Bureau d'Enquêtes sur les Accidents de Transport
The Land Transport Accident Investigation Bureau (BEA-TT)’s activities cover a wide variety of areas. The Bureau deals with railway transport, urban guided transportation systems (underground, tramcars), cable haulage systems, road transport (notably heavy goods vehicles and public transport by coach and bus) as well as navigable waterways. Each of these sectors has its own regulations and its own economic, technical, professional and even cultural logic.
Each investigation will also have to scrutinise the occurrence under a multiplicity of angles, be it infrastructure, operations, rolling stock, staff training, medical aspects, regulations, etc.
This diversity in investigations to be conducted necessitates for the BEA-TT to call upon temporary investigators and experts whenever necessary in order to secure all required competencies.
Finally, the BEA-TT will need to promote among the main players of land transport systems, the circulation of all the knowledge that the Bureau and its partners will have acquired through all the accident investigations or the studies they will have carried out. The BEA-TT will also be entitled to launch studies or research on the subject of accidentology.
BEA-TT reports are published in French, with an summary available in English. The reports in this category are therefore all in French and the English summaries are copied below. For the original reports and the full set of BEA-TT reports, please see the BEA-TT Web Site.
Documents
Collision of two trains on 21 November 2007 near Barchetta
On Wednesday 21 November 2007, at about 9:50 a.m., two trains from Bastia (Haute-Corse) and Corte (Haute-Corse) were involved in a head-on collision between the stations of Ponte-Nuovo and Casamozza.
Following this accident, there were 30 injuries, 4 of which were serious.
The investigation revealed that the direct and immediate cause of the accident was the failure by one of the drivers of the two trains, to respect the compulsory stop in the open track station at Barchetta. This was not compensated for by the guard.
Two factors may have contributed to the failure to respect the stop signal at Barchetta :
- The conversation between the driver and the guard on arrival at Barchetta,
- the relatively invisible position on the driver’s desk of the red stopping order.
Two organisational factors were also involved in this accident :
- the absence of monitoring of the stopping order issued, which makes it impossible to check whether the driver respected them, in retrospect,
- the absence of a document laying down the conditions for keeping a train log, requiring guards to keep one properly.
Furthermore, the internal layout of the vehicles may have caused or aggravated injuries to passengers.
Eight recommendations were made by the BEA-TT following this accident.
They were intended to :
- eliminate or reduce the number of crossings in the Open track stations (OTS),
- better ensure respect for stop orders in OTS,
- reduce the risks of injuries to passengers in the event of impact,
- improve the traceability of safety measures.
Concerning the Fire on Eurotunnel Freight Shuttle 7412 on 11 September 2008
On 11 September 2008, Eurotunnel freight shuttle 7412 departs from the English terminal of the Channel Tunnel at Folkestone on time (15:36 hrs ). It is carrying twenty-five lorries and two vans. The amenity coach, in which the lorry drivers are travelling, is in its normal position, immediately behind the leading locomotive.
At about 15:54 hrs, a fire is detected on board the train. The train stops just before 15:59 hrs near marker PK49, which is in the last third of the tunnel.
Of the 32 people on board the train, 28 are quickly evacuated to the service tunnel. Four passengers who had ventured into the rail tunnel are recovered a little later ; the first two at about 16:13 hrs and the last two at about 16:26 hrs.
The operations involved in the evacuation to the French terminal end at 18:44 hrs, i.e. almost 3 hours after the start of the event.
Fire-fighting operations start at 16:56 hrs. They are fully operational by 17:53 hrs and end the next day at around 12:00 hrs.
The fire did not cause any deaths or serious injuries ; 6 people with slight injuries were evacuated to hospital in Calais.
Regarding equipment, all the loaded wagons and lorries were affected by the fire. Both locomotives and the amenity coach suffered damage due to the high temperatures and smoke to which they were exposed. The North Tunnel, in which the shuttle was travelling, suffered considerable damage and could not be reopened to traffic until February 2009.
The initial cause of the fire is still not known exactly, but we suspect that a road vehicle caught fire and the fire spread to the whole of the rake. It should be noted that one of the vehicles on board had an electrical fault, resulting in it being impossible to turn off its headlights, and this vehicle was in the part of the rake where the fire appears to have started.
The investigation by the two French and UK organizations (BEA-TT and RAIB) was performed jointly, in accordance with the agreement between them. It mainly concerns the performance of the evacuation and fire-fighting operations, with particular attention paid to any factors that might have made these operations more difficult or more dangerous, and any mishaps that might have been observed.
Although the event only resulted in minor injuries to people, there were a number of factors that directly affected the evacuation process and fire-fighting operations.
The main factors identified by the investigation are :
The stopping point of the shuttle, which meant that the amenity coach door normally used for evacuation was not opposite a cross-passage,
The fact that the amenity coach door normally used for evacuation was locked out of use,
Communication difficulties between the chef de train and the passengers,
The delay in opening the cross-passage door and starting the supplementary ventilation system,
Excessive delays in attacking the fire, connected with electrical safety procedures,
Numerous faults in technical systems.
Some organizational factors and areas for improvement in the safety management system were also identified.
The scope of the investigation does not cover an evaluation of the measures taken or planned by Eurotunnel (ET) after the fire and, in particular, the plan to create extinguishing stations (SAFE stations) in the rail tunnels.
The investigation has led to 39 recommendations being made concerning, in particular, the following areas :
Evacuation,
Fire-fighting,
Rolling stock,
Infrastructure and equipment,
Procedures and tools used by the rail control centre,
Safety management system.
Works Employee Hit on a Level Crossing at Bayard, on 26 February 2008
On 26 February 2008, two employees were working on the decking of level crossing No. 37 (LC 37) at Bayard, on the Blesmes Haussignemont section at Chaumont. This LC is very close to a canal bridge and the barriers of the two installations work together.
At about 10:20 a.m., the barriers of the LC were lowered at the same time as those of the canal bridge to allow a boat to pass through. Although the barriers of the LC were still not raised, the Safety man authorised the resumption of work. At about 10:25 a.m., the two employees working on the track were surprised by the arrival of a train on track 2. One of the men was hit by the train and was killed.
The investigation revealed that the main direct cause of the accident is the failure to comply with instructions concerning conditions for the resumption of work.
The absence of any warning as to the arrival of the train was a secondary cause of the accident.
The use of installations to inform the flagman of approaching trains, with information beyond that required for safety, may have contributed to a mental model encouraging interpretation and failure to comply with instructions, and the resumption of work under dangerous conditions.
Two recommendations were made by the BEA-TT following this accident. They concern the following aspects :
the training of the employees and respect for instructions,
procedures for informing the flagman of the approach of a train.
Collision Between a Train and a Car on 21 January 2008 on a Level Crossing at Neufchateau
On Friday 25 January 2008, a driver at the wheel of a stolen car was being chased by three gendarmes also in a car, on the RD164 near Neufchâteau. The driver arrived at level crossing No. 82 which was closed. He drove round the half-barrier of the level crossing which was lowered and entered the right of way whilst a freight train was passing on track 1, thus blocking road traffic. The stolen vehicle stopped on track 2 waiting for the train to the clear the way. The gendarmes arrived on the level crossing, got out of their vehicle and entered the right of way of track 2 to arrest the driver of the stolen car. Train 49250 then arrived on track 2 and hit the stolen car and the gendarmes.
The three gendarmes and the driver of the stolen car were killed outright or after being sent to the hospital.
The fact that the vehicle entered the level crossing appears deliberate and the level crossing operation was normal.
The BEA-TT, whose investigation was limited to the railway aspects, had no recommendations to make.
Collision Between a TER and a Car on 3 December 2007 on a Level Crossing at Cadaujac
On 3 December 2007, at 9:10 a.m., a private car with three people on board entered the right of way of level crossing No. 10 at Cadaujac (Gironde) and fouled the clearance of the on-coming train. The train collided with the vehicle causing the death of the three occupants.
The main cause of this accident was the car driving on to the level crossing with the half-barriers closed.
The analysis of the circumstances could not establish with certainty the reasons for the movement of the vehicle nor the behaviour of the driver.
This accident highlights, in particular, the risk involved in crossing level crossings and therefore the need for drivers to approach them with great care and in perfect control of their vehicles.
Since this accident involved general aspects of road safety, the BEA-TT made no special recommendations but underlined the utility, as part of communications on road safety, of reminding drivers that level crossings are critical points on their journeys and that they must be crossed without any driving errors or mechanical incidents.
Derailment of a Passenger Train on 9 November 2007 at Pertuis
On Friday 9 November 2007, on the single-track line between Grenoble and Marseille, the train TER 17 417 made up of a diesel locomotive and four coaches was travelling from Briançon to Aix-en-Provence. At 8:11 p.m. at mileage point 365,848, in bend with a radius of 490 metres at a speed of 105 kph, between the stations of Manosque and Meyrargues, all four axles of the locomotive were derailed over a break in the outer rail. The front bogies of the first two coaches were also derailed, the other axles remained on the rails.
The vehicles remained in the vertical position and did not tip over below the railway line. There were no injuries amongst the passengers (approximately 150), the driver or the guard.
The track was damaged over a distance of 300 metres by the destruction of 500 twin block concrete sleepers ; the running gear and under-body equipment of the rolling stock were also damaged. The amount of the damage to the railway infrastructure was more than € 300,000 and the operation of the line was interrupted for three days.
The immediate direct cause was the undetected failure of a thermit rail weld in an area of continuous welded rails (CWR).
The following causal factors explain why this failure was not detected :
this line is not fitted with track circuits.
cracks under the rail flange are virtually impossible to detect by the ultrasonic rail testing vehicles.
the detection of a rail failure by drivers is difficult. In this case, several drivers had driven over this break without noticing anything. The track environment in this area, due to the frequent alternation of sections of CWR track and normal rails, does not give drivers a stable aural reference.
Three recommendations were made in the report :
Since several failures of thermit welds over a limited period of time (3.5 years and 4.5 years), in limited area (5.4 km and 1.7 km) in two areas of continuous welded rails on the Aix-en-Provence/Manosque line, additional investigations should be conducted to map the stability of other welds on these sections of CWR, in the top stretch of tracks in bends.
Other lines of the national rail network with the same characteristics shall be inspected on the basis of experience feedback on the failures of rails and a weld health report shall be drawn up (lines without track circuit, areas of continuous welded rails on concrete sleepers, section in curves and the top stretch of rails).
Drivers’ failure to detect the break which appeared after the failure of the weld is worrisome, since it is probable that more than one driver drove over this important failure. To improve drivers’ ability to detect such failures it would be useful to test a catalogue of sounds representing various track faults for various types of traction units, with drivers being trained on driving simulators.
Violent Buffing of a Train on 13 August 2007 in the Versailles Rive Gauche Station
On Monday 13 August 2007 at 10:27 a.m., Transilien train No. 141 280 running between Paris-Invalides and Versailles Rive Gauche collided with the buffers of track 3 in the Versailles Rive Gauche station at a speed of 6 kph.
There were no injuries, whether among the passengers, the driver or other SNCF employees.
The accident caused material damage to the fixed installations and rolling stock.
Whilst the driver was decelerating his train to enter the Versailles Rive Gauche station, his vigilance was affected by drowsiness which caused him to loose control of the train. He could not prevent the train from hitting the buffers at the end of the line.
The direct cause of this accident would appear to the driver’s irrepressible drowsiness during the buffing of the train, which suggests lack of sleep the night before the day of the accident. The cause of this lack of sleep has not been established with certainty.
The analysis of this event led to reiterating two recommendations already made in a previous report from the BEA-TT, concerning rolling stock (speed of release threshold of the doors of Z2N train sets) and the infrastructure (study of a damping system for trains which collide with buffers at the end of the track).
Collision Between A Tram and a Car on 4 June 2007 at Saint-Herblain
On 4 June 2007, on the Nantes tramline No. 1 at Saint-Herblain, a collision between a tram and a private car caused the death of the female passenger of the car.
The accident occurred at about 12:15 p.m.
A tram, which had just left the "Schoelcher" station, in Saint-Herblain, near Nantes, collided with a car, drove on to the Vasco de Gama roundabout. The motorist, who was looking for his way, drove on to the roundabout without noticing the tram or the signals protecting its passage.
The tram collided with the right hand (passenger) side of the car and pushed it for some forty metres, before violently colliding with an overhead contact line mast against which the car was crushed.
The direct cause of the accident lies in the driver of the car’s poor observation and failure to respect road signs.
The delay in applying the emergency brakes of the tram was a factor that aggravated the accident and was decisive in the violence of the second impact against the mast.
The layout of the roundabout, in order to integrate the tram platform, does not guarantee optimum safety :
the presence of a fixed obstacle (the mast, supporting the overhead contact line) a few dozen centimetres of the "obstacle limit clearance" and in the immediate vicinity of the edge of the roundabout was an aggravating factor ;
the absence of pre-signalling on entering the roundabout could have affected the driver’s perception of the urban environment and its constraints.
Other factors, associated with the design of the rolling stock (old, non-optimised design of the front of the tram in the event of an impact, absence of a powerful audible warning) or the understanding of the signals (ambiguity of the flashing red light which was clearly not interpreted correctly), may also have contributed to the accident.
Finally, it would have been easier to analyse the accident had a more advanced video and recording system been on board the tram.
During this investigation, it appeared that the safety of the roundabouts crossed by trams raises complex, specific issues which must be handled with care. In particular, their legibility is an important safety factor, particularly for visiting road users or those not used to the location.
The recommendations therefore call for the following :
the implementation, on the Nantes tramway, of a programme to modify the location of overhead contact line support masts on the roundabouts giving the most cause for concern ;
the completion of the programme to improve the safety of roundabouts in Nantes as part of the long term development plan adopted by "Nantes Métropole" ;
better informing users as to the mandatory nature of a flashing red light ;
pursuing the experimentation and optimisation of blocking signals and those at the entrance of roundabouts to promote those with the best guarantees for safety and the optimisation of traffic ;
studying developments to Nantes rolling stock, likely to improve safety (audible warning in particular) ;
improving recording systems by fitting trams with video cameras directed towards the front, covering the space to be crossed, and by increasing the parametric content of recorders, in accordance with the list recommended by the STRMTG.
Collision of an Incoming Train into a Buffer in Paris-Est Train Station on 9 November 2007, Pertuis
At 8.23 am on Thursday 05 April 2007, suburban train 117120, comprised of a Z2N double motor unit and travelling from Château-Thierry to Paris, collided into the buffer of platform 21 in Paris-Est train station at a low speed. This train was in the latter stages of its journey Meaux-Paris and was exceptionally crowded (easily more than 2,200 passengers) due to disruptions to previous trains.
58 people with minor injuries were attended to by the emergency services.
The material damage was limited to the buffer of platform 21 and the front and intermediate systems of the train.
The rail infrastructure was not at fault. The driver was endeavouring to reduce the delay in leaving Meaux by gaining 16% over the journey time in accordance with driving regulations. Although he had correctly passed the last KVB beacon (speed control by beacons) at the rear of the arrival platform and was careful to avoid releasing the passenger doors (6 km/h threshold), the driver braked to bring the train to a complete stop at a late stage. Realising that there was a danger that the train would be unable to stop in time, he applied the brakes of his train in full instead of emergency braking (pressing the emergency push button), which could have reduced the stopping distance.
The identified causes or aggravating factors of the accident are the following :
late braking,
the failure to use the emergency brakes,
the reduction in breaking power by one inactive bogy amongst the sixteen, and
the rigidity of the buffers at the rear of platforms in Paris-Est train station, which increased the impact felt by passengers.
Doubts remain over the quality of handling of the brake as to the correct refilling of the braking equipment. Following confirmed cases in which the brake was partially worn by misuse, the feedback process introduced by the SNCF to make drivers aware of this risk was extended over a period that appeared excessively long, and had not been completed at the time of the accident.
Assessment of the conditions leading to this accident prompted the BEA-TT to make recommendations in the following areas :
consideration of the particular features of the braking system (full application and emergency braking) in driving and training directives,
improvement in the ergonomics in the braking system for future engines,
quicker consideration of feedback in the continuous education of drivers,
the speed criteria blocking and unblocking the passenger doors, and
equipping the ends of platforms in Paris-Est train station with shock absorbers.
Collision with a Female Passenger on the 1st March 2007 in the Station of Villeneuve-Triage
On 1 March 2007, at 6:45 a.m. in the station of Villeneuve-Triage, on SNCF RER line D, a female passenger climbed down on to track 2bis alongside platform 1 for reasons unknown at the same time as train 126520 travelling towards Paris at 108 kph entered the station. She was hit by the train despite emergency braking by the driver and died immediately.
The recommendations made following the technical investigation concern two categories of measures :
remind users that if it is necessary to cross the tracks, they must not climb down on to the tracks but take the underground passages or bridges intended for this purpose ;
review the layout of signs, the maintenance and cleanliness of signs and warning devices.
Derailment of an EMV (Track Maintenance Machine) on 27 February 2007 in the Station of Carcassonne
On Tuesday 27 February 2007, at approx. 12:40 p.m., an SNCF track maintenance machine (track maintenance machine type EMV 97) was derailed on a derailing stop in the station of Carcassonne (Aude) during shunting on a service track. Once it derailed, it fouled track 2.
When informed by the driver of the EMV, the Traffic controller at Carcassonne closed the signals protecting the track 2. No accident occurred.
The immediate cause of this incident was the driver of the EMV running past an absolute stop signal.
Two other causes played a part in the incident :
the protection gear (derailing stop) is not appropriate for this type of train (fitted with a guard- iron), which resulted in the fouling of the adjoining track,
the Traffic controller did not remind the driver of the EMV of the presence of a intermediate stop signal (Cv No. 120) between the origin of the movement and its destination, which could have contributed to accidentally running past the signal.
The recommendations made following the technical investigation concern the organisation of shunting and the derailing stops used by the infrastructure manager :
remind traffic controllers of the importance of fully informing employees involved in movements in the station and, especially, employees less familiar with the installations of the station,
examining the installation of a standard derailing stop on track 4 between points 120b and 118a.
Fatal Accident That Occured on 10 November 2006 at the Station of Chaville Rive Droite
On 10 November 2006, at around 10:22 am, a passenger on train 133473, comprising two carriages in a multiple-unit configuration and terminating at Versailles Rive Droite, activated the emergency alarm and jumped from the train as it passed through the station of Chaville Rive Droite at 88 km/h. The person was seriously injured upon impact with the platform.
Train 133473 was initially intended to provide a slow stopping service between Saint?Cloud and Versailles Rive Droite, stopping at every station including Sèvres - Ville d’Avray and Chaville. This service was modified after the train’s departure, becoming a direct service from Saint?Cloud to Versailles Rive Droite, thus removing the stops at Sèvres - Ville d’Avray and Chaville.
The driver of train 133473 was alerted to the fact that the emergency alarm had been activated andthat a door had been opened while the train was moving. He stopped the train at the station of Viro flay Rive Droite to inspect his train and rearm the alarm. Later on in his journey, the driver of the following train, 133479, informed him that a person was lying lifeless on the ground at the station of Chaville Rive Droite, a short distance from the beginning of the Versailles-bound platform.
The emergency services were called to the incident and attended to the victim, who was taken to hospital by ambulance. The person died shortly after being admitted.
The direct cause of the accident was the victim’s attempt to alight from the train when it was moving. The individual in question probably panicked when they realised the train was no longer stopping at their station.
There were two indirect causal factors, relating to the design of the rolling stock and to operational management practices :
the lack of a mechanism, on the rolling stock concerned, to prevent the doors from opening when the train is moving and the alarm has been activated,
the SNCF’s cancellation of services to certain stations in the event of disrupted traffic, even after the train has departed from its station of origin.
The recommendations made subsequent to the technical investigation covered two types of measure :
study possible modifications, using rolling stock taken to the workshop for extensive maintenance work, which in the event of an Alarm Signal with Intercom (SAI) being activated would prevent the doors from being opened manually above a speed equivalent to the lowest detectable speed, and establish a programme to implement these modifications,
revise and clarify the regulations applicable to service changes, by strictly restricting the removal of regular stops, especially after the train has left its station of origin.
Crash Involving a Train and a Wide-Load Vehicle at a Level Crossing in Domene on 18 October 2006
At 1.05 pm on Wednesday 18 October 2006, TER regional train 885717 running on the Grenoble-Montmélian line collided with a wide-load vehicle on level crossing no. 18, Rue de l’Industrie in Domène (38). The accident caused no casualties but damaged the material involved.
The direct cause of the accident was the presence of a wide-load vehicle manoeuvring on the right of way of the level crossing when the tracks were open for the circulation of trains in accordance with the normal system.
The company responsible for the haulage failed to respect the statutory obligations in relation to the use of level crossings by wide-load vehicles. These breaches, particularly the failure to inform the SNCF in advance, made it impossible for the latter to indicate to the haulage contractor the timeslot in which the level crossing could be used, or to ensure it a safe passage by activating the procedure for temporarily halting the circulation of trains in the area. Similarly, the forces of law and order were not informed and were therefore unable to be present during the manoeuvres.
Failures to respect these obligations are not currently regulated and the potential penalties are low.
In view of preventing such risks, the three recommendations aimed to implement a more rigorous control-sanction system for wide-load vehicles and the obligation for haulage contractors to provide evidence that they have met the duties incumbent upon them by the order requiring individual authorisation to be sought for such vehicles crossing points presenting particular danger.
Train Collision That Occured on 11 October 2006 on the French/Luxembourg Border at Zoufftgen
On Wednesday 11 October 2006, extensive track works on the French network required one of the two tracks of the Thionville-Bettembourg section of international line to be neutralised from 8h50 to 16h30. Consequently, trains in both directions were using the other track under the Wrong-track Working Fixed Equipment (WWFE) system.
While an SNCF freight train was travelling on this track from Thionville to Bettembourg, a Regional Express Train (RET) was travelling in the opposite direction on the same track via Bettembourg station.
These two trains collided head on at around 11h44, on French territory at about ten metres from the border, near Distance Marker (DM) 203.700 (Commune of Zoufftgen).
As a result of this accident, six people died, one was seriously injured and fifteen others had minor injuries.
The first of the three carriages of the Luxembourg RET was totally destroyed ; the other two were badly damaged. The French locomotive of the freight train was totally destroyed and the first eight wagons were totally destroyed or badly damaged.
The direct and immediate cause of the accident was human error : the Traffic Controller of the Bettembourg Central Control Post mistakenly issued the driver of the RET an order to pass through the "danger" signal protecting the section of track on which the freight train was travelling.
The other causes and factors that contributed (or could have contributed) to this accident can be classified into four groups :
direct causal factors relating to mistakenly issuing the pass-through order, and which concern the Bettembourg Central Control Post (CCP) : the incorrect staff handover procedure just before the accident, the high frequency of signal faults, the poor ergonomics of the available documentation, and the ergonomics of the Visual Control Panel which could be improved ;
direct causal factors relating to the failure of attempts to rectify the situation : incorrectly pressing the radio warning button (or failing to press this button), delay in implementing the traction power cut-off procedure, failing to transmit the warning to the Thionville Control Post, and the limited capacity of the telephone system at the Bettembourg CCP ;
underlying causes regarding staff skills : insufficient knowledge by the CCP staff of the procedures to be followed, particularly for issuing pass-through orders or for handling emergency situations, and the absence of practical training in emergency procedures ;
organisational causes regarding the Safety Management System and the regulatory framework of Luxembourg Railways (CFL) : unrealistic division of tasks between the Bettembourg CCP staff, lack of encouragement to gain experience and laissez-faire approach to monitoring staff and implementing management control.
Furthermore, the investigation highlighted several factors that, although they did not play a part in the development of the accident, would have compromised the effectiveness of any attempts to rectify the situation that should normally have been made : the hidden fault on the ground-train radio at the Bettembourg CCP, the fault on the ground-train radio of the freight train, the lack of continuous radio warning transfer near the border, and the lack of a direct connection between the Bettembourg CCP and the East-France Substation Unit.
This investigation makes twenty-two recommendations. They relate to preventive actions focused on the following objectives :
to remind staff finding themselves in the position of issuing an order to pass through a signal set at "danger" that they must not do so until they are sure that the reason for the signal remaining in "danger" position is really the consequence of a fault in the equipment ;
to take the necessary steps to reduce the number of faults in the signalling equipment ;
to provide documents to help in the decision-making process ;
to improve the legibility of the Visual Control Panel at the Bettembourg CCP ;
to re-train the Bettembourg CCP staff ;
to review the consistency of the safety regulations at CFL and the role of the traffic controllers ;
to improve the reliability of the communication and warning equipment and procedures, particularly the cross-border aspects ;
to ensure that the systems made available to the staff work properly ;
to improve the protocol for staff handover and its implementation ;
to train staff in the emergency procedures that are most likely to occur ;
to review the experience feedback scheme ;
to ensure that checking and monitoring of staff by the management is as thorough as possible.
Derailment of a Works Train, on the 24 July 2006 at Culoz
On Monday 24 July 2006, at about 6:30 p.m., the works train 818 729 was running from the station at Culoz (its base) towards the track replacement worksite of Moirans-Grenoble. During the acceleration of the train, as it was passing through the passenger station at Culoz, the "working group" was derailed. This "working group" is the unit that removes old sleepers, lays new sleepers and levels the ballast, which is supported on the track by a deballasting axle.
The deballasting axle, after the first derailment at pk 101.747 of the Culoz - Aix-les-Bains line, jumped several times on either side of the track 1, whilst the working group broke up, after having lost the locking pin on the right hand side of the support arm of the deballasting axle. Although the derailment was observed by railway employees, the driver of the train could not be alerted, since this train was not equipped with a track to train radio. The working group collided with the lower and side clearances. At pk 103.222, at the origin of the bridge over the Rhone, whilst the front of the works train was well engaged, the out of clearance mass of the working group hit the deck of the first span of the bridge ; this span left its supports and collapsed. A certain number of parts of train P21/95 fell into the Rhone, including the deballasting axle.
One person was slightly injured, belonging to a contractor working close to the construction site of a new bridge to replace the present one.
The consequences were serious : the deck of the bridge of the track 1 was destroyed, the active part of specialised train P21/95 was destroyed. Traffic was disrupted for two days on both lines 1 and 2 between Culoz and Aix-les-Bains. Traffic was then restored on line 2, while that on line was 1 was only restored one year and 24 days later when the new bridge was commissioned.
Neither the traction conditions nor the railway infrastructure, which did not require immediate corrective measures, were the cause.
The immediate direct cause of the derailment was the weight transfer from the left wheel of the deballasting axle in presence of a left transition curve leaving a bend, which was probably the result of the combination of three factors :
a probable asymmetry of the distribution of weights of the working group of the train ;
greater torsional stiffness of the unit (working group and suspension of the deballasting axle) than originally ;
alternating weight transfers between the left and right hand wheels of the deballasting axle due to transversal shake of link supporting the working group.
A fourth factor was discarded (influence of an abnormal configuration of the lifting system of the working group) since we were not able to perform all the tests involving it.
The conditions for the certification of train P21/95, which included a complex suspended element, were insufficient to provide sufficient details as to the dynamic behaviour of the train.
The consequences of the derailment were aggravated by the absence of a track to train radio link.
A insufficient security as to the preparation of the routing of the train was revealed by the loss of the locking pin of the right arm working group (probably due to the insufficient engagement of the pin, absence of secure locking of the pin by split pin) ; furthermore, it would appear that it is necessary to reinforce the traceability of exchanges between the operators responsible for the movement of the works train.
The review of the conditions of this accident resulted in recommendations concerning the inspection of works trains before line running (coherence of the checks and role of operators).
In so far as track-to-train communications are concerned, a recommendation was made in favour of equipping such works trains with a track to train radio link.
Finally, we recommended, for future complex track maintenance vehicles, checking their ability to negotiate curve transitions and apply the complete protocol for dynamic testing on line for vehicles using new technologies.
Near-Collision Between Two Trains on 28 June 2006 at the Station of Tencin-Theys (38)
On 28 June 2006, train 885750 (the TER regional train between Chambéry and Grenoble) was stopped in Tencin?Theys station on track 2, as it waited for the line to be declared clear by a rail maintenance train dispatched previously. Having passed through the station of Pontcharra-sur-Bréda, train 738584 arrived behind train 885750 on the same track. The driver of train 738584 was surprised by the unexpected presence of the other train, but having already slowed down in accordance with the signalling on the line, he managed to stop his train twenty metres from the back of the stationary train.
This incident demonstrated that two trains were located on the same track section at the same time, a situation that contravenes regulations.
This particular line is equipped with a double-track manual block system that does not allow the track to be declared clear at the previous station until the train has passed the semaphore at the next station and the semaphore is closed. Proof that the train has actually arrived at the next station is provided by a treadle actuated by the train.
Four causes were underlined :
The main direct cause of the incident was human error. Indeed the line was declared clear inaccurately when the rail maintenance train dispatched towards Grenoble departed from the station. This allowed a second train to enter a section of track that was already occupied, without the driver of this second train being notified of the fact,
The second direct cause was also linked to human error and involved the failure to protect train 885750, which was stopped at the station. When train 738584 reached the approach to the station, its driver did not encounter the protection signal (disc D2) in the closed position and therefore had not prepared to stop safely behind a stationary train,
The third cause was a lack of organisation on the part of the employees operating the station that morning. The duty station controller for the previous night had not correctly performed the handover to his successor, that is to say, he failed to coordinate the different tasks relating to the safety of railway traffic,
The fourth cause, which relates to the installations, was the ineffectiveness of the protection systems designed to ensure that track sections are declared clear safely : the safety systems governing the operation of the block system (actuation of a treadle, closing of the semaphore) were bypassed fortuitously, despite the fact that the track was occupied.
Hence, three recommendations were made :
two calling for modifications to the installation : changing the location of a treadle and modifying the protection signal’s control circuit,
a third relating to how a team’s work is coordinated by the duty station controller.
Derailing of Train 5941 on 25 February 2006 in Saint-Flour (15)
On Saturday 25 February 2006, express train 5941 from Paris to Béziers was running on the single-line stretch of railway between Neussargues and Béziers, and derailed at kilometre point 692,480 in the municipality of Saint-Flour (Cantal county). At this point the line is on a curve with a adius of 296 m, and on a slight slope. The entire train derailed (the locomotive and three carriages), and the locomotive and front carriage were thrown against the rock face.
Two of the passengers were slightly hurt, while the rolling stock and 100 m of infrastructure were seriously damaged.
The direct cause of the accident was a broken rail on the outside of the curved line, at a thermit weld. Periodic ultrasound checks had detected no precursory signs of a fault in the rail. The break, together with the loss of a fastener, led to a significant mismatch between the two detached ends, causing the train to derail at this point.
At the root of the accident were the fact that the line was obsolete and an inadequate maintenance policy.
The line, which is equipped with “bullhead” rails, is prone to causing derailments in the event of a rupture, and replacement parts for these “ancient” rails are no longer available. Moreover, the wider sleeper spacing contributes to an increase in the stresses exerted on them. Lastly, the gradual removal of ballast over time has made it impossible to maintain the line at the correct level.
Maintenance policy rules out any form of regeneration (“continuous surface” method). Thus, the number of welds on the line has increased to compensate for the lack of rail replacement, creating fragile points, and the one-off replacement of individual wooden sleepers has brought about a displacement phenomenon, because it is impossible to add re-levelling ballast.
These observations lead us to formulate the following recommendations :
in the short term, a methodology should be set out to mark out the “special zones” in which train speed should be reduced to prevent derailments in the event that “bullhead” rails rupture.
replacing the rail, wherever possible, with a continuous bar instead of carrying out welding. This measure would firstly require still-healthy “bullhead” rails to be obtained,
the set-up of a programme to re-level the lines equipped with “bullhead” rails, in which the replacement of sleepers should be accompanied by the addition of ballast,
in the long term, the replacement of the “bullhead” rails with Vignole rails.
Fire in Two Underground Trains on 6 August 2005 at Simplon Station
On Saturday 6 August 2005, at 4:35 pm, underground train no. 6046 had just stopped at Simplon station, in Paris, as part of the “Porte d’Orléans - Porte de Clignancourt” trade mission being performed on line 4 of the RATP network.
As passengers were getting on and off the train, thick smoke began to rise out of carriage five. In the meantime, on the adjacent line, train 6033 stopped at the station to drop off and pick up passengers. So much smoke was billowing out of the train that the passengers of train 6046 decided to evacuate of their own accord and in accordance with the instructions of the driver of train 6033. The fire brigade was called and arrived at 4:52 pm. The RATP had trouble activating the smoke extraction system and only at 5:25 pm did the fire fighters manage to gain access to the fire, which they successfully extinguished at 6:00 pm.
Nineteen people were slightly hurt : one passenger and eighteen RATP employees who suffered from smoke inhalation. The accident could have had much more serious consequences had circumstances been slightly different (peak time, fire in a tunnel, etc.). A total of four carriages on both trains were damaged, as well as guide bars on the line, electrical cables and the “Simplon” electrical substation. Traffic on the line was able to resume the next day, but without stopping at Simplon station.
The immediate cause of the fire was a double failure of the electrical traction system of one of the motor coaches, which occurred when the train was stopped at Simplon station :
firstly, the rupture of the servomotor contact arm that actuates the traction controller, interrupting the engine shutdown process ;
secondly, the latent failure of the cut-off switch, which should have opened but remained in the closed position.
As a result, the motor bogie remained in “traction” mode, despite the fact that the train was stationary, causing one of the wheels to spin and its tyre to heat up with the friction before bursting and catching fire.
The second direct cause of the fire was the tyre’s high flammability and vulnerability to the risk of combustion. Indeed, tyres are made of a material that reacts very differently to the other materials affected by the fire, which behaved in a satisfactory manner. Special instructions must therefore be followed when they are used.
Various aggravating factors, of both a technical and organisational nature, delayed or hindered the fire’s subsequent management. In particular, it was not possible to run the smoke extraction system in a satisfactory manner after an initial error had been made.
The factors highlighted relate to :
the vast number of documents to be consulted and instructions to be given by RATP’s duty inspector in order to implement the emergency procedures,
the ineffectiveness of the smoke extraction instructions provided in the “line operator’s guide” in dealing with smoke inside Simplon station,
the communication difficulties encountered between the various intervening parties, notably as a result of poor knowledge of the different contact numbers, the confusion that plagued the different exchanges and the often poor technical quality of the radio links.
The ten recommendations formulated after the technical enquiry cover five types of measure :
prevention of the electrical faults that started the fire,
prevention of the risk of the wheels spinning on all trains fitted with tyres,
re-examination of the smoke extraction instructions provided in the line operator’s guide, to ensure that it is constantly updated, easy to use and accurate in its content,
implementation of a centralised, remote-controlled smoke extraction system on all RATP lines where trains are fitted with tyres,
thorough and efficient organisation of communications between the intervening parties in the event of an accident.
Collision That Occured on 9 June 2005 at Level Crossing 83 in Saint-Laurent-Blangy
On Thursday 9 June 2005, at 5:14 pm, the Regional Express Train (TER 848 932) from Lille, which was carrying 150 passengers, collided with a semi-articulated lorry loaded with 944 gas canisters (butane and propane with a total weight of around 12 tonnes) and immobilised on level crossing no. 83 in Saint-Laurent-Blangy in the Pas-de-Calais county. The accident provoked a fire causing the gas canisters to explode one after the other, creating a fireball that was visible from several kilometres away.
Despite the presence of many people in the area, nobody was hurt. However, material damage to installations, buildings and vehicles was considerable.
The initial cause of the accident was the rupture of one of the trailer’s compressed air lines, which caused the lorry to become stuck on the level crossing a few minutes before the TER was due to arrive. The driver of the TER, who had not been alerted soon enough, was unable to avoid the collision, despite carrying out an emergency stop. The presence of gas canisters was an aggravating factor and explains the magnitude of the explosion.
The fact that nobody was injured or killed, thanks to the sensible and quick reaction of the SNCF staff present at the scene and the particularly fortunate way in which the event unfolded, must not allow us to underestimate the danger involved in such a situation or the probability of it occurring.
The analysis enabled the BEA-TT to take into account two main types of causal factor when putting forward its preventive recommendations :
those relating to the infrastructures and their operation. The situation at this level crossing, which sees rail traffic of around 200 trains per day and average road traffic of 10,000 vehicles/day, 15% of which is heavy goods vehicles, is preoccupying.
those relating to heavy goods vehicles, driver behaviour and the transport of dangerous goods. The way in which the compressed air line to the trailer’s brakes ruptured, without any apparent external cause, leads us to highlight the particular care with which a vehicle used in the transport of dangerous goods must be maintained. Furthermore, had the driver sounded the alert more swiftly, the collision may have been avoided.
Regarding these different points, the BEA-TT has formulated three recommendations : the removal of this level crossing, a study into provisional measures to reduce the risks of collisions pending its removal, and the inclusion of critical situation procedures in the training given to drivers involved in the transport of dangerous goods.
Special attention should be drawn to the importance of checking brake lines as part of vehicle and trailer maintenance.
Rail Accident That Occured in a Francardo in 27 May 2005
On Friday 27 May 2005, at around 7:30 pm, train 51 from Bastia (Haute-Corse) to Corte (Haute-Corse) and train 8 from Ajaccio (Corse du Sud) to Bastia (Haute-Corse) collided head-on at kilometre point 53,200, between the stations of Francardo and Ponte-Leccia. These two trains were supposed to cross at the passing point at Francardo.
Train 8 had made up for most of the delay it had suffered. Seeing that train 51 had not yet arrived at Francardo, the guard of train 8 asked the signalman at Ponte-Leccia to switch the passing of the trains from Francardo to Ponte-Leccia. The latter agreed to do so, despite the fact that he had already routed train 51 to Francardo. Once train 8 left Francardo station, a head-on collision was inevitable.
Each driver saw the other train just before the collision, and they were able to perform emergency braking, thus limiting the impact. Neither train derailed and 14 people were slightly injured.
This accident was caused by human error (train sent down a single-line section that was already occupied) resulting from an exchange of defective dispatches (the text received was different from the text sent, the recipient failed to properly check the, etc.).
The investigation brought to light several factors that contributed to the accident, relating to the management of both train traffic and rail staff. It also produced the following recommendations :
exchange dispatches according to a thorough procedure, by applying checking and real-time recording rules,
make the dispatch register more legible,
carry out a study to improve the current traffic management method, so as to prevent an error made by a single employee from causing an accident,
keep to the speed limits,
improve the performance of the radio system between the train and the control rooms,
use one-to-one interviews as part of staff management.
Derailment of a Freight Train which Occured on 13 June 2006 at La Ferte-sur-Chiers
On Friday 27 May 2005, at around 7:30 pm, train 51 from Bastia (Haute-Corse) to Corte (Haute-Corse) and train 8 from Ajaccio (Corse du Sud) to Bastia (Haute-Corse) collided head-on at kilometre point 53,200, between the stations of Francardo and Ponte-Leccia. These two trains were supposed to cross at the passing point at Francardo.
Train 8 had made up for most of the delay it had suffered. Seeing that train 51 had not yet arrived at Francardo, the guard of train 8 asked the signalman at Ponte-Leccia to switch the passing of the trains from Francardo to Ponte-Leccia. The latter agreed to do so, despite the fact that he had already routed train 51 to Francardo. Once train 8 left Francardo station, a head-on collision was inevitable.
Each driver saw the other train just before the collision, and they were able to perform emergency braking, thus limiting the impact. Neither train derailed and 14 people were slightly injured.
This accident was caused by human error (train sent down a single-line section that was already occupied) resulting from an exchange of defective dispatches (the text received was different from the text sent, the recipient failed to properly check the, etc.).
The investigation brought to light several factors that contributed to the accident, relating to the management of both train traffic and rail staff. It also produced the following recommendations :
exchange dispatches according to a thorough procedure, by applying checking and real-time recording rules,
make the dispatch register more legible,
carry out a study to improve the current traffic management method, so as to prevent an error made by a single employee from causing an accident,
keep to the speed limits,
improve the performance of the radio system between the train and the control rooms,
use one-to-one interviews as part of staff management.
Rail Accident that Occured at Longueville on 16 February 2005
On 16 February 2005, at 7:23 pm, train 117 710 from Provins (Seine-et-Marne) hit train 117 578 sidelong at Longueville station (Seine-et-Marne). Luckily, nobody was injured and only material damage was suffered : the front carriage of the train that was hit was split open, the locomotive that collided with it incurred chassis damage, and both the line and adjacent platform were deformed. The two trains involved were of the push-pull (with a driver’s cab at each end) “stainless” diesel type. The Longueville to Provins line is operated by the CFTA, a subcontractor of the SNCF.
At Provins station, the driver performed the procedure to secure train 117 710 incorrectly, as a result of insufficient mechanical protection of the handle on the reversibility lock. Thus, the mechanical system that switches the locomotives, as well as activating the brakes, was not locked in the “leading” locomotive position and instead found itself in an unstable position between the “leading” and “trailing” positions. The vibrations transferred from the engine to the switch system caused the brakes to be released, making the normal brake lever in the cab of the locomotive ineffective. When the driver noticed his train was drifting while stopped at the station, he did not make use of the emergency braking systems available to him. He only used the locomotive’s handbrake, which acts on a single axle (rather than four) and was not powerful enough to stop the train before it reached the shunting where train 117578 was stationary. The driver had insufficient knowledge of the professional behaviour to follow in an emergency situation.
The locomotive in question, a BB 66400 that had been in service since 1969, was faulty : the mechanical reversibility lock was not locked in the normal operating position. Thus, the engine’s vibrations caused the axle of the reversibility lock to rotate, deactivating the brakes.
The SNCF has been asked to modify locomotives of this type by making it impossible to action the reversibility lock incorrectly, or by replacing it with an electrical control system, or by including a check on the driver’s checklist to ensure that it is indeed locked.
The SNCF has also been asked to determine whether any other types of locomotive operating on the railways (whoever the operator concerned) and equipped with a similar brake inhibitor system need to be modified as a consequence of the incident, and to notify the owners.
As regards the experience of drivers, a seven-kilometre section of line such as Longueville - Provins is a rather enclosed environment in which to operate trains, and one that allows habits to form and provides little experience of unusual operating conditions. The main operator and its subcontractor, together with the DGMT, should re-examine such organisations, whose restricted operational scope does not allow real train driving experience to be acquired, and as a consequence, sufficient feedback of past events to be obtained.
On the management front, the CFTA must enhance its driver and conductor training programmes : drafting and implementation of training specifications, practical training on rolling stock, face-to-face interviews performed systematically, improved content in safety action plans.
Accident of 24 November 2004 at Level Crossing No. 71 in Millau
On 24 November 2004, at around 5:00 pm, an accident took place in Millau (Aveyron), at the intersection between the RN9 primary road and the rail line from Béziers to Neussargues, on level crossing no. 71.
A semi-articulated lorry became immobilised on the railway line as the Paris to Béziers train approached. Despite an emergency stop, the train could not avoid the collision. The accident caused minor injuries to three people.
The Minister for Transport, Infrastructure, Tourism and the Sea asked the Land Transport Accident Investigation Bureau to conduct an investigation into this accident.
The aim of this report is to determine the circumstances and causes of the accident and to formulate preventive recommendations.
It would appear that the direct cause of this accident was an error by the lorry driver, who proceeded onto the level crossing without checking that there was enough space to clear it completely.
However, two other factors also played a crucial role :
The location of the level crossing in a built-up area, where it was often in the middle of traffic jams.
The road works being performed nearby, which those in charge had not taken into account as an additional cause of traffic congestion around the level crossing.
The report puts forward a number of recommendations for the management of road works located near level crossings, and for the design and signalling of level crossings that are subject to frequent road congestion, notably level crossing no. 71 in Millau.
Tramcar Accident Which Occured in Rouen (Seine-Maritime) on the 30th of August 2004
The Rouen tramcar system in partially underground, which is equipped with a block signalling system similar to that of the metro. On the morning of August 30th, 2004, when passenger presence was still limited, a tramcar rake which had so far operated normally, passed a closed signal at danger and did a rear-end shunt into a rake stopped underground. The stopped rake had been waiting for clearance to enter the next block. The driver’s safety device on the rear rake was functioning and apparently still activated, but was insufficient to prevent the accident from occurring.
One person was seriously injured and 7 others slightly injured. The damage was limited to the rolling stock and both rakes were badly damaged.
Human failure was at the origin of the accident. A sudden indisposition of the driver was alleged at the beginning of the investigation then discarded. The driver’s lack of alertness as he began to doze off appears far more likely. The driver had resumed work that morning, returning from his summer leave. He had a definite lack of sleep because of taking up his position early in the morning ; he had skipped breakfast and was most likely under the influence of an anti-depressant drug prescribed after he had been attacked two year earlier.
A first recommendation was sent to the management of the Rouen Public Transport System, for it to study how to match drivers’ living patterns and work patterns, particularly for drivers under medical treatment or under medical monitoring for partial unfitness at their usual job position. The management should hence study the allocation of worked days in order to reduce the risk of lack of alertness when returning after a leave of absence.
The report also recommended that the tunnel signalling system of the Rouen underground network as well as the rakes be fitted with devices to control passing at danger. Such arrangements should be included in the "Guided Transport" baseline document which would then progress on the matter of passive resistance of rakes (compliance with Euro-standard EN 12.663).
Another recommendation also suggested that during the next upgrade of the Rouen tramcars IT traffic management system, which processes the exchange of information between tramcar drivers and the Main Control Centre, new features would include permanent location of all tramcars and monitoring of block occupancy. Voice radio links should be unbroken wherever the driver is, inside his cab or outside of it when he is troubleshooting.
Links with rescue services should also be improved.
Finally, various improvements should be introduced to the rakes and to the tunnel to improve lighting in degraded situations, and to make it easier for passengers to evacuate on their own.
Technical Investigation into the April 7th 2004 Electrocution of a Teenager in the Saint-Nazaire
The tragic circumstances surrounding the death by electrocution on April 17, 2004, of a teenager standing on the top of a wagon stabled in the Saint-Nazaire train station, led the Minister to request that the director of the BEA-TT launch a technical inquiry.
The results of the investigation led to the formulation of recommendations on the following :
strengthening the robustness of fences around specific railway facilities,
reinforcement of signage warning against electrical hazards,
preventive information to specific target groups,
response instructions for the emergency services,
improvement of the exchange of information between the emergency services and the French National Railway Company - the SNCF.