3. Investigations by the Directorate General in 2011

Transcription

`|Ç|áàÜç
`|Ç|áàÜç yÉÜ \ÇyÜtáàÜâvàâÜx tÇw gÜtÇáÑÉÜà
DIRECTORATE-GENERAL OF THE ITALIAN RAILWAY INVESTIGATION BODY
Annual Report
2011
Contents
Page
1. The Directorate General of the Italian Railway Investigation Body 3
1.1. Foreword by the Director General
3
1.2. Reference standards
6
1.3. Role and aim
7
1.4. Organisation
8
2. Accidents and the safety regime
9
2.1. Commencement of investigations by the Directorate General
9
2.2. Institutions involved in the investigations
10
3. Investigations by the Directorate General in 2011
11
3.1. Investigations on accidents
11
3.2. Railway safety studies and research activities
22
4. Other Directorate General activities in 2011
25
5. Recommendations
26
6. Conclusions
28
The following personnel from the Institutional and International Relations Division–Safety Database
collaborated in the preparation of this report.
Massimo Costa
Director
Salvatore De Marco
Functionary
Direzione Generale per le Investigazioni Ferroviarie
[Directorate General of the Italian Railway Investigation Body]
Italian Railway Investigation Body
Translation provided for information purposes, by the Translation Centre for the
bodies of the EU. The only valid version is the original version provided by the NIB
2
1. The Directorate General of
the Italian Railway
Investigation Body
1.1. Foreword by Director
General
The annual report on the activities of the
Directorate General of the Italian Railway
Investigation Body, which performs the functions
of Investigative Body provided for by Directive
2004/49/EC of the European Parliament and of the
Council and by Legislative Decree No 162 dated 10
August 2007, is prepared annually in accordance
with said rules and regulations, and for the second
year it is published in the form of booklet to
facilitate easy and concise consultation by
everyone.
During 2011 the Directorate General which I
direct has seen certain improvements in its
production capacity with the substantial division of
the responsibilities between the two Divisions for
the two main areas of activities (international
relations and investigations), as the new Divisional
Directors took up their positions at the end of 2010.
However, in my opinion, these improvements are
still not sufficient, since there are still serious
shortfalls in terms of human and financial
resources.
The activities have substantially moved forward
with regard to the general aims and also with
respect to the strictly technical-operational
objectives which were established at the end of
2010, including:
the renewal and consolidation of relations with
the European Commission (Directorate General
MOVE) and with the European Railway Agency
(ERA) as well as the strengthening of major
bilateral relationships with investigative bodies in
other EU countries;
an analytical study of the railway accidents at
level crossings. Since incidents at level crossings
continue to be one of the main causes of fatal
accidents within the rail system, the Directorate
General started a systematic study of these
accidents in 2011. The study concluded with a
series of proposals for technological modifications
to the systems and to the accessories and certain
proposals for modifications to regulations. The
results achieved were also obtained thanks to
collaboration with certain investigation bodies of
other European countries, which enabled the
Directorate General to check which were the best
practices at the EU level;
an analytical study of the derailments and
especially a study of the derailment detection
devices (DDD).
the commencement
of a meaningful
collaboration with the Italian judicial authorities in
relation to rail accident investigations. This type of
collaboration was also specifically requested at
European Commission level. At the end of 2010 the
Commission complained about Italy’s failure to
comply with the provisions of Directive
2004/49/EC which expressly provides for a process
of virtuous cooperation–while respecting respective
competences–between the judicial authorities and
the National Office responsible for investigating
technical causes. In Italy the national office
responsible is in effect my Directorate. A
particularly important result of this collaboration
was the decision of the Tribunal of Lucca to permit
the Board of Inquiry of this Directorate General
(appointed to investigate the Viareggio railway
accident of 29 June 2009) to participate in the
special evidentiary hearings initiated by the
preliminary investigating magistrate (GIP) of Lucca
during 2011. The technical investigation of the
accident performed by the Directorate General runs
in parallel with the investigation started by the
judiciary. Activities in 2011 consisted of joint
3
the Italian Railway
Investigation Body
testing of the materials associated with the special
evidentiary hearing.
Many of the activities of the Directorate General
were concentrated on the accident in Viareggio. But
I am pleased to confirm that, in parallel with the
inquiry and as I mentioned in the 2010 annual
report, we have seen, even though with expected
resistance, the beginnings of a complex process of
research and analysis aimed at the future
drafting/finalisation of legislation and regulations at
both a national and EU level aimed at the
prevention of similar occurrences.
This process has in part already led–having
clarified the technical mechanisms which caused
the Viareggio accident–to a new general attention to
the issue of safe transportation of hazardous goods
by rail, with a renewed technical awareness in this
specific technical sector.
The inquiry on the Viareggio accident, which was
concluded on 23 March 2012 (a date which can
now be referred to with the publication of this
annual report), presented 11 recommendations
mainly regarding the need for amendments to the
regulatory system, with extremely innovative
aspects regarding the adoption and control of
mandatory maintenance processes for railway
vehicles carrying hazardous goods as well as the
crucial issue of the “traceability” of the
maintenance activities.
Already back in 2011, before completion of the
inquiry, the results were announced and debated by
the Directorate nationally and internationally (the
European Commission, the European Railway
Agency, the International Rail Transport
Organisation), in an attempt to stimulate the
establishment of new working groups on the issue,
in advance of the completion of the inquiry.
One cannot hide the fact that the reactions,
especially at an international and EU level, have
still not shown an “immediate willingness to
change”, precisely because of the significantly
innovative nature of the contents of the
recommendations.
All innovative paths are difficult, bristling with
obstacles and sometimes resistance by the sector,
but the action of the Directorate General of the
Italian Railway Investigation Body will stand firm,
within the institutional limitations, in following the
process, which will obviously be the subject of
normal critical and pluralistic evaluation, in order to
implement the recommendations issued.
I have no doubt that has been started will result,
even in the near future, in a reduction in the number
of incidents. I wish to emphasise a guiding
principle for the recommendations issued following
the Viareggio incident: it is not solely a question of
improving the chain of operational procedures and
merely
“better
identifying
a
chain
of
responsibilities”. It is also a matter of effectively
preventing the occurrence of disasters of this
proportion through the avoidance of the de facto
risk presented by a serial avoidance of
responsibilities resulting from suspect, if not even
clearly false or inconsistent, certification processes.
The development of rail transport liberalisation
has accentuated the contrast between the “quality
by reputation”–typical of historically consolidated
operators–and the concept of “quality by
certification” typical of a liberalised situation.
In effect, one wants to prevent the second
concept, which is valid and incontrovertible at a
conceptual level, from becoming dangerously
vacuous at a real level through the concentration of
“major responsibilities” in the hands of just a few
parties (maintenance workshops or ECM–Entity in
Charge of Maintenance). These parties are often
selected by the sector on the basis of the cost of
4
the Italian Railway
Investigation Body
their services alone, a criterion which is clearly
mistaken and therefore risky.
Again this year I must conclude this brief note of
introduction with a thought for the victims of the
accident in Viareggio and, above all, express to the
victims’ families the satisfaction of having now at
least issued a complex framework of safety
recommendations aimed at the relevant authorities,
at both an Italian and EU level–which have been
reminded many times and on various occasions of
the duties, not merely moral but also institutional,
of the parties involved in carrying forward the
actions.
I feel confident in saying that this Directorate
General, with its staff, collaborators and external
experts, feels it a privilege to be able to start and
consolidate the virtuous processes, always
operating with the appropriate spirit of service
towards the State and its citizens.
I take this opportunity to confirm that with a new
specific Management Decree issued at the end of
the summer of 2012, I authorised the Viareggio
Board of Inquiry to perform the second part of the
investigations (overturning of the tank wagon
containing LPG, fracturing of the tank, and
catching fire of the contents), after the first part had
fully defined the primary technical causes of the
incident.
This is due to the fact that the documentation in
possession of the Board has now been enriched
with new analytical material which I trust will
permit final identification–in a truly definitive
manner, or at least highly probable from an
engineering point of view–of the element present
on the infrastructure which led to the fracturing of
the tank and the resulting consequences.
Marco Pittaluga
5
the Italian Railway
Investigation Body
1.2. Reference standards
Legislative Decree No 162 of 10 August 2007,
implementing Directive 2004/49/EC, established–
within the Ministry of Infrastructure and Transport–
the Directorate General of the Italian Railway
Investigation Body (DGIF). This decision was
rendered operational with Presidential Decree No
211 of 3 December 2008 (Regulation on the
reorganisation of the Ministry of Infrastructure and
Transport) and finalised with Ministerial Decree No
307 of 2 April 2009.
6
the Italian Railway
Investigation Body
1.3. Role and aim
The main aim of the Directorate General of the
Italian Railway Investigation Body is the
improvement of rail safety.
This aim is pursued by identifying the causes of
the accidents or operational incidents and defining
any safety recommendations.
The investigations started following railway
accidents or incidents (which the Directorate
General performs with its own staff or external
investigating officers) are aimed at identifying the
direct causes, contributing factors and the
underlying causes which have led to the incident.
The aim is therefore not merely to analyse the
technical aspects which have led to the event, but to
go even further, analysing also the procedural and
regulatory aspects to check for any errors or
shortcomings.
The final investigation reports must be finalised in
a short time which is compatible with the
performance of the activities that the EU and Italian
regulations specify to guarantee transparency
(providing information on the development of the
investigations to all parties involved, allowing
access to and commenting on the results, presenting
opinions on the investigations and being authorised
to express comments on information in reports).
The final investigation reports contain any safety
recommendations proposed by the Investigating
Board or by the investigating officer.
The Directorate General sets out any further
recommendations on the basis of the causes
identified (as well as those highlighted in the final
investigation report) and transmits them, together
with the report, to the interested parties (the ANSF,
the Infrastructure Operator, the Railway
Undertakings, etc.) and to the European Railway
Agency. It should be noted that the investigations in
no way aim to establish liability for civil or
criminal damage, as the judiciary is the sole
authority competent to do so.
The Safety Recommendations represent the core
business of the Directorate General and their issue
starts the process for improvement of safety which
results in the sharing of the recommendations at EU
level, through the European Railway Agency, with
the counterpart investigating bodies of the other
countries.
7
the Italian Railway
Investigation Body
1.4. Organisation
Ministerial Decree No 167 of 29 April 2011
provides for the organisation of the Directorate
General in two divisions:
Division 1–Institutional and International
Relations Division–Safety Database
Division 2–Investigations on rail accidents
Responsibilities of Division 1:
relations with European Railway Agency;
relations with the National Railway Safety
Agency;
relations with Network Operators and Railway
Undertakings;
relations with the other investigation bodies of
the EU;
relations and conventions with outside bodies
(Railway Police, Civil Protection Agency, etc.);
preparation, management and updating of of
safety database;
annual report.
Responsibilities of Division 2:
establishment of investigating boards for railway
accidents;
coordination of investigations;
performance of investigation procedures;
investigation of operational incidents;
preparation of the recommendations regarding
safety issues pursuant to Article 24 of Legislative
Decree No 162 of 2007;
training of investigation staff;
establishment, management and updating of the
list of experts for performing the role of
investigating officers.
DIRECTOR-GENERAL
Marco Pittaluga
Division 1
Division 2
Institutional and International
Relations
Safety Database
Massimo Costa
Investigations on rail accidents
Eugenio Martino
8
2. Accidents and the safety
regime
2.1. Commencement of
investigations by the
Directorate General
The Directorate General of the Italian Railway
Investigation Body (DGIF) conducts its remit as
envisaged by Directive 2004/49/EC for the purpose
of conducting investigations:
following serious rail accidents;
following accidents and incidents that, under
other conditions, could have led to a serious
accident, including technical failures of structural
subsystems or of railway system components.
Investigations are performed in compliance with
EU and Italian regulations and aim to provide
recommendations for the improvement of rail safety
and accident prevention both in Italy and in other
EU member states.
The activities of the various investigative bodies
within the EU take place within a process of
common application of best practices, with
investigatory procedures and methods being
harmonised, thus providing a mutual interchange of
best investigative practices applied by the various
states in the different and varied sectors of
relevance to railway operations and to railway
safety understood as a system composed of various
components.
It should be noted that in cases where there is no
strictly formal obligation to open an investigation
as explicitly codified in the standard, the opening of
an investigation by the DGIF is based on
parameters of a more general nature. In practice, the
Directorate General has the discretionary powers to
decide whether or not to open an investigation. In
exercising its discretionary power it evaluates:
whether the event is part of a series of accidents
or incidents relevant to the system as a whole;
the potential impact of the event on railway
safety at the EU level;
the media coverage of the event, in order to use
this factor as the preferred channel for the
dissemination of recommendations following
investigations;
any requests formulated by infrastructure
operators, railway undertakings or the Italian
National Safety Authority (ANSF).
The range of the investigations and the relevant
procedures are established by the Directorate
General also taking into account the lessons it
hopes to learn from the accident or incident for
safety improvement purposes.
As already mentioned, the regulatory provisions
specify that the investigation should not seek in any
circumstances to establish fault or liability and
above all that the recommendations issued are
formulated–in order to ensure the effectiveness of
the process–in a clear and detailed way but without
sacrificing general coverage of the field of
application, where necessary for the prevention of
accidents.
9
2. Accidents and the safety
regime
2.2. Institutions involved in the
investigations
The investigations carried out in 2011 saw the
involvement, for various aspects, of the following
institutional bodies:
The National Railway Safety Authority (ANSF),
as the recipient of the majority of the safety
recommendations and, as provided for by Article 21
of Legislative Decree No 162 of 10 August 2007,
being an involved party;
The European Railway Agency, as an informed
party on the investigations in progress and being a
recipient of the recommendations and the
investigation reports;
The Ministry of Infrastructure and Transport,
Directorate General for Highway Safety and Local
Authorities, involved for various reasons in certain
investigations having particular aspects requiring
their involvement, especially for issues regarding
road-rail interaction points.
10
3. Investigations by the
Directorate General in 2011
3.1. Investigations on accidents
The accidents which must be immediately
reported by the Italian infrastructure operator are all
those listed in the table below. All these accidents,
whatever their consequences, must be reported, to
allow the Directorate General to decide whether or
not to commence an investigation.
The incidents which justify the proposal of
interventions to improve rail traffic safety are
incidents whose determining causes and critical
aspects merit evaluation because of the seriousness
of the incident or potential incident (i.e. an incident
which through a fortunate combination of
circumstances remained a theoretical risk or did not
actually result in an incident) or because of the
excessive frequency of occurrence. For this reason,
the Italian Railway Investigation Body has defined
specific criteria for selection of the type of events
that must be reported to it–whatever the
consequences of the accident–by the Infrastructure
Operator and Railway Undertakings.
These criteria, defined at the end of 2008, still
represent the points of reference for the acquisition
of the data with which the Directorate General
operates. The examination of the information
permits a rapid and overall evaluation of the
incident and its severity and allows a decision to be
taken as to whether or not to open an investigation.
The types of incidents which are to be promptly
reported and the number of such incidents
occurring in 2011 are detailed in Table 1.
Table 1–Events reported to the DGIF
Type of event
TOTALS
Collisions
193
Fatal collisions
67
Non-fatal collisions
Collision between trains or between a train and an obstacle
62
Incidents relating to trains transporting hazardous freight
13
Signals wrongly passed by trains
16
Train derailments, derailments
27
Level crossings wrongly left open
12
Uncontrolled movement of railway vehicles
1
Fires on rolling stock
11
Uncoupling of passenger trains
1
Damages amounting to at least €150,000
-
Collision between work vehicles
-
Serious incidents occurring in sidings or in depots
-
Other (incorrect routing, missing slow-down signal)
39
Interruptions in rail traffic lasting more than 6 hours
18
Investigation is therefore the main duty of the
Directorate General which, from the date of its
establishment, established Investigation Boards of
NOTES
with the remit to investigate individual incidents or
series of incidents.
11
3. Investigations by the
Directorate General in 2011
This activity continued in 2011 with the
completion of many of the investigations initiated
in 2010 and with the appointment of new
Ministerial Committees or individual Investigating
Officers (for details, see Table 2).
Closed at 31.12.2011
Table 2–Investigations in 2011
Date of incident
Place
22.06.2009
Prato–Vaiano section
14.12.2009
Verzuolo
from 2000 to 2010
various
19.12.2009
Scala di Giocca
04.11.2010
Vipiteno
Open at 31.12.2011
from 18.09.2009 to
26.08.2010
from 01.01.2009 to
04.05.2009
various
various
29.06.2009
Viareggio
from 21.04.2010
various
15.01.2011
Villa San Giovanni
27.01.2011
Incident
Inquiry end date
(publication of
final report)
Derailment of train transporting hazardous
goods
05.07.2011
Runaway rolling stock
13.04.2011
Improper passing of stop signals (SPAD–Signal
Passed At Danger)
20.05.2011
Collision of train No 8921 with an obstacle
06.06.2011
Splitting of train No 48867 and partial loss of
cargo
Discharge of hazardous material from railway
wagons
Accidents relating to passengers boarding or
leaving trains in motion
Derailment of freight train transporting
hazardous goods
Problems with operation of level crossings
07.02.2011
20.05.2011
under completion
(Ended on 23.3.2012)
under completion
Derailment of freight train 57369
(Ended on 06.03.2012)
Metaponto–Sibari line
Fatal accident of a worker repairing the line
(Ended on 06.03.2012)
08.05.2011
Lentini–Gela line
Collapse of two arches of a railway viaduct
under completion
08.06.2011
Rome–Florence DD line
09.06.2011
Sempione Tunnel
12.07.2011
Collision of train with work vehicle
(Ended on 18.07.2012)
Fire on freight train
(Ended on 20.07.2012)
Parma–Vicofertile section Collision of a truck at a level crossing
(Ended on 05.06.2012)
Series of collisions at the level crossing
(Ended on 05.06.2012)
Derailment of ETR 485.036 Frecciargento train
during shunting
(Ended on 17.02.2012)
23.07.2011
Monza–Arcore section
31.07.2011
Napoli Centrale
24.09.2011
Verona–Brenner line
Splitting of passenger train 13468
under completion
22.11.2011
LameziaTerme C.le–
Catanzaro Lido line
Derailment of regional train 3793 following
collapse of a railway bridge
under completion
A detailed description is given below of the
individual events investigated.
22.06.2009–Prato–Vaiano section, derailment
of train transporting hazardous goods
12
3. Investigations by the Directorate
General in 2011
On 22 June 2009, at 4:56 a.m., the Trenitalia
freight train No 55399, consisting of 23 wagons
and pulled by locomotive E652.152, running
regularly on the down line track, stopped at
kilometre marker 20+480, between the stations of
Vaiano and Prato Centrale, due to a rupture of the
brake pipe as a result of the detachment of wagon
15–a two-axle tank wagon–from the next wagon.
The detachment was caused by abnormal
running conditions of the tank wagon which,
diverted to the progressive kilometre marker
25+585, had in the meantime lost its wheelsets,
damaging the infrastructure for a stretch of
approximately 2700 metres.
When the train came to a complete standstill it
was split into two sections:
the first, at the Prato side, with the locomotive,
14 wagons intact and the tank wagon without
wheelsets;
the second, at the Vaiano side, with 8 wagons,
the first of which had been damaged by the
wheelsets lost from the tank wagon.
The tank wagon slightly overran the clearance
gauge of the adjacent track for up-line trains
(direction Prato-Bologna), where the regional
Trenitalia train No 11674 was due to arrive at
05.05 a.m. (having departed from Prato Centrale
at 5.02 a.m.), which lightly struck the tank wagon
with a handrail of locomotive E464.
The regional train also came to a halt, stopped
by the train driver who was alerted by the sound
of impact. The tank wagon was carrying about 20
tons of anhydrous hydrogen fluoride. Despite the
derailment, the distance travelled for several
kilometres and the subsequent collision with the
regional train, there was no spillage or dispersal
of the tank contents.
No injuries were suffered by the train crew or
passengers in the incident.
The incident was the result of the derailment
caused by the breakage of the main leaf of the left
leaf spring of the first axle (in the train’s direction
of travel) of the two-axle tank wagon. This
finding was based on the condition of the surfaces
of the leaf spring, on the analysis of Board
documents and on the surveys performed on site
immediately after the event.
The investigation ended on 05.07.2011 and this
was followed by the issue of five
recommendations by the Directorate General.
14.12.2009–Verzuolo, runaway rolling stock
On 14.12.2009, at 6:39 p.m., the freight train No
50406 (consisting of 13 wagons loaded with
paper, attached to locomotive D100 051 HU) ran
away out of control from the station of Verzuolo
(in direction of Saluzzo) along the SaviglianoSaluzzo-Cuneo line.
The runaway of rolling stock occurred during
train shunting operations by the railway
undertaking SBB Cargo Italia Srl, having
completed the shunting manoeuvre out of the
railway junction of Cartiere Burgo.
The column of runaway vehicles reached the
station of Saluzzo where it impacted with
passenger train No 4405, previously evacuated by
Trenitalia personnel, after a telephone alert by
personnel of the RFI.
The investigator assigned identified the direct
cause of the incident to the loss of continuity of
the main brake pipe which made it impossible for
the train crew to apply the train brakes.
Other factors also caused the incident:
1. Failure to activate the emergency stop
2. Failure to activate the handbrake, not present
on the last wagon, by the shunter of SBB Cargo
Italia Srl.
13
General in 2011
The indirect cause of the accident is, on the
other hand, due to the improper conduct of the
drivers and shunting personnel who were
responsible for composing and inspecting the
train and for shunting the train out of the junction.
The investigation ended on 13.04.2011. The
investigation made a number of recommendations
addressed to the railway undertakings.
SPAD at various locations, from 2000 to 2010
The investigation related to a series of incidents
of improper passing of stop signals at danger
(Signal Passed At Danger–SPAD) which occurred
on the national railway network. Recent incidents
were focused on.
The Ministerial Board has identified human
error as the direct cause of the incidents.
The contributing factors can therefore be
attributed to altered psychological and physical
conditions, insufficient attention, failure to follow
procedures or poor training of personnel.
The investigation ended on 20.05.2011 and,
considering the measures already put into place,
no recommendations were issued.
19.12.2009–Scala di Giocca, train collision
against an obstacle
On 19 December 2009 at 6:12 a.m., Trenitalia
regional train No 8921, connecting Porto Torres–
Ozieri–Chilivani, consisting of railcar Aln 6683205 (front of train) and Aln 663-1173, at
kilometre marker 31+531 struck an obstacle
occupying the railway line at the left side of the
driver’s cab. The collision caused the derailment
of the front Aln, the death of the driver, slight
injuries to passengers and crew and damage to the
rolling stock and infrastructure. The second Aln
remained on the track.
The investigator assigned found that the event
was not attributable to rail traffic problems.
Analysis of documentation supplied to the DGIF
shows that the infrastructure operator of the place
where the accident occurred had put in place
works to protect the railway line in question.
The examination of the incident led to the issue
of a recommendation to the Italian National
Safety Authority. The investigation ended on
06.06.2011.
04.11.2010–Vipiteno, splitting of freight train
Train No 48867 of the railway undertaking RTC
(Rail Traction Company), consisting of a main
locomotive, a secondary locomotive and a trainset
of 20 double-deck car transporter wagons,
departed Brennero for Verona Q.E. at 9:45 p.m.
On arrival at the outgoing points at the station of
Vipiteno it stopped because the emergency brake
was applied following the rupture of the main
brake pipe. This was in turn caused by the
splitting of the Laaeks wagon, third from the
front, into the two half-wagons composing it, due
to the loss of the pin of the coupling joining the
two halves of the rolling stock.
There was material damage to the wagon, the
load and the infrastructure and traffic on the line
was disrupted.
The Ministerial Board assessed the event as
being attributable to insufficiency or absence of
control of a recent maintenance intervention
performed on the central coupling of the wagon.
The Board indicated that the inspection of towing
equipment should be more careful and systematic.
The investigation ended on 07.02.2011.
Discharge of hazardous material from railway
wagons at various locations, from 18.09.2009 to
26.08.2010
14
General in 2011
The investigation focused on railway incidents
involving trains carrying hazardous material from
18 September 2009 (train No 54493), up to
26 August 2010 (train No 48129). These incidents
had been unusually frequent during the period
considered.
The investigations identified defects in
mechanical seals or the incorrect positioning of
certain components of the same as the most
common causes of the incidents. In certain cases
the loss of hazardous material was caused solely
by the improper tightening of the closing
components of the tank wagons.
Amongst the contributing factors identified by
the Ministerial Board were shortcomings in
inspections to verify that no material would be
lost from wagons and to verify the tightness of
sealing components, and poor maintenance of the
tank wagons and equipment.
The analysis of the incidents, the dynamics and
the causes has resulted in two recommendations
to the Italian National Safety Authority relating to
a necessary clarification of responsibilities during
certain stages of the international transportation
of hazardous materials, and the need to take or
continue to take coordinated action with the
individual national safety authorities of
neighbouring countries aimed at intensifying
inspections of trains transporting hazardous
materials. This is because it was found that the
largest number of these events occurred on tank
wagons from abroad and especially from France.
The investigations, started on 21.06.2010, were
completed on 20.05.2011.
Accidents relating to passengers boarding or
leaving trains at various locations, from
01.01.2009 to 04.05.2009
These investigations relate to accidents
involving passengers getting onto or alighting
from trains in motion.
Following the first investigations, the railway
undertakings initiated a process to change the
methods of opening/closing doors on all trains
with centralised door control. Current doorclosing methods may be classified by type of
train:
- Eurostar trains–centralised door control with
remote door closing and door locking on
activation of the door closing signal by the crew.
The doors open at the request of the traveller,
subject to the consent of the driver.
- IC and IR (Intercity and Interregional) trains–
remote closing and locking of doors for a specific
period of time.
- vintage trains–manual opening and closing of
doors.
A further activity involves analysing notices to
users about malfunctions: if there is a door
malfunction, a printed notice should be affixed to
the door in question, and travellers should be
notified in good time so that they can prepare to
get off the train and ensure that the door which
they intend to use is in service.
29.06.2009–Viareggio, freight train derailment
The investigations relating to the derailment of
29.06.2009 at the station of Viareggio continued
throughout 2011 and ended on 23 March 2012.
The direct cause of the derailment was already
identified in 2009 as being the structural failure of
a front axle of the first tank wagon. The various
destructive tests on the materials were completed
in November 2011.
As well as carrying out further research into the
direct causes and identifying the contributing
factors and the underlying causes of the event, the
15
General in 2011
Board concentrated on the following activities
during 2011:
participation in the lengthy activities
regarding the special evidentiary hearing, carried
out between March and November in
collaboration with the investigating judiciary and
consisting in a long series of tests, mainly
destructive, on the materials involved in the
railway accident;
several meetings with all the parties involved
to also allow them to access the initial results
obtained by the Board, pursuant to the provisions
of Legislative Decree No 162 of 10 August 2007;
analysis of rebuttals of these results by the
parties involved.
The Board of Inquiry and the DGIF have, as
already mentioned, disclosed in advance partial
results, mainly through the European Railway
Agency, including the contents of the
recommendations issued subsequently.
The primary cause of the Viareggio accident is
now clear and specific (fatigue fracture of an
axle). The proposal for amendments to the rules
and regulations in force for securing a new degree
of safety is contained in the preliminary
recommendations expressed in April 2012 and
that they are based on that fundamental cause, on
which the Investigating Board has formed a
precise and clear judgement.
The issues relating to the kinematic motion of
the overturning of the first tank and its sliding on
the superstructure, the kinematics of the entire
train, the dynamics associated with the unique
motion itself of the tank and other parts of the
train, the mutual influences and the consequent
cause of the fracturing of the tank are currently
the subject of investigation.
Problems with operation of level crossings at
various locations, from 21.04.2010
Investigations continued in 2011 (and are
nearing completion) into the problem of level
crossings being improperly opened during the
passage of trains.
The Board appointed to ascertain the causes has
recently acquired new documentation from the
Infrastructure Operator. The documentation is
being analysed and regards certain incidents
which have been identified that are worthy of
further study.
15.01.2011–Villa San Giovanni, derailment of
freight train
On 15.01.2011 at 1:30 a.m., the Trenitalia
Cargo freight train 57369 derailed at the Villa San
Giovanni station, whilst it passed from the 3rd
track to the Bolano tracks, after passing through
the departure signals showing line clear. The
event caused damage to the infrastructure and the
rolling stock, and blocked rail traffic.
The investigations continued through 2011 and
are now ended.
The results of the investigations showed that the
derailment was caused by shortcomings in
infrastructure maintenance.
Since it also emerged that that these
shortcomings were due to an incorrect conduct of
the personnel employed by the Infrastructure
Operator, recommendations were made to
promote initiatives aimed at improving the Safety
16
General in 2011
Management System of the railway undertaking
with regard to the activities of certain members of
staff responsible for the maintenance checks. The
Infrastructure Operator was also asked to identify
procedures which guarantee problem-solving
measures following the finding of technical
failings.
The investigation is still in progress and the
most probable cause for the collapse is considered
to be the failure of a foundation.
27.01.2011–Metaponto–Sibari line, fatal
accident of a worker repairing the line
Various activities were in progress during the
night between 26 and 27 January 2011 as part of a
programme of works for renewal of the track
equipment on the Metaponto-Sibari line. These
works included replacement of the ballast in the
single track section between the stations of
Policoro and Nova Siri.
At approximately 00:40 a.m. during the
performance of these activities–which were
carried out under track interruption regime–at the
progressive kilometre marker 67+300, an
electrical and electronics system technician
climbed down from the cab of the ballast clearing
machine, for no apparent reason and, whilst
walking along the ballast on which the works
were being performed, was sucked into and
spiked by the ballast removal chain, dying
instantly.
The investigation has ended and the direct cause
of the event has been identified as human error by
the worker.
08.06.2011–Rome–Florence DD line, collision
of train with work vehicle
On 07.6.2011 at approximately 10:57 a.m., the
train 9452 formed by ETR 485-036 rolling stock,
travelling on the up line track of the Rome–
Florence DD line, at kilometre marker 163+130
close to the southern entrance to the Fasciano
tunnel, struck the roof of the driver’s cab of an
excavator which, whilst working on the retaining
wall of the cutting section, on the approach to the
tunnel, had fallen onto the railway line
obstructing the gauge of the up line track.
As a result of the impact, the excavator suffered
damage to the driver’s cab and the rolling stock,
which stopped because the emergency brake was
applied by the locomotive crew, suffered damage
to the access ladder to the service door on the lefthand side in the direction of travel of the
BAAC006 locomotive, to the cover of the
grounding of the first axle in the train’s direction
of travel, as well as damage to the fairing.
Nobody was injured.
The investigation has ended and the
investigating officer has identified the falling of
the excavator from the embankment as the direct
cause of the incident and a regulatory
shortcoming as the secondary cause of the event.
08.05.2011–Collapse of a railway viaduct
On 08.05.2011, a railway viaduct collapsed
along the Caltagirone–Niscemi section, at
kilometre marker 326+645. The viaduct in
question had 13 arched spans with masonry
columns and plain concrete arches. It was
constructed in the 1960s.
09.06.2011–Sempione Tunnel, freight train
fire
On 9.6.2011, at approximately 5:55 a.m., a fire
occurred on the BLS freight train 43762 inside
the Sempione tunnel.
The train stopped inside the tunnel, along the up
direction of the Iselle–Briga line, in Italian
17
General in 2011
territory but on the line operated by the Swiss
Infrastructure Operator (SBB CFF FFS).
The two locomotives and the first four carriages
were taken out from the tunnel during the initial
phases of the rescue operations and were not
damaged. The remaining wagons were
completely destroyed in the fire.
The 2IS bore suffered considerable damage to
all the area involved in the fire.
The investigation has ended.
The direct cause of the incident was identified
as the open door of the semi-trailer which raised,
due to the effect of tunnel draught, the crossbar of
the foldable cover tarpaulin, causing a series of
short-circuits of the contact line and the resulting
fire.
The absence of a multi-purpose portal and in
particular of an automatic system for locating
fires and checking the gauge was identified as the
indirect cause.
The
investigation
resulted
in
five
recommendations, regarding the need to install a
multi-purpose gantry for checking the trains
entering the tunnel and checking the level of
safety of the tunnel itself.
Recommendations were also made to check
application of the procedures for controlling the
semi-trailers in the stations for loading on the
trains, to perform random checks on the trains in
exchange at the Domodossola II station and to
assess the need to repeat the complete inspection
at the origin in the case of prolonged stops of the
freight trains.
12.07.2011–Parma–Vicofertile section,
collision with a truck at a level crossing
On 12 July 2011, at approximately 8:37 a.m.,
Trenitalia regional train 21500 collided against
the semi-trailer of an articulated truck which was
on the track between the closed barriers of the
level crossing at kilometre marker 4+813 of the
Vicofertile–Parma single track section.
The train driver, after departing with the
departure and the level crossing protection signals
showing line clear, reached the speed of
approximately 120 km/h, which was permitted by
the speed limit for the line, and, having seen the
obstacle on the track, activated the emergency
braking and abandoned the driver’s cab. The train
struck the semi-trailer loaded with scrap ferrous
materials and suffered serious damage (driver’s
cab completely destroyed) but it did not derail,
stopping approximately 300 m after the point of
impact. After the impact the semi-trailer rotated
by almost 180°, suffering serious damage, and
during rotation it damaged the corner of the
nearby housed owned by FS [State Railways
Group], knocked down a pole of the aerial contact
line, which was damaged over a length of
approximately 200 m, and scattered the scrap
ferrous material over the line.
About thirty people, including passengers and
train staff, were slightly injured during the
collision, and they were immediately rescued by
the ambulance service. The level crossing barrier
18
General in 2011
in front of the locomotive was completely
destroyed.
The investigation has ended and the
investigating officer has identified as the direct
cause of the accident as the error made by the
driver of the truck when approaching and passing
across the level crossing, which was not
completed within the time allowed for by the
system. It is considered plausible that the error
was accidental, since the truck driver was not
suitably warned of the presence of the level
crossing by the road signs and was authorised by
the signs to perform the manoeuvre which, both
in terms of the minimum curve requirements for
heavy goods vehicles and in terms of the poor
visibility of the luminous sign due to its position
and the weather conditions, was difficult and
presented a high risk of entrapment.
23.07.2011–Monza–Arcore section, series of
collisions at the level crossing
The investigation concerned a series of three
incidents on the Milan–Lecco railway line, along
the Monza–Arcore section, at the level crossing
situated at kilometre marker 1+265:
fatal collision with a person by regional train
No 2572 (owned by Railway Undertaking
Trenitalia–TLN) which occurred at 6:10 p.m. on
6.5.2011;
Trenitalia–TLN) which occurred at 8:25 a.m. on
8.5.2011;
Trenitalia–TLN) which occurred at 9:42 p.m. on
23.7.2011;
All three incidents had fatal consequences and
they occurred when the barriers were correctly
closed.
The investigations have ended and for all the
incidents the direct cause is the improper crossing
of the level crossing by the victims of the
incidents, who crossed the railway track by
passing beneath the correctly closed barriers, in
violation of Article 147.3. of the Highway Code.
31.7.2011–Napoli Centrale, derailment of
Frecciargento train during shunting
On 31.7.2011, at approximately 3:50 p.m., the
Trenitalia empty rolling stock ETR 485.036, with
train No 19418, departed from the Vehicles
Maintenance Yard in Naples travelling towards
the Napoli Centrale station. During the shunting,
the second bogie of the seventh passenger
carriage and the first bogie of the eighth
passenger car of the train derailed in composition
of the direction of travel.
The derailment occurred at the cross-over
78a/78b, when passing the ordinary points No
78a. The derailment knocked down the electric
traction poles, with consequent power failure to
tracks XXIV to IX in the Napoli Centrale station,
but there were no injuries to individuals.
19
General in 2011
The investigation has ended and the direct cause
of the derailment was identified as the poor state
of
repair
of
the
railway
infrastructure.
24.09.2011–Verona–Brenner
line, splitting of passenger train
On 24.9.2011, at 1:14 p.m., the
coupling hook of the penultimate
carriage failed–during braking
caused by the intervention of the
SCMT [Train Running Control
System]–on the Venice-Calais
express train 13468 of the company
Venice Simplon Orient Express
(VSOE), which had departed from
Verona at 12:54 a.m., consisting of
17 carriages owned by VSOE and
hauled by two E405 locomotives
owned by Trenitalia. The train was on the
Verona–Trento section of the Verona–Brenner
line, and had reached kilometre marker 33+903
between Dolcè Communication Station and Peri
Station.
The two sections of the train stopped at
approximately 40 metres from each other as a
result of the emergency braking caused by the
rupture of the main brake pipe.
Both sections were transferred to Verona PN
station from where the train, after the necessary
maintenance works, departed towards Chiasso via
Milan at 7:59 p.m.
There were no injuries to individuals nor
damage to the infrastructure, and only slight
damage to the rolling stock
The investigation is under completion.
22.11.2011–Lamezia Terme Centrale–
Catanzaro Lido line, derailment of passenger
train following collapse of a railway bridge
20
General in 2011
On 22.11.2011, at approximately 6:45 p.m., the
Trenitalia regional train 3793, hauled by
locomotive Aln 668-1059, with 19 people on
board, of whom 17 passengers and 2 members of
the train crew, derailed immediately after crossing
the viaduct on the River Cancello, due to
structural failure of the viaduct and consequent
misalignment of the track. The train was
travelling along the section between PM Feroleto
and Marcellinara, at the progressive kilometre
marker 20+266.
Following the derailment the locomotive
stopped on the embankment downstream of the
viaduct, tilting approximately 45 degrees to the
right-hand side in the direction of travel. The
crew evacuated the train and sheltered the
passengers inside the Cancello tunnel, due to the
poor weather conditions throughout the entire
area at the time of the derailment. About an hour
after the incident the crew and the passengers
were collected by locomotive Aln 668 1043 and
carried to Marcellinara where they received
support and first aid. Ten passengers were taken
for further checks to the Lamezia Terme hospital
whilst the crew and the other ten passengers
continued their journey by a replacement bus
service coming from Marcellinara station.
The investigation is under completion.
21
General in 2011
3.2. Railway safety studies and
research activities
As part of the activities aimed at improving rail
safety, the Directorate General carried out studies
in 2011 concerning some of the critical aspects
which have the greatest affect on the Italian rail
system and other activities aimed at preparing the
basis for analytically and proactively performing
subsequent detailed investigations on the
accidents.
In particular, the activities carried out in 2011
and now ended are:
an analytical study of the railway accidents at
level crossings.
an analysis of the RFI Safety Database and the
information reports in order to study a method for
reclassification of the events and causes, in line
also with the principles for classification of the
causes pursuant to Directive 49/2004/EC;
an analysis of the applicability of the
Derailment Detection Devices (DDD) and
checking the progress of the ERA’s efforts.
The analytical study of the railway accidents at
level crossings considered the events which had
affected the level crossings over the period July
2010–August 2011, highlighting the following
subdivision of the incidents:
anomalous events:
o road traffic infringements (77%)
o acts of vandalism (10%)
o further anomalies (7%)
accidents:
o road traffic infringements (50%)
o acts of vandalism (10%)
o suicide or attempted suicide (10%)
o animals on track (15%)
Considering that the conduct of road users is a
decisive cause of the anomalous events and of the
accidents at level crossings, and considering that
the technology applied at the level crossings tends
towards the automation of the systems for the
command and control of the signalling, closing
and protection devices, resulting in the fact that
they are unmanned, the main cause of the
accidents at level crossings is the inadequate
behaviour of the road users.
It is therefore clear that the greatest benefits for
the reduction of accidents at level crossings
would derive from the adoption of solutions
which, on the one hand, increase the awareness
by the road users of the risks and the knowledge
of the correct behaviour in the case of danger (e.g.
road vehicle trapped between the barriers) and, on
the the hand, reduce (by discouraging) incorrect
behaviour.
The Infrastructure Operator has found itself
having to manage the risk of the presence of a
lightweight road vehicle between the barriers,
sometimes reducing this risk by adopting barriers
with trespass and obstacle detection systems
and/or escape areas. On the one hand, these latter
areas allow a motor vehicle to stop in a safe area
(which should be more clearly identified and
signposted) and, on the other hand, they allow in
some cases for a heavy goods vehicle to be
accommodated between the barriers which have
been correctly closed.
However, in these emergency cases, the road
user is still left without tools, even of an
informative nature, to be able manage them,
without immediate and effective in-situ
instructions, especially with regard to the need to
clear the level crossing in the case of entrapment,
even with an obligation to be able impose the
knocking down of the barriers.
This study highlighted that in certain cases the
road user is exasperated by the lengthy closing
22
General in 2011
times which are such as to induce deliberately
inappropriate behaviour, often also with the
certainty of not incurring any penalties.
Lastly, the critical aspects highlighted by the
study, which associated the above-mentioned
events with the technological types of the level
crossings (full or half barriers, closing control,
speed and traffic on the line, closing times)
provide information on the priorities for the safety
management interventions.
The analysis of the RFI Safety Database aimed
at implementing a method which allowed a
reclassification (possibly in an automatic manner)
of the events present in the RFI Safety Database
and their causes, in line with the classification
principles indicated in EU Directive 2004/49/EC
on rail safety.
The study looked at a data base of 17,664 events
which affected the railway network operated by
RFI over the period July 2010–August 2011.
With regard to the activities for reclassification
of the events, starting from the types of event
associated with each record RFI Safety Database,
it was noted that these types of event:
are in fact defined on the basis of the internal
needs of the the Infrastructure Operator;
do not identify the main event (as required by
Directive 2004/49/EC);
refer to the first event of the chain of events
which led to the main event.
It has been seen that there is a Classification
field in the RFI Safety Database which contains a
classification of the main event that satisfies the
needs of RFI, but does not have an immediate
correspondence either with the list of the major
events according to DGIF or with the definitions
of incidents and near incidents pursuant to
Directive 2004/49/EC.
Based on these considerations, the following
actions were taken:
a scheme for reclassification of the events was
implemented which associates with each of the 90
types of events present in the RFI Safety
Database the possible main events on the basis of
the event description;
a procedure was defined for automating
reclassification of the main event starting from
the type of event indicated in the RFI Safety
Database and therefore (where possible) using the
information contained in the Classification field
of the RFI Safety Database.
The main events were identified both on the
basis of the list of incidents considered of
importance by the Directorate General and on the
basis of the incidents and “near-incidents”
pursuant to Directive 2004/49/EC.
The automatic procedure for reclassification of
the main event allowed reclassification of more
than 96% of the events and approximately 82% of
the incidents.
During a second phase of the study, each of the
main events identified were associated with the
first events of the chain which precede it. This
made it possible to obtain information about
which first events of the chain could cause the
main event and the contribution of each first
event of the chain to the main event in question.
Lastly,
consideration
was
given
to
reclassification of the possible causes of the
incidents which, in accordance with the principles
expressed in Directive 2004/49/EC, were divided
into three categories (direct causes, contributing
factors and underlying causes) and some
reference sectors were identified for each of these.
These elements enabled the implementation of a
classification scheme which may be used for
associating, manually, the relative causes to each
23
General in 2011
event. It emerged that it was not possible to
proceed automatically with the association of the
causes to the events, due both to the lack, in the
RFI Safety Database, of any reference to the
causes of the events listed therein, and because,
due to the normal practice, the causes of an event
are only identified after completion of the
investigations (carried out internally by the
Infrastructure Operator or by the Railway
Undertaking involved).
With regard to the project for checking the
applicability of the derailment detectors and
checking the progress of the ERA’s efforts, the
Directorate General participated in workshops on
these aspects, held at the headquarters of the
European Railway Agency.
Some of the sector studies carried out about this
issue, even though they concentrate on the
continuous and systematic commitment by the
railway undertakings and by the infrastructure
operators to observe the correct maintenance
policies for vehicles and track, they have
highlighted that the devices constitute an addition
to a series of coordinated actions. It is clearly not
possible from the available documentation to
establish how many derailment events have had
less serious consequences in terms of injuries to
individuals or damage to property due to the
direct application of derailment detection devices
and how many similar events there have been
which have not benefited from the support of a
derailment detection device that have caused
considerable damage. But it may be stated with
certainty that the Viareggio incident would have
had a less serious outcome if an immediate
reduction in the kinetic energy involved had been
induced through the adoption and action of
derailment detection devices.
24
4. Other Directorate General
activities in 2011
During 2011 a boost was given to participation by
the Directorate in meetings organised by the ERA
(European Railway Agency) and relations with the
European Commission were strengthened.
The need became clear to establish bilateral
communication channels with other national
investigation bodies.
The year 2011 saw the participation of this DGIF,
in the role of Italian NIB (National Investigation
Body), in various working groups, that is, in
specific groups organised as part of the network of
investigation bodies working on issues such as the
classification of the causes of incidents and the
training of investigation staff.
Preliminary findings from the investigations on
the Viareggio incident were presented in 2011
within OTIF (Intergovernmental Organisation for
International Carriage by Rail), during a meeting
held in Malmö (Sweden) and also in various
meetings of the NIB-Network.
It may be said with satisfaction that the Italian
NIB has become one of the most active national
bodies during 2011. The precise positions adopted
by DGIF on the various issues (especially the
independence of the investigation bodies) have
without doubt contributed towards achieving
correct and coherent final decisions and been
decisive in guiding the international meetings of the
NIB and the European Railway Agency.
With regard to the bilateral activities, these were
performed during 2011 specifically with contacts
with the investigating bodies of the following
countries:
The Czech Republic, for a common analysis on
the classification of the causes of the incidents;
The United Kingdom, for an exchange of
technical information on the issue of accidents at
level crossings;
Switzerland, at the time of the fire in the
Sempione transnational tunnel. The completed
investigation, conducted in parallel by this DGIF
and by the SAIB (Swiss Accident Investigation
Board) was one of the first fruitful examples of
collaboration between two national investigation
bodies. It should be noted that Switzerland, even
though it does not form part of the European Union,
has in fact adopted, given also its geographical
position, almost all the procedures resulting from
the EU Directives on railway issues.
25
5. Recommendations
Pursuant to Legislative Decree 162/2007, the
General Directorate, on the basis of the causes
identified, sets out the recommendations and
transmits them to the interested parties (the ANSF,
the Infrastructure Operator, etc.) and to the
European Railway Agency.
Event
Vipiteno,
04/11/2010
Splitting of train
No 48867 and
partial loss of cargo
Following the investigations completed in 2011,
the Investigative Body issued a number of
recommendations to those responsible for safety.
An overview of these recommendations is
provided in Table 3.
Table 3–Recommendations issued by the Directorate General
Date
Recipient
Recommendation
of issue
01/03/2011
1.
ANSF
2.
ANSF
Verzuolo,
14/12/2009
Runaway rolling
stock
10/05/2011
1.
Railway
undertaking SBB
Cargo Italia S.r.l
2.
Railway
undertaking SBB
Cargo Italia S.r.l
3.
ANSF
Various,
since
18/09/2009
Discharge of
hazardous material
from railway wagons
17/06/2011
1.
ANSF
2.
ANSF
Scala di
Giocca,
19/12/2009
Derailment of a
locomotive Aln 668
due to a landslide
30/06/2011
PratoVaiano,
22/06/2009
Derailment of freight
train transporting
hazardous goods
20/07/2011
1.
ANSF
1.
ANSF
The coupling gear, since it is connected with operational safety,
must be subject to systematic (i.e. not random) performance
checks during maintenance
These checks must be performed wherever possible by two
different persons.
Pay careful attention to and increase, as part of the relative
safety management system, the activities for training personnel
operating in the sector, adopting suitable initiatives for raising
awareness and making individuals responsible regarding the
risks and consequences which can result from non-compliance
with the regulations, procedures and instructions
Activate and strengthen the control and monitoring of the
activities of the personnel who can be most important with
respect to compliance with regulations, requirements, instructions
and procedures regarding rail safety issues (e.g. revision of train
manning documents)
Check the correct fulfilment, by the Railway Undertaking, of the
above-mentioned recommendations, as part of the relative
institutional activities (audits and checks of the safety
management systems)
It is recommended that the National Railway Safety Authority check
implementation of the formalities pursuant to ANSF Directive No
1/dir/2010 so that, in all the transport phases, including
terminalisation and shunting, there are suitable procedures to clarify
assignment of the responsibilities for the trains transporting
hazardous materials, even in the case of unforeseen extension of the
times for delivery or receipt of the trains, arriving early or late
compared with the timetables. The possibility of introducing deterrent
penalties in the case of failure to apply the procedures by the railway
operators should also be evaluated.
It is recommended that the National Railway Safety Authority
undertakes or continues coordinated actions with the individual
national safety authorities of neighbouring countries, aimed at
intensifying inspections of trains transporting hazardous materials.
To continue the activities already underway in relation to the
issue of hydrogeological risk, so that the Infrastructure Operator
puts in place or reinforces works and surveillance and monitoring
operations in the areas of the relative network exposed to risk,
systematically checking the efficiency and effectiveness of the
railway traffic safety measures adopted.
To record the results of the tests performed on all components
important to railway safety.
The results of the tests (NDT, US-MT tests, work schedule datasheets, etc.) conducted on components considered important for
railway traffic safety should be included in a common database to
facilitate subsequent verification of the condition of the
component or the development of any defects or abnormalities
detected throughout the life cycle of the component.
26
5. Recommendations
Such data must be made available to all persons responsible for
the inspections and to other duly certified and accredited bodies
responsible for maintenance.
2.
To remove from service all safety critical components (leaf
springs, wheels, bushes, axles, etc.) which have an incomplete
or uncertain service history.
3.
To define the “maximum operating life” of safety critical
components.
In order to prevent railway accidents, it may be useful to
introduce a maximum time limit for the service life of mechanical
safety devices (axles, wheels, bushings, leaf springs, etc.) taking
into account the concept of cyclic fatigue to which certain
mechanical components are subject during operation
To schedule maintenance operations on the basis of operating
times and also on the basis of the number of kilometres in
service.
In order to prevent train accidents, it may be necessary to
introduce the concept of maintenance at preset time intervals and
at a preset number of kilometres. Inspection and maintenance
would then take place whenever the first of these preset
conditions is fulfilled. This opportunity should be taken since it is
dictated by the different use of wagons based on the structure of
the railway market which has changed over the last twenty years,
with changing conditions imposed by a supranational economy.
To conduct further research and analysis aimed at assessing the
possibility / desirability of adopting instruments to detect potential
derailment conditions (DDD–Derailment Detection Devices).
ANSF
ANSF
4.
ANSF
5.
ANSF
Parma–
Vicofertile
section,
12/07/2011
Incident at the level
crossing
19/09/2011
1.
RFI
Monza–
Arcore
section,
23/07/2011
Series of collisions
at the level crossing
19/09/2011
1.
RFI
It is recommended that the Railway Undertaking RFI SpA,
collaborating with the relative local road traffic authorities in order
to prevent further incidents, immediately upgrade and if
necessary integrate both the pre-signalling signals and the
luminous and acoustic signalling devices installed at the level
crossing on the Strada Manara side. The devices must be
located so as to be visible from the road at the greatest possible
distance and checking the consistency of the road signs on
Strada Manara and on the access roads to it, with regard to both
the signals prohibiting the transit of heavy goods vehicles
installed on the Strada Pontasso and the effective possibility of
circulation by heavy goods vehicles along Strada Manara with
regard to the minimum curve requirements for heavy goods
vehicles when approaching the level crossing.
It is recommended that the Railway Undertaking RFI SpA, after
completing the activities already identified for raising the
awareness of the users, of which the full usefulness is shared,
and collaborating with the relative local road traffic authorities in
order to prevent further incidents, implement an information
system (including information boards or other suitable means of
information, highlighting the specific critical nature of the level
crossing situated at kilometre marker 1+265 of the Monza–
Arcore section), in order to prevent further incidents.
27
6. Conclusions
As in 2010, a substantially positive situation has
emerged for 2011 with regard to railway accidents,
even compared with other EU countries, although
there are still certain critical elements, as mentioned
below, which are the subject of serious
considerations by the DGIF for the development of
future investigations.
There is a continuing gradual decline in what
could be described as the long established types of
railway incidents such as collision and derailments
or events connected with operating errors in rail
traffic management or with train driving errors.
The reduction of this series of events is without
doubt due both to the positive development of all
the constituent parts of the Safety Management
System (SMS) and the positive affects of all the
innovative technologies adopted in recent years
especially in the field of train monitoring.
In general, a valid and widespread effectiveness
can be observed in the safeguarding of the railway
traffic safety in strictly operational terms by the
Italian Infrastructure Operator RFI, as part also of
the actions put into place by the National Railway
Safety Authority since it was first established.
However, as already mentioned, four main types
of incident still remain in Italy, which can be briefly
summarised as follows:
1) Incidents linked to infrastructure maintenance
shortcomings (superstructure and civil engineering
works). In the main these result in derailments and
can be closely linked to the continuing lack of
sufficient funding (given the well known financial
situation in Italy) available for infrastructure
maintenance and the prevention of hydrogeological
disturbances.
2) Incidents linked to the maintenance
shortcomings or age of the rolling stock (especially
goods wagons). The implementation throughout
Europe of the latest EU regulations could certainly
mitigate the seriousness of this factor.
Unfortunately, Italy often suffers the effects of
maintenance shortcomings originating in other
countries which have consequences for rail traffic
across the Italian network (the Viareggio accident is
a case in point).
3) Collisions with persons on the railway line
(often identified as cases of suicide) represents a
phenomena which is increasing significantly: 193
fatal and 67 not-fatal incidents in 2011 (compared
with 174 fatal and 59 non-fatal incidents in 2010)
strengthened the Directorate General’s intention of
continuing the studies on this phenomenon started
in previous years, if the financial resources are
sufficient to perform systematic analyses on this
area of “repeated incidents” in order to examine and
investigate what remains in terms of incidents
compared with the above-mentioned survey on
suicides.
(4) Level-crossing accidents: accidents and
incidents involving users who are not railway users
(pedestrians, cyclists, road users, persons
occasionally on the railway line inappropriately or
involuntarily). Also in this respect the Directorate
General carried out a study in 2011, related to the
occurrence of accidents, which concluded that there
is the need to make certain modifications to the
systems and the regulations (see subsection 3.2.)
These proposals will be presented at the end of
2012 at an international meeting (12th Global Level
Crossing and Trespass Symposium, London, 8-10
October 2012).
On this specific issue and with regard to the
provisions of sub-section 3.2., this Directorate
General considers it worthwhile starting discussions
with the Directorate General for Traffic Control of
the Ministry for Infrastructure and Transport and
with the Highway Police, the bodies currently
involved in the updating of the Highway Code.
28
6. Conclusions
Discussions would assess the introduction from the
first driving lessons for new drivers of clearer and
more understandable instructions on the driver
behaviour to be adopted when approaching and
passing through a level crossing. Discussions would
also look at a specific penalty framework designed
to act as a strong deterrent to dangerous behaviour.
Dangerous behaviour here would include foolish
attempts to pass over the crossing despite the
display of stop warning signs and abandoning a
vehicle between the barriers without trying to
remove it to free the passage of the oncoming train.
From the studies carried out so far, it has been
seen that most of the drivers are not aware that the
barriers are fitted with trespass and obstacle
detection systems connected to the signalling
system. These systems detect obstacles on the
crossing and signal this to the train in arrival so that
it can start the braking procedure, even
automatically, with all the prior notice necessary to
avoid impact.
With regard to the Viareggio incident, the cause
of perforation of the tank wagon from which the
liquefied petroleum gas escaped and then caught
fire, had not yet been definitively determined at the
time of preparation of this report. As soon as the
further elements acquired have been studied and
processed, which it is thought will be by the end of
2012, it is believed that an answer may be given to
this major question.
The main aim of the Directorate General of the
Italian Railway Investigation Body remains the
monitoring of the response of the railway world
(and especially the institutions) to the eleven
recommendations issued in April 2012 and to the
further recommendations which could be issued by
the end of 2012 on the basis of the new results
obtained. The first institutional responses,
especially at an EU level, lead one to believe, as
already mentioned, that the discussions between the
institutions will not be a smooth path to follow.
This Directorate General is working in a proactive
manner
for
the
dissemination
of
the
recommendations and above all for clarification to
the interested parties, including the EU bodies, of
the technical contents of the recommendations
already issued and of the expectations on the rapid
implementation of their contents. These activities
are considered to be of absolute priority and they
are carried forward, within the limits of the
institutional roles, as absolutely urgent and binding.
29

3. Investigations by the Directorate General in 2011

Transcription

Similar documents

Historic Builders SECOND HALF

Agreement Signed for the Construction of Mieso-Dire Dawa

angleškem

1. The Story of the Lost Child 2. Esco a fare due passi

1. - FOIS - Indian Railways

kindergarten 2013 - Railway Town Public School

www.us14-cn.com Village of Barrington TRANSPORTATION

BUONGiORNO!

BRIDGE OVER THE RIVER KWAI

Railroad track Câmpina - Predeal (RO)