Trains directed onto the wrong track more than one hundred times in one year
The Safety Investigation Authority has completed a theme investigation into the safety of rail traffic, placing the emphasis on identifying factors that affect the wrong routings. Wrong routing refers to a situation in which a train is directed onto the wrong track.
The investigation found that trains were directed onto the wrong track more than one hundred times in 2015. Most of these incidents were attributable to errors in manual controlling. A large number of structural and indirect factors lie behind such errors.
The remote control system does not take sufficient account of the fact that higher rail traffic speeds require modifications to the interlocking systems. Being controlled by the automatic route setting system, trains need to slow down or even stop at signals before the signal indicates that driving is permitted. The traffic control system has also been in an almost constant state of change. Furthermore, several different systems are used. Insufficient time is available for providing personnel with training in the new or modified systems. Traffic controllers feel that they have insufficient say in the planning of new systems and development of old ones.
The safety management system of the Finnish Transport Agency has not been updated comprehensively for five years, despite the fact that the operating environment and organisations have changed. On several occasions, the Finnish Transport Safety Agency (Trafi) has detected shortcomings in the quality control of the Transport Agency’s service providers. On the other hand, no clear and uniform system exists for reporting on wrong routings that covers all rail traffic operators, owners of the railway network and safety authorities. Traffic controllers leave some deviations regarding wrong routing unreported.
The investigation also found that the regulations and instructions in effect were not identical with those actually used in some cases. The Railway traffic control manual of the Transport Agency in effect during investigation was classified as confidential, which placed constraints on its use.
The data consisted of 101 cases, of which 13 were subjected to a more detailed investigation. Approximately 500,000 trains run on Finnish railways each year, which means that millions of routes are formed on an annual basis.
Traffic controllers responsible for forming train routes and their safety were also queried. These controllers work around the clock in seven centres and some separate sites.
In most situations resulting in a wrong route being formed, controlling could have been handled by the automated system, but it was thought that manual controlling led to smoother traffic and facilitated the work of traffic controllers. Some traffic controllers also distrusted the systems, finding that they slowed down their work and made it too restrictive. The manual forming of routes led action-based slips, memory-based lapses and thinking errors.
In many cases, such errors only resulted in minor disruptions in traffic, as the engine driver noticed the faulty position of the switch or signal. In one case, a passenger train being directed onto a track with no platform created a genuinely dangerous situation
In order to reduce the number of wrong routes, the Safety Investigation Authority recommends that the Finnish Transport Safety Agency ensures the enforcement of five recommendations directed at the various actors.
The Finnish Transport Agency should, in collaboration with Finrail Oy, ensure that, as a general rule, routes are formed by the automated system. The Transport Safety Agency is obligated to create a uniform system for the reporting and classifying of deviations, covering all actors.
The Transport Agency must also ensure that the instructions directly affecting the work of traffic controllers are kept up to date and that they are not put into use without sufficient orientation being given to personnel. Neither should new systems or modifications to systems be introduced unfinished or without sufficient orientation. When procuring traffic control systems, steps must be taken to ensure that any development needs emerging in the systems can be implemented smoothly during the system’s lifespan.
In addition to actual recommendations, the Safety Investigation Authority wishes to highlight two safety-related observations; these concern insufficient instructions for the inspection of switches and the signal for emergency stop.
Chief Rail Safety Investigator Esko Värttiö, tel. +358 29 51 50708