation agreements with the Finnish and Latvian safety

investigation authorities, the northern and southern neighbours respectively.

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With the involvement of other parties, it is the role of the investigator-in-charge to

interpret and integrate the information gathered while drawing up the investigation

report. The investigator-in-charge contacts all the parties involved, listens to their

viewpoints and opinions and before the end of the investigation, presents to them a

summary of the results of the safety investigation. The summary is discussed with the

authorities, businesses, institutions and individuals involved in the case. As a result of

the discussion, the investigator-in-charge prepares the investigation report to be

signed and subsequently published.

Neither the investigator-in-charge nor members of the investigation committee have

ever been part of a police criminal investigation, an internal investigation,

misdemeanour proceedings of the Technical Regulatory Authority or any other

investigation of the given case. Neither have the representatives of these institutions

participated in the safety investigation.

2.3 Investigation process and approach of the Investigation

Body

The Safety Investigation Bureau receives initial notifications of railway accidents and

incidents from two sources. The Emergency Centre notifies the ESIB by email and

via the public 24-hour helpline of all occurrences in air, water and rail that it is aware

of. Railway infrastructure managers and possessors and railway undertakings and if

they have become aware during regulatory activities, the Technical Regulatory

Agency, notify the Safety Investigation Bureau by means of public communication

immediately after an accident, a serious accident or an incident. A written notification

of an accident or a serious accident containing additional information is made to the

ESIB in an agreed format within three working days by the infrastructure manager

that made the initial notification. At the Safety Investigation Bureau request, they

make a written notification of an incident in an agreed format also within three

working days. All written documents received by the ESIB are stored within a digital

document management system.

The initial verbal notification made by the infrastructure manager usually reaches

directly the official dealing with the safety investigations of railway accidents. On

other occasions, the notification is forwarded on by the colleague who received it.

Upon receiving the verbal notification, the case proceedings begin. The official in

charge of safety investigations of railway accidents clarifies the initial circumstances

of the case and, if necessary, will obtain additional information. He makes an initial

assessment based on the Railways Act and the safety investigation manual and

makes a suggestion to the Director of ESIB as to whether to begin a safety

investigation or not. In the case of a serious accident the official notifies the Director

of the Safety Investigation Bureau immediately by telephone. The Director of the

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Safety Investigation Bureau maintains records of notifications received and if

necessary, requests additional information. The Director’s position on whether to

begin or not to begin a safety investigation is final and binding to the official dealing

with the investigations of railway accidents.

Pursuant to the Railway Safety Directive 2004/49/EC and Subsection 42 (8) of the

Railways Act, the Safety Investigation Bureau must decide whether to begin an

investigation or not as a maximum one week after receiving notification of an

accident, serious accident or incident. The ESIB will notify the European Union

Agency for Railways within a week of the decision to begin a safety investigation by

entering the relevant information to the database of the European Union Agency for

Railways.

A Ministry Directive “Safety Investigation Procedures” provides a unified multi-modal

approach for conducting safety investigations of maritime, aviation and railway

accidents. Based on the Ministry Directive, the ESIB Director has approved a “Safety

Investigation Manual” which has been drawn up by the officials. The manual consists

of a generic main part and annexes. The annexes about individual, more specific

activities are either common to all or separate for each mode of transport.

The safety investigation is usually conducted by the official responsible for

investigating railway accidents who will then fulfil the role of an investigator-in-charge.

Once the decision has been taken to begin the safety investigation the investigator-

in-charge informs the relevant parties of the decision, drafts an investigation plan and

sets out to fulfil it. The investigator-in-charge coordinates the gathering, storage and

analysis of data and evidence and the contracting of experts as well as any other

necessary activities.

The investigator-in-charge communicates with natural as well as legal persons via

various methods and means of communication, depending on what is most suitable

at the time. To ascertain the causes and other circumstances of the occurrence the

investigator-in-charge works in active cooperation with victims, state and local

government authorities, businesses and organisations. The more important verbally

forwarded information is recorded; written information is stored within the document

management system. Upon receiving notification of the investigation, the railway

undertakings retain all evidence and details of items, technical circuits, documents,

recordings of the data recording equipment and other information which might be

important in determining the causes of the occurrence. If requested by the

investigator-in-charge, these are presented to him. The Safety Investigation Manual

contains an annex which describes on which occasions direct causes, underlying

causes or root causes are determined by the safety investigation. Only causes that

are relevant to the case are determined by the safety investigation. Information about

the safety investigation is generally issued by the investigator-in-charge, or, by prior

agreement, a member of the investigation committee or the Director of the ESIB. If

there is persistent high risk, a safety alert is made on behalf of the Safety

Investigation Bureau.

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An annex of the Safety Investigation Manual contains instructions how to ensure that

all individuals and parties concerned are heard. The safety investigation is conducted

as openly as possible. The investigator-in-charge turns to those involved to find out

their views and to give them an opportunity to present their attitude, position and

opinions on the proceedings of the safety investigation and its results. The

investigator-in-charge can disclose the details and developments of the safety

investigation to the extent where it does not jeopardize the identification of the

causes of the case and development of recommendations for increasing safety.

Information that has restricted access pursuant to cases specified by The Public

Information Act is not disclosed during or after the safety investigation.

From the point of view of railway safety, it is important to identify the connection

between the company’s safety management and the case under investigation. In

cases that are not related to the management of infrastructure managers, an

assessment is made about the conformity to the principles of the safety management

system with a view to clarify the case and involve them in safety activities. These

principles are covered in the relevant annex of the Safety Investigation Manual.

The investigator-in-charge is responsible for the investigation report to be completed

in a timely manner and in the prescribed format. The recommendations presented in

the report are subject to proceedings by the addressees and the results of the

proceedings are to be presented in a report to the ESIB. The Safety Investigation

Manual contains an annex which directs the investigator-in-charge to exchange

information with the body conducting proceedings while they are taking place.

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3 Safety Investigations

3.1 Overview of completed investigations

During 2016 the Safety Investigation Bureau received 20 initial accident notifications

which is 6 less than in the previous year. The Safety Investigation Bureau listened to

various opinions and assessed the occurrences. Based on their characteristics, none

of the occurrences qualified for a safety investigation and the ESIB only collected

material related to the accident from railway companies and compared the

information contained therein.

During the year the Safety Investigation Bureau received initial notifications of 13

incidents out of which 10 were track breakages. Track breakages on Estonian

railways started at the end of 2015 when there was a sudden drop in air temperature.

The Safety Investigation Bureau did not begin a safety investigation about these as

they did not cause traffic hazards. The ESIB conducted a survey about the track

breakages and published its opinion as a result of this.

Summary of the safety investigations completed in 2016

Table 1

Type of

case

investigated

Number

of cases

Casualties Estimated

losses

(EUR)

Trend

compared

to last year Deaths Seriously

injured

Accident - - - - -

Incident - - - - -

There were no safety investigations completed in 2016.

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3.2 Safety investigations completed and commenced in

2016

During the reporting year there were no situations where a safety investigation of an

accident, serious accident or incident that took place the previous year, remained

open and was completed in 2016.

No safety investigations were completed or commenced during the year.

Safety investigations completed in 2016

Table 2

Date of occurrence

Title of the investigation (Occurrence type, location)

Legal basis Completed (date)

- - i -

Basis for investigation: i = pursuant to the safety directive

Safety investigations commenced in 2016

Table 3

Date of occurrence Title of the investigation (Occurrence type, location)

Legal basis

- - i

Basis for investigation: i = pursuant to the safety directive

3.3 Safety surveys completed in 2016

In the previous years the winters had been mild, with few changes in temperature. In

the early hours of 28 December 2015 there was a sudden drop in temperature and a

few hours later the first track breakage occurred. There were no breakages on New

Year’s Eve or New Year’s Day. By the evening of 05 January 2016 there had been 7

track breakages on the infrastructure of Estonian Railways Ltd, 6 of these in thermit

Annual report 2016

21

welds. These did not lead to any dangerous traffic situations and therefore no safety

investigations were commenced. The Safety Investigation Bureau conducted a

survey about the occurrences, drew up their position which was forwarded to

Estonian Railways Ltd and the Technical Regulatory Authority.

Safety surveys completed in 2016

Table 4

Launch date Name of the survey

Legal basis Completed (date)

02.01.2016 Track breakages on the Estonian Railways Ltd infrastructure during the end of 2015/ start of 2016 ESIB’s opinion

iii 28.01.2016

Basis for survey: iii = voluntary – other criteria (national rules that do not refer to the

Safety Directive)

In addition to Estonian Railways Ltd there were also track breakages on the

Edelaraudtee Infrastruktuuri AS infrastructure after 05 January until the weather

stabilised. Detailed data for the survey was collected about the occurrences that took

place until 05 January.

3.4 Summary of the safety survey completed in 2016

To formulate the ESIB opinion, the survey “Track breakages on the Estonian

Railways Ltd infrastructure during the end of 2015 start of 2016” was conducted

about the incidents that took place at 03:46 on 28.12.2015 between Kabala and

Sonda stations, at 23:00 between Kohtla and Püssi stations, at 05:40 on 30.12.2015

on the 2nd main track of the Reola station, at 07:26 on the 1st main track between

Tallinn-Balti and Järve station, at 08:25 on the 2nd main track between Tapa and

Aegviidu stations, at 15:25 on 02.01.2016 on the 1st main track between Oru and

Jõhvi stations and at 21:55 on 05.01.2016 on the 1st main track of the Veriora station.

Six of the track breakages in question had taken place in thermit welds, out of which

5 had been completed in the summer or late autumn of 2014 or 2015. One thermit

weld had been done in 1998 as part of major repairs to the track. The only contact

weld that broke was completed in 1987.

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The first thermit weld to break was between Kabala and Sonda stations which had

been completed on 08.06.2015. This is described by the following photo:

Photo 1. Track breakage in the thermit weld on 28.12.2015 between Kabala – Sonda

stations km 229 picket 6

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The survey can be summarised as follows:

The track breakages occurred on the porous structure of the thermit welds as a result

of deviation from technological requirements when an increase of internal mechanical

pressure caused by the sudden and extensive drop in air temperature was added to

the usual workload of the weld and consequently led to the cracking and breaking of

the weld.

The requirements for thermit welds or depositing the thermit mix have not been

adhered to and consequently, the thermit is not sufficiently resistant to external

agents.

The company does not have the equipment or appropriate instructions for checking

that the internal structure of the thermit conforms with the guidelines or assessing its

quality.

The company has implemented measures for operational activities in prevention,

detection and elimination of track breakages. The business will develop steps and

measures for ensuring better quality and inspection of thermit works.

The Safety Investigation Bureau considers measures implemented and planned by

the company sufficient to reduce track breakages and does not consider it necessary

to begin a safety investigation about any of the thermit breakages described above.

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3.5 Comments of investigations

In the recent years, safety investigations have been conducted in cases where, in

addition to other relevant conditions being present, there has been at least one

fatality. None of the tendencies regarding changes in the number of fatalities in the

cases investigated can be considered statistically reliable. To date, the number of

fatalities per safety investigation has been one or two individuals.

Total number of deaths and injuries

Table 5

Year Deaths Injured in road vehicle / of them seriously

Injured in rolling stock / of them seriously

2012 - - -

2013 1 - -

2014 2 - 12/-

2015 - - -

2016 - - -

Total 3 - 12/-

Breakdown of the number of injured and deaths over the past five years is shown in

the following table:

Breakdown of the injured and deaths

Table 6

Breakdown by type of persons

Year, number

2012 2013 2014 2015 2016

Deaths Passengers - - 1 - -

Staff - - - - -

Third parties

- 1 1 - -

Total - 1 2 - -

Injured Passengers - - 12 - -

Staff - - - - -

Third parties

- - - - -

Total - - 12 - -

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3.6 Accidents and incidents investigated during the past five

years (2012 – 2016)

During the past five years there has been a safety investigation about one accident

and one serious accident where the derailment of the train that happened as a result

of a collision with a road vehicle on level crossing involved fatalities. When assessing

the circumstances of the accidents and incidents that took place in the reporting year,

at no time did a situation arise where a safety investigation would have been

compulsory.

Breakdown of investigated cases by years

Table 7

Title of the case Year, number of investigations

2012 2013 2014 2015 2016 Total

Art 19.1,2

Train collision - - - - - -

Train collision with an obstacle

- - - - - -

Train derailment - - - - - -

Level crossing accident

- - 1 - - 1

Accident to person caused by RS in motion

- - - - - -

Fire in rolling stock

- - - - - -

Accident involving dangerous goods

- - - - - -

Art 21.6 Train collision - - - - - -

Train collision with an obstacle

- - - - - -

Train derailment - - - - -

Level crossing accident

- 1 - - - 1

Accident to person caused by RS in motion

- - - - - -

Fire in rolling stock

- - - - - -

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Accident involving dangerous goods

- - - - - -

Incident - - - - - -

Total - 1 1 - - 2

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4 Recommendations

4.1 Short review and presentation of recommendations

During the past five years various recommendations have been made in the safety

investigation reports to various recipients. The safety authority has been informed of

all recommendations but it has not always been the body conducting proceedings.

Recommendations have been developed during the safety investigation.

Recommendations for improvement of safety

Table 8

Field of activity of recommendation

Year, number of recommendations

2012 2013 2014 2015 2016

Maintenance and care of railway infrastructure

- - - - -

Care, maintenance and managing of rolling stock

- - - - -

Organisation of supervision

- - - - -

Road traffic management, road traffic control devices

- 1 1 - -

Winter maintenance of roads

- - - - -

Dissemination of information concerning traffic, training

- - 1 -

Amendments to legal acts and regulating instructions

- - - - -

Operation of traffic lights, railway traffic control

- 1 2 - -

Organisation of operation of railway communication devices

- - - - -

Use of information recording equipment

- - - - -

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Professional qualifications of railwaymen

- - - - -

Other arrangements - - - - -

Total - 2 4 - -

The following table shows the results of the implementation of recommendations

based on the data from 01 April 2017.

Implementation of recommendations

Table 9

Recommendations issued

Recommendation implementation status

Implemented In progress

Not to be implemented

Implementation suspended

Year No No % No % No % No %

2012 - - - - - - - - -

2013 2 2 100 - - - - - -

2014 4 4 100 - - - - - -

2015 - - - - - - - - -

2016 - - - - - - - - -

Total 6 6 100 - - - - - -

Proceedings of recommendations are conducted by the addressees until the

proceedings have been completed. During proceedings the addressee of the

recommendation presents an annual report in specified format to the Safety

Investigation Bureau.