Railway incident investigation report

The Railway Safety Regulator (RSR) published an incident investigation report on the Denver rail collision, with recommendations to rail operators.

In addition, the Passenger Railway Association of South Africa (PRASA) was found to have some system deficiencies (see below).

The RSR Board of Inquiry (BOI) concluded that human error caused the Denver collision of 28 April 2015 at approximately 07h10.

Business Express Train 1602, which was travelling from Pretoria Station to Johannesburg Park Station collided with the rear end of Metroplus Express Train 0600, at Denver Station in south-eastern Johannesburg.

The driver of Business Express Train 1602 passed a signal at danger.

The Metroplus Express Train 0600 was on the platform, protected by signal DN 2 which was at danger and signal DN 1 which was on caution.

It was discovered during the investigation that the train passed both signals before the impact.

Part of the Denver train collision scene in Johannesburg (EWN).
Part of the Denver train collision scene in Johannesburg (EWN).

The BOI concluded that the driver of Business Express Train 1602 was over-speeding at the time of the accident. The train was moving at a speed of 91km/h in a 70km/h zone.

The inquiry also found that brakes in Business Express Train 1602 were applied very late.

The evidence indicates that the driver of Business Express Train 1602 only started applying brakes 332 metres from the point of impact.

The investigation revealed a number of organisational system deficits at PRASA (see below).

They include defective communication systems, deficient employer and employee relations, use of old infrastructure, inefficient staff wellness programmes, insufficient work capacity and failure to effectively monitor train personnel.

The BOI concluded that the driver of Metroplus Express Train 0600 may have not properly seen signal DN 11 due to the impaired vision caused by the sunlight during the time at which the incident occurred.

The inquiry also established that there was delayed communication on the date of the incident.

The driver of Metroplus Express Train 0600 reported that the incident took place while he was waiting and trying to phone operations to advise him because the signal was not clear.

The section manager at George Goch Centralised Traffic Control Office (CTC) also informed to the BOI that the incident took place while he was waiting for contact numbers of the driver of Metroplus Express Train 0600 from the operations office in Braamfontein.

It took about six minutes between the first communication and impact, suggesting the communication was too inefficient.

From the available information and evidence, the BOI, therefore, concluded that human factor or error was the major contributor to the incident.

The BOI made a further observation that the fact that the driver of Metroplus Express Train 0600 was not scheduled to drive the train on the morning of the incident, compromised the safety processes.

The driver of Metroplus Express Train 0600 was not tested for substance abuse and his fitness for duty was therefore not properly established.

Sequence of events leading to the Denver railway collision

Both trains departed Pretoria station on schedule at 06h00 and 06h15 respectively and were en-route to Park Station in Johannesburg.

ii. At approximately 07h06, Metroplus Express Train 0600 came to a standstill in front of signal number DN11 at the Denver Station.

iii. The driver of Metroplus Express Train 0600 confirmed that he stopped at signal DN11 as a result of his inability to clearly see the aspect of signal DN11.

iv. After stopping, the driver proceeded to contact the local George Goch CTC to request a directive or authorisation to proceed.

Metroplus Express Train 0600 was protected by signal DN2, which at the time of the accident was displaying a danger/red aspect.

v. Signal DN1, which precedes signal DN2, was displaying a yellow aspect, which served as a caution to the driver of Business Express Train 1602 to take certain actions from a train handling point of view in order to stop at the following signal, should that signal display a danger aspect.

vi. While in the process of contacting the George Goch CTC, Business Express Train 1602, which had been proceeding in the same direction as Metroplus Express Train 0600, passed a signal displaying a danger aspect and collided with the rear-end of Metroplus Express Train 0600.

Organisational system deficits in PRASA

The Passenger Railway Association of South Africa (PRASA) was found to have some system deficiencies, said the RSR.

Lack of maintenance:
• Absence of an effective backup power
System at George Goch CTC.
• Replacement of the old searchlight signals.

Ineffective communication:
• Competency to maintain trunk radio system not within PRASA: Train Operations change train numbers without communicating with the technical department – and cellphones are used as a result.
• Neotel VoIP telephones not operational at CTCs all the time.

Human Factors:
• Shortage of personnel.
• Ineffective management of overtime payment.
• Non-adherence to the Human Factors Management (HFM) Standard.
• Understanding of the HFM standard by PRASA personnel.
• Inadequate support from the Employee Assistance Programme.

Ineffective allocation of capital funding.

Railway safety recommendations

A competent person /contractor must be appointed to assist with the immediate maintenance and repairs of the existing trunk radio system and related equipment.

ii. PRASA must, as a matter of urgency, provide a separate power supply backup to the VoIP telephone system and the trunk radio system or couple these systems to the existing backup supply at all CTC’s.

iii. Risk assessments must be done on all searchlight signals. These signals must be replaced with 3-aspect signals or other resourceful signals.

iv. PRASA must effectively prioritise the implementation of the Automated Train Protection System to avoid human error, which causes incidents of this nature.

v. PRASA must review the maintenance expenditure budget in light of the fact that the infrastructure is old and needs high maintenance.

* Sources; RSR Railway Incident Investigation Report. On Track.

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2 thoughts on “Railway incident investigation report

  1. The Denver accident investigation report leaves one to muse: Will the organisation of the future repeat the mistakes of the past?

    On 28 April 2015 two passenger trains collided, leaving one person fatally injured and 240 people injured.
    On 28 April 1949, between Mlamlankunzi and New Canada station, a train driver passed a signal at danger and collided with two stationary trains, a guard and the train driver lost their lives and 141 were injured.

    What a coincidence!

    The accident report revealed; “Lack of maintenance, ineffective communication, as well as well human factors (shortage of personnel). This is a serious diagnosis!
    PRASA is operating under a degraded mode of operations. Briefly put, the system is operating under a restricted manner on a daily basis. This is akin to a patient whose life depends on a dialysis machine in order for him to survive.

    There must be an acknowledgement on the part of all stakeholders (including commuters) that the system is operating under a degraded mode of operations.

    The operator should take infinite pains to catapult the system into normal operations. It is also important to note that the Japanese railway system is operation under normal operations and when there is any abnormality on the system, for example, Tsunami or earthquake, all stakeholders expend all their efforts to get the system back to normal operations.

    All our safety interventions have been designed around normal operations; when in reality our system is a degraded mode of operations. This is a serious dilemma!

    The tragedy of this situation is that we have now normalised a degraded mode of operations as being normal operations. We need to take a leaf out the the Israelites’ book when God commanded them to leave Mount Sinai because they had stayed for long.

    As a country, we have stayed in a degraded mode of operation for too long and now it time for us to move on to normal operations.

    During the 1999 International Railway Safety Conference in Canada, The East Japan Railway Company unveiled a Safety Plan 21 – Safety Policy for the 21st Century. One of the areas that was addressed by the policy was a complete installations of train collision prevention measures.

    These issues were to be addressed:
    (1) installation of a new function of speed verification into the lines with ATS-SN (Automatic Train Stop) and
    (2) further installation of an ATS-SN device which prevents wrong departure.

    Let me borrow language from Benjamin Disraeli: “You can’t have fruit when the tree is in blossom”. Simply put, you can’t have a world class passenger service , when your service is operating under a degraded mode of operations.

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