Metro accident investigation completed on 27 July 2016 – Safety Investigation Authority gives five recommendations to improve safety
A departing metro train collided with a metro train standing at the Itäkeskus metro station in Helsinki on the night of 27 July 2016. The sides of the departing test drive train and the teaching train standing at the turnout area of the station collided and the test drive train was derailed. According to the prevailing practices, the teaching train had parked in the turnout area during a break held by the drivers and trainee drivers. The traffic controller was unaware of the risk this posed. No one was injured in the accident.
On the night of the accident, teaching trains were being used to train metro drivers for the new West Metro. New M300 series metro trains were being test driven at the same time.
The Safety Investigation Authority gives five safety recommendations in order to improve the safety of metro traffic, prevent similar accidents in the future and avoid damage. The Safety Investigation Authority does not conduct safety investigations in order to attribute legal liability.
The Safety Investigation Authority recommends that Helsinki City Transport and the safety device supplier investigate and analyse the requirements relating to the operational safety of the metro railway system thoroughly in order to avoid potential faults being carried across to the next system in the course of the current safety device revision.
The accident investigation revealed a defect in the design of the safety equipment, which has been transferred through more than two generations of equipment. This enabled the formation of a route for the test drive train, despite the fact that the teaching train was in the turnout area. In addition, the centralised traffic control system set a different route to the one intended by the traffic controller.
The Safety Investigation Authority recommends that the Finnish Transport Safety Agency ensure that Helsinki City Transport’s safety management system is developed so that it meets the requirements set by the European Railway Agency (ERA) for safety management systems. The requirements set out in the recommendation should be extended to all urban rail transit operators.
A safety management system was only required of HKL in the summer of 2016, on the basis of the new Act on Urban Rail Transit. As a result, the system was undeveloped. For example, the processing of safety deviations was inadequate, metro train collisions had not been recognised as a risk and driver errors were not handled in time. The organisational change in HKL disrupted the processing of deviations and the deviation system was not sufficiently clear to its users.
The Safety Investigation Authority also recommends that Helsinki City Transport should schedule night-time metro trains and other units and draw up a driving programme for them. The control of night traffic is challenging. Test drive and teaching traffic running outside the timetables had not been planned and coordinated sufficiently well. It was difficult to form an overall picture of the situation.
In addition, the Safety Investigation Authority recommends that Helsinki City Transport ensure that recommendations S265 and S266 given by the Safety Investigation Authority in investigation report B2/2008R are extended to also apply to metro traffic. The recommendations in question were adopted on the basis of the investigation of a tram collision on 16 August 2008.
In the metro train collision, the driver’s lack of competence was due to major deficiencies in the training system. Drivers have been granted qualifications without mastering fundamental issues. Refresher training had not been systematically planned or organised for staff engaged in traffic safety tasks.
Veli-Pekka Nurmi, Executive Director of the Safety Investigation Authority, tel. +358 (0)295 150 701
Esko Värttiö, Chief Rail Safety Investigator, tel. +358 (0)295 150 708
Sakari Lauriala, Head of Communications, tel. +358 (0)295 150 714