Improvements in level crossing safety still necessary
The Safety Investigation Authority's investigation of the level crossing accident that occurred in Kemijärvi on 12 December 2018 has been completed. The accident took place in the early hours of the morning when a freight train and a waste collection lorry collided at an unprotected level crossing on the Kuusivaarantie road. As a result of the collision, the driver of the lorry died and one of the two engine drivers in the locomotive was injured. The waste collection lorry was completely destroyed in the collision, the derailed locomotive was badly damaged, while the derailed wagon was slightly damaged. Traffic on the track section between Rovaniemi and Kemijärvi was interrupted for five days.
In order to reduce the number of similar accidents, to alleviate their consequences and to improve the post-accident measures, the Safety Investigation Authority issues eight recommendations:
In order to ensure that all safety risks of the waste collection process are identified and that a functional feedback handling process and instructions and orientation for the collection process are instituted, the Safety Investigation Authority recommends that the joint municipal authority for waste management Lapeco, in cooperation with the contractors, implement the following recommendation: The safety management related to the waste collection process shall take comprehensively into account the requirements of the work processes and the identification of occupational safety and traffic safety risks. Instructions shall be drawn up for the work processes and the orientation of the employees, and they shall be documented. Processes for handling feedback shall be defined in order to improve the operations.
A more extensive nationwide survey of the safety of waste collection processes should also be initiated, with the Association of Finnish Local and Regional Authorities possibly acting as the responsible body. A joint survey would provide different actors with tools to improve safety.
Secondly, in order to provide drivers with a proper signal of a change in conditions that would direct them to lower the speed while approaching a level crossing, the Safety Investigation Authority recommends that the Finnish Transport and Communications Agency ensure that the Finnish Transport and Infrastructure Agency and other road keepers review all speed limits, particularly at unprotected level crossings, and ensure that they comply with the guidelines.
On the road in question, the speed limit was the 80 km/h general limit on the approach to the level crossing. According to the guidelines, a level crossing should have a speed limit of 50 km/h. The speed limits are specified in the guidelines of the Finnish Transport and Infrastructure Agency. The Finnish Road Association should inform private road managers and the municipalities of the Association of Finnish Local and Regional Authorities of the matter. The transport and infrastructure areas of Centres for Economic Development, Transport and the Environment have already begun correcting the speed limits at level crossings on the roads to comply with the guidelines. The corrections will be finished in the autumn of 2019. Speed limit signs of 50 km/h were installed at the Kuusivaarantie level crossing in June 2019.
Thirdly, the Safety Investigation Authority recommends that the Finnish Transport and Communications Agency ensure that in its track projects, the Finnish Transport and Infrastructure Agency prepares a plan and a timetable for the correction of the risks identified at level crossings.. It must not be possible to transfer the risks into the future as residual risks.
Level crossings had been identified as risks during the superstucture replacement project implemented on the track section, but they were transferred into residual risks although the raising of the track during the project deteriorated the already poor conditions. The legislation does not require the correction of level crossings during track projects, and the road keepers in the area were not aware of the track project. Road keepers should be involved already during the planning stage of track projects so that the common risks related to level crossings could be identified and managed in a comprehensive manner.
Fourthly, the Safety Investigation Authority recommends that the Finnish Transport and Communications Agency ensure that VR Group changes the emergency lighting of the Sr3 locomotive to meet the TSI requirements.
In the collision, the fuses of the locomotive's batteries broke down, causing the emergency lighting to fail. The locomotive's emergency lighting did not have the independent power supply required by the TSI.
Fifthly, in order to guarantee the recording of important motion data required during accident investigations on the rolling stock of all EU countries alos in the event of a power loss in the locomotive, the Safety Investigation Authority recommends that the European Railway Agency (ERA) ensure the implementation of the following recommendation: An independent power supply is required for new rolling stock being type approved that guarantees the operation of the recorder for a minimum of 30 minutes after power has been cut off.
In the collision, the fuses of the locomotive's batteries broke down, causing the data recorder to fail. Independent power supply is not required for data recorders in the TSI, which means that important information may be missed during accidents if power is cut out.
Sixthly, the Safety Investigation Authority recommends that the Finnish Transport and Communications Agency ensure that railway operators ensure that the cabin windows of the rolling stock are made of glass that does not cause additional injuries when breaking in an accident.
The wrong kind of shattering of the side windows of the locomotive's cabin in the accident and the missing fragment retention film increased the injuries of the engine drivers. The cabin windows should be made from laminated safety glass or have fragment retention films applied on them.
Seventhly, in order to achieve clearance operations that are as efficient and economical as possible, the Safety Investigation Authority recommends that the Ministry of Transport and Communications ensure that the Finnish Transport and Infrastructure Agency initiate a new review of the regulations concerning clearance work and clarify the roles of the actors in clearance operations.
An exceptional amount of clearance work was required after the accident, slowed down by the confusion between the infrastructure manager and the railway transport operator concerning responsibilities, command relationships and the use of rescue equipment. Clearance operations are currently not efficient or economical, particularly with a view on the entire rail network. The problem stems from the infrastructure manager's interpretation of the regulations on clearance operations, which prevents the railway transport operator from carrying out clearance operations. The Finnish Transport and Infrastructure Agency has started planning the reorganisation of clearance and rescue operations nationally so that in the future, the operations are neutral and independent of the railway transport operators. There is an intention to take steps in the matter with the changes in railway transport legislation made in 2019 so that the operational personnel are chosen through an open tendering process.
Eightly, the Safety Investigation Authority also recommends that the Finnish Transport and Communications Agency define an approval process for the risk assessment and supervise that the corrective measures are taken.
There was no process for the handling of the risk assessment required by the authority for the track project, there were no instructions on the matter, and the identified risks did not lead to action.
For further information, please contact:
Director, professor Veli-Pekka Nurmi tel. 02951 50701
Rail Safety Investigator Lasse Laatta tel. 02951 50709
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