R2012-03 Incident in train traffic at Vammala station, Finland on 19 October 2012

An extensive railway line superstructure project of long duration was under way between Lielahti and Kokemäki section of line. At times, a great deal of stock was present in the same area of this large work site, requiring careful consideration of the repository for stock between shifts. When choosing repository for these maintenance machines, the aim was to minimise journeys to work sites. After the workday of Friday 19 October 2012, machinery used for superstructure work was driven for storage onto track 043 of Vammala station. Use of track in traffic usage for the storage of machinery between shifts had been agreed earlier at a trackwork meeting. However, the traffic controller was to be informed separately each time trackwork machines were left on the track.

As trackwork ended on the afternoon of Friday 19 October 2012, the trackwork supervisor and traffic controller held a telephone conversation on axle counting sections still occupied after the trackwork. The trackwork supervisor reported that all occupied sections could be released. The traffic controller gave emergency release commands to reset axle counters of occupied turnout and track sections. Such a command was also given for track section 043 of Vammala station. At 4.38 pm, an incident developed at Vammala station when, according to its route, a freight train approaching the Vammala railway yard from Äetsä was supposed to switch to secondary track 043, to await oncoming traffic. Upon arriving at the Vammala station entry turnout, the engine driver noted the presence of the machinery on the safety track to the left and, soon after, that track 043 was also full of maintenance machines. At this point, the machinery was around 100 metres away. The engine driver braked and the train stopped around 50 metres from the machines on the track. After having to reverse back onto the line, the train was driven onto track 041 at Vammala. Due to this situation, the passing of oncoming traffic could not be organised as planned.

The direct cause of this incident was the release of the track sections occupied by the maintenance machines with emergency release commands. This enabled later to set a route towards the machines on track 043 of Vammala station. A factor in the incident was the trackwork supervisor's forgetting to notify the traffic controller of the machinery on the track – the traffic controller was therefore unaware of its presence. Protection command enabled by the railway safety device system were not used in order to protect the work site – such a system could have been used to maintain information on the track's occupied status or to prevent to set train routes. When clearing the occupied track sections, the traffic controller and trackwork supervisor did not go through the status of each track section individually. Both parties acted in a routine-based and very rapidly manner. These factors increased the chances of an error being made. The trackwork supervisor had a large number of tasks to remember and releasing the track for use by traffic was the final task of the working week. These factors too increased the chances that something would be forgotten.

In order to avoid similar incidents and possible accidents, the Safety Investigation Authority (SIA) recommends that the Finnish Transport Safety Agency (Trafi) ensure that the following recommendations are implemented:

  • The Finnish Transport Agency should ensure that the command based track blocking is used effectively in centralised traffic control.
  • The Finnish Transport Agency should identify the best practices for resetting axle counting after trackwork and should include these practices in the railway traffic control manual.
  • The Finnish Transport Agency should ensure that traffic restriction notifications are also used when stock is stored on tracks in traffic usage.
  • The Finnish Transport Safety Agency should ensure that concrete guidance is given on risk management procedures, that those engaged in various activities are familiarised with these instructions and that the implementation of risk management procedures is monitored.

R2012-03 Report (pdf, 2.62 Mt)

Recommendations 334-337

 
Published 2.9.2013