C4/2009R A passenger train ended up on the wrong track in Koria, Finland, on 1 October 2009

At 12:29pm on Thursday, 1 October 2009, a dangerous situation occurred at the Koria operating point on the Lahti-Kouvola railway section, when a passenger train ended up on the wrong track in front of a goods train.

Several sub-projects relating to the Lahti-Luumäki-Vainikkala construction project were underway on the Lahti-Kouvola railway section. With regard to the Koria operating point, work was in progress relating to the commissioning of a new switchover monitor system to be installed on the Lahti-Kouvola railway section. Since the Automatic Train Protection (ATP) system was not operational at the Koria operating point, special arrangements had been made there, including the manning of the switchover monitor at the operating point.

A goods train arriving from the direction of Lahti had stopped on the southbound track, to the west of the Koria operating point. The dangerous situation occurred when a passenger train, arriving from the direction of Kouvola along the northbound track and passing through the turnouts near the western end of the Koria operating point, entered the southbound track in front of the goods train. The engineer of the passenger train noticed the danger in time and managed to bring the train to a halt 200 metres ahead of the locomotive of the goods train.

The immediate cause of this dangerous situation was the transverse route created ahead of the passenger train by the traffic controller. The traffic controller’s picture of the situation was not up to date, as a result of which his perception of the location of the passenger train was incorrect.

The situation arose due to signal E being inoperative. No switchover monitor was employed to secure all routes.

Another contributing factor lay in a feature of the switchover monitor, which enables the turnouts on the route being set to turn even if one or more of the railway sections in the switch lane area are taken. Furthermore, the switchover monitor in use enabled a ‘drive’ signal to be displayed for the goods train.

Ambiguous instructions were issued for centralised traffic control during the construction work at the Koria operating point. Furthermore, the operating model did not utilise the safety features of the switchover monitor to the full.

To prevent similar situations from occurring, the investigation committee recommends that safety planning be enhanced during transitional stages.

C4/2009R Report (pdf, 1.2 Mt)

•Recommendation S280