R2013-02 Collision of a freight train with an excavator on the Pännäinen–Kolppi section, Finland, on 7 November 2013 and other occurrences and incidents in 2013

On Thursday, 7 November 2013 at 5.17 p.m., freight train 5489 collided with an excavator carrying out trackwork on the track section between Pännäinen and Kolppi, on which superstructure and electrifica-tion works were being conducted. Located near Pännäinen Station, the trackwork supervisor had requested the traffic controller for permission for an excavator to carry out trackwork. The permission was given for the work to begin on the Pännäinen−Kolppi section "behind a freight train". The trackwork supervisor informed the excavator driver of the permission. At the time, the excavator was located 3.4 kilometres from Pännäinen Station towards Kolppi.

Having driven the excavator partially onto the track, the driver noticed the lights of an approaching train and immediately attempted to get off the track. Only moments earlier, the engine driver had realised that signal P523 had been switched to display Stop and had begun emergency braking from the speed of 50 km/h. However, the locomotive’s left buffer hit the left rear corner of the excavator's top carriage and the locomotive’s lower part hit the rear left corner of the excavator's undercarriage.

The excavator driver sustained minor injuries in the collision. The freight train had two Dv12 locomotive. The collision caused a hole into the fuel tank of the first engine, and fuel leaked onto the track. The left steps of both engines were either bent or broken. The excavator was damaged beyond repair. The track and track equipment did not suffer damage. Traffic at the accident site was interrupted for 3.5 hours. The total costs of the damage to the rolling stock amounted €4,300 and to the excavator €80,000.

The immediate cause of the accident was attributed to incorrect or unclear communication regarding the trackwork permission given during a conversation between the trackwork supervisor and the excavator driver. The confusion was caused by the permission given by the traffic controller and and wording "behind the train", and the trackwork supervisor's location at Pännäinen Station without visual contact with the excavator. Works permission practices had developed between the traffic controllers and trackwork supervisors that expedited trackwork but contributed to hazards. Short-circuit conductors were not used for securing the construction site. The root cause of the accident was a prolonged exceptional situation at Pännäinen Station, which was attributed to the trackwork contract and its delay. The traffic controller and the trackwork supervisor were overloaded with work. The delay in the contract was caused by several factors, such as employee incompetence and problems in communication, management and monitoring.

Of the other accidents and incidents covered by this investigation, four unauthorised trackworks, four cases of machinery driven beyond the authorised construction site and some other isolated cases were analysed in more detail. In addition to human error, lack of knowledge, and deliberate risktaking was found to have played a role in causing these events. Other underlying factors in a number of cases included problems in communication, and deficiencies in work planning and employee induction.

This investigation focused in particular on the safety training for trackwork, safety culture and safety management, and monitoring. The training leading to a trackwork safety qualification, in line with the instructions issued by the Finnish Transport Agency, and the trackwork supervisor's training, meeting the requirements determined by the Finnish Transport Safety Agency (Trafi) and supplemented by the additional requirements set out by the Finnish Transport Agency, currently fail to ensure compliance with safe practices.

Certain worrying aspects were observed regarding trackwork safety culture, arising from competitive bidding, outsourcing of works, and the resulting subcontracting chains. A weak safety culture was indicated by observations such as those concerning situations where contractors had knowingly disregarded safety instructions and regulations, trackwork had been initiated without appropriate authorisation, trackwork safety areas had been disregarded and tools had been left on the track. The critical nature of safety device for the safety of rail traffic was at times not understood or disregarded.

Safety management and monitoring made by the Finnish Transport Agency were found to be ineffective. Competitive bidding lacked appropriate emphasis on compliance with safety regulations. There is little field monitoring, and if safety deficiencies are detected, by and large the only tools for addressing them are discussions or warnings.

In order to avoid similar accidents in the future, and to improve trackwork safety, the Safety Investigation Authority, Finland recommends that the Finnish Transport Safety Agency (Trafi) ensures the implementation of the following new recommendations:

• The Finnish Transport Agency will determine stricter minimum requirements for trackwork safety training.
• The Finnish Transport Agency will ensure that trackwork supervisors focus on their traffic safety function, and develop better tools for trackwork supervisors for ensuring safety.
• The Finnish Transport Agency will include in all trackwork contracts the detailed financial con-sequences for the contractor arising from compliance or non-compliance with safety regulations.
• The Finnish Transport Agency will ensure that contracts include a separate and sufficient timeframe for planning trackwork and clarifying responsibilities before trackwork is begun.
• The Finnish Transport Agency will increase the field monitoring of trackwork safety regulations by allocating appropriate resources for such work.
• The Finnish Transport Agency will allocate sufficient resources for developing the careful, sys-tematic and rapid processing of safety deviations.

In addition, the Safety Investigation Authority, Finland reiterates recommendations issued previously:

• S312 A single and common accident and deviation database for all those operating the railway system in Finland should be created. (S1/2011R)
• S183 Shunting work practices should be developed by regulations, instructions and education in a way that “conditional permissions" to shunting movements or to any other traffic would not be given. The permission to a movement should be given once and only in case the movement is really possible. (C8/2002R)
• S119 Short-circuit conductors should be introduced to secure an occupied slot. (C6/1998R)
• S173 Working in too short time periods should be avoided. (C5/2001R)
  

R2013-02 report (pdf, 3.05 Mt)