R2019-S1 Theme investigation of shunting accidents and incidents

The investigation was undertaken because of the large number of accidents and incidents oc-curring during shunting operations. Another factor behind the investigation was the large number of shunting operators and infrastructure managers. The objective of the investigation was to gather detailed information on shunting accidents and incidents and use this infor-mation to identify safety defects that could be addressed to improve the safety of shunting work.

The investigation studied shunting accidents and incidents that occurred between 1 January 2019 and 30 April 2020. The events were divided into seven categories: collisions, derail-ments, signal passed at danger (SPAD), incorrect route, forcing a point open, runaway of wagons, and other shunting accidents and incidents. The shunting accidents and incidents reported to the Safety Investigation Authority were entered into a table according to the type of the event. Thirteen accidents and incidents from the period 1 September 2019 to 30 April 2020 were selected for more detailed investigation, and brief individual investigation reports were pre-pared for each of them. Determining what impact the involved individuals as well as the activ-ities and safety management of organizations had on the cases was a key part of the study.

When the facts had been collected, an analysis event was held in which the investigation team sought to identify the background factors of shunting accidents and incidents. The cases were analyzed with the Bowtie method. There were two objectives to the analysis: Firstly, the background factors related to the cases were compiled in a structured manner according to their nature, as well as the solutions that could have prevented the accident or incident. Sec-ondly, the consequences of the cases were examined, along with how they could have been managed. Then key factors were identified based on the analysis and conclusions drawn from them. Finally, the investigation team drew up safety recommendations that could be implemented to improve the safety of shunting work.

The following conclusions were made:

1. Rushed work and assumptions decrease the safety of shunting work and can lead to neglecting to keep a lookout or check the actual state of things.

2. Self-direction, the requirements of planning your own studies, and the assimilation of information and verification of competence are emphasized in online training.

3. Not enough attention has been paid to the lighting of railway yards and rolling stock. Obsolete lights should be replaced with new energy-efficient technologies.

4. The visibility of track signs needed during shunting work is poor, especially in artificial light, so their colors can be confused with each other.

5. Deviation reports will only be filed if they are processed quickly, feedback is given and corrective measures are implemented. The boundaries between operators should not pre-vent the correction of shortcomings in safety.

6. It is crucial to take all operators and user groups, as well as the mutual effects of the changes on each other, into account when making changes.

7. Shunting instructions and the supervision of their compatibility are currently not sufficient in a multi-operator environment.

8. Standardized communications and a culture of asking questions have been neglected in the railway industry. They are vital for safety, especially in uncertain situations. Old practices die hard.

9. Not enough attention has been paid to the compatibility and usability of railway information systems. Technical regulations to ensure the compatibility of systems are insuffi-cient in the industry.

10. Traffic control is largely organized according to the needs of train traffic, and shunting work is viewed as a support function. This can lead to overlooking the safety aspects of shunting.

11. The annual financial impact of shunting accidents is significant because of the large number of annual incidents.

12. The threshold for making railway emergency calls is still too high.

In order to avoid accidents and incidents in the future, the Safety Investigation Authority rec-ommends that the Finnish Transport and Communications Agency (Traficom) ensures that:

1. Railway training institutions, infrastructure managers and railway operators develop their online training in order to ensure the assimilation of the required information and the professional competence of employees taking the courses.

2. Infrastructure managers improve the lighting of railway yards with modern technology.

3. Railway operators improve the lights of locomotives used for shunting with modern technol-ogy.

4. The Finnish Transport Infrastructure Agency reviews track signs and ensure their visibility and unambiguity.

5. The Finnish Transport and Communications Agency develops its safety deviation information system so that it can be used to follow the processing of deviations. Furthermore, the Finnish Transport and Communications Agency ensures that all operators in the railway in-dustry have functional deviation management processes.

6. The Finnish Transport Infrastructure Agency assumes overall responsibility for shunting work instructions in Finland by supplementing the Train Traffic and Shunting Safety Guide-lines document in this regard. Operators can only be permitted to have supplementary local guidelines drawn up in cooperation with other operators.

7. The Finnish Transport Infrastructure Agency and railway operators improve the interoperability and usability of their information systems.

8. The Finnish Transport Infrastructure Agency implements technical safeguards for protecting routes from traffic entering from class 2 traffic control areas.

9. The Finnish Transport Infrastructure Agency, Finrail Oy, railway industry training institu-tions, railway operators and infrastructure managers stress the importance of making railway emergency calls in their basic and refresher training.