R2015-S1 Theme Investigation on wrong routings in train traffic in 2015

The Safety Investigation Authority investigated factors causing wrong routings in train traffic, by examining a number of selected cases and going through all of the wrong routes formed in 2015, based on data made available by the Finnish Transport Agency, Finrail and VR. A total of 13 individual cases from 2015 were investigated. Brief reports of these were drafted and appended to the investigation report. The individual cases were selected for investigation on the basis of predetermined criteria (the seriousness, distructions, location and type of incidents). Furthermore, a query directed at traffic controllers sought to gather information, experiences and views related to the issue.

The Finnish Transport Safety Agency (Trafi) is charged with monitoring and developing rail safety and collaboration within the railway system, including the drawing up of regulations. Trafi supervises the operation of the Finnish Transport Agency and, through this, the operations of Finrail, which is the organisation in charge of controlling railway traffic. The Finnish Transport Agency administers the state-owned railway network, managing and assigning rail capacity to various operators. The Finnish Transport Agency is responsible for controlling railway traffic on the state-owned railway network, but purchases traffic control services from Finrail Oy, providing the company with instructions and monitoring its operations in accordance with the safety management system. Finrail controls traffic on the state-owned railway network, ensuring its safety. Traffic control is the responsibility of traffic controllers who have been trained in their duties and meet all the other requirements set for traffic controllers by Trafi. Railway traffic is controlled around the clock in traffic control centres located in Helsinki, Tampere, Kouvola, Seinäjoki, Oulu, Pieksämäki and Joensuu, and in some separate sites.

Most errors in 2015 related to wrong routings which occurred when the traffic controller was forming a route manually. In many cases, the automated system could have been used. Traffic controllers did not take maximum advantage of the automated system's functions or features. Routes were formed manually, because the traffic controllers believed that this made traffic run smoother and facilitated their work, and they distrusted the automated system. On occasion, traffic controllers also found that the automated system slowed down their work and made it too restrictive. In some sections of the railway network, the part of the automated system dealing with train numbers was not in use, despite the technology itself being in place. The manual forming of routes led to action-based slips, memory-based lapses and thinking errors.

In many cases, such errors only resulted in minor traffic disruptions, as the engine driver noticed the faulty position of a switch or signal. In one case, a passenger train being directed onto a track with no platform created a dangerous situation as passengers attempted to board the train, and lack of time prevented the station personnel from making an announcement and warning other traffic.

Higher rail traffic speeds require modifications to the interlocking systems. Insufficient attention has been paid to this within the remote control system. Trains need to slow down or even stop at signals until the signal indicates that driving ahead is permitted. The systems used for traffic control have also been in an almost constant state of change, which has affected the users of the systems. Several systems are in use and are subject to continuous changes. There is insufficient time to traffic controllers in the use of new or modified systems before their deployment.

At some traffic control points, small, unclear or erroneous display symbols, or a lack of symbols designating passenger platforms, hamper the work of traffic controllers. Several parallel traffic control systems were in use at some traffic control points. This hampered the work of traffic controllers as they moved between control tables, or worked at several tables simultaneously. Traffic controllers feel that they have insufficient say in the planning of new traffic 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 Finnish Transport Agency’s service providers. Obtaining an overall picture of the number of wrong routings is hampered by the fact that traffic controllers occasionally leave wrong routings unreported. 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. Finrail classifies some wrong routings as qualitative deviations. However, a wrong routing classified as a qualitative deviation may cause a dangerous situation for passengers if a passenger train is directed onto a track with no platform. The roles of the Finnish Transport Agency and Finrail as purchasers of control services and service providers are partly unclear. This hampers collaboration in the development of traffic control systems.

The regulations and instructions in effect were not identical to those actually used. Furthermore, the Railway traffic control manual in effect during the investigation has been classified as confidential. A high classification hampers the use of the manual. The Railway traffic control manual contains information that is useful in the training of instructors who train engine drivers and those responsible for trackwork, contributing to the safety of traffic and making it run more smoothly.

In order to reduce the number of wrong routes, the Safety Investigation Authority recommends that the Finnish Transport Safety Agency ensure the enforcement of the following new recommendations directed at various actors:

1. The Finnish Transport Agency should, in collaboration with Finrail Oy, ensure that, as a general rule, routes are formed by the automated system.

2. The Finnish Transport Safety Agency is obliged to create a uniform system for the reporting and classifying of deviations; one covering all actors.

3. The Finnish Transport Agency must 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 the sufficient orientation of personnel.

4. The Finnish Transport Agency must ensure that new systems or modifications to existing systems are not introduced incomplete, or without the sufficient orientation of staff.

5. When procuring traffic control systems, the Finnish Transport Agency must take steps to ensure that any development needs emerging in a system can be implemented smoothly during the system’s lifespan.

The Safety Investigation Authority would also like to highlight the following aspects:

• Instructions for the cancellation of a departure signal on tracks controlled via radio signals, issued as a voice mail communication based on a flash message, should be included in the instruction entitled Viestintä valtion rataverkolla (‘Communication on the state-owned railway network’.)

• When commissioning a switch for traffic control, clear written instructions positions should be drafted for the checking of the various signals.

• In the case of international traffic at border crossing points, it should be possible to relay a message via the engine radio to stop the train immediately. Similarly, a shared, manually operated signal should be available.

Reports only in finnish

R2015-S1 report (pdf, 1.62 Mt) R2015-S1 annex 1 (pdf, 0.03 Mt) R2015-S1 annex 2 (pdf, 0.04 Mt)

R2015-S1 Conclusions (pdf, 0.05 Mt) R2015-S1 Safety recommendations (pdf, 0.06 Mt)

R2015-S1-01 Tuomioja-Report (pdf, 0.79 Mt) R2015-S1-02 Hyvinkää-Report (pdf, 0.47 Mt) R2015-S1-03 Kerava-Report (pdf, 0.8 Mt) R2015-S1-04 Kouvola-Report (pdf, 1.3 Mt) R2015-S1-05 Ruukki-Report (pdf, 0.98 Mt) R2015-S1-06 Uusikylä-Report (pdf, 0.48 Mt) R2015-S1-07 Joutseno-Report (pdf, 1.32 Mt) R2015-S1-08 Kuopio-Report (pdf, 0.52 Mt) R2015-S1-09 Riihimäki-Report (pdf, 0.56 Mt) R2015-S1-10 Vainikkala-Report (pdf, 1.0 Mt) R2015-S1-11 Haarajoki-Report (pdf, 0.47 Mt) R2015-S1-12 Joensuu-Report (pdf, 0.74 Mt) R2015-S1-13 Laihia-Report (pdf, 0.55 Mt)