Lessons from an accident Marion Segretain, French National Safety Authority (EPSF)

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Lessons from an accidentMarion Segretain,
French National Safety Authority (EPSF)
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Contents

• What happened?
• Involvement of the different stakeholders
• Role and interfaces between the stakeholders
• Conclusions

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What happened ? (1)

• When?
• On October 11th 2006 at 11.45 AM.
• Where?
• At the border between France and Luxembourg on
  the area of the French city of Zoufftgen.
• What?
• A regional passenger train from CFL and a freight
  train from SNCF collided.

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What happened? (2)

• Line equipment
• Double track with fixed equipment for occasional
  wrong-track working (automatic block).
• Circumstances
• One track was closed for maintenance. The freight
  train was normally running on the wrong line. The
  passenger train was sent with a written running
  order as the signal remained closed.
• Consequences
• Six persons died, two were seriously injured and
  fourteen were shocked.
• Traffic was totally stopped on both tracks for 5
  days.

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What happened? (3)

• Immediate conclusions
• The minister of Transport from Luxembourg
  declared 4 days later that the accident was due
  to a human error in the Bettembourg station
  (CFL). However, the investigations were still
  going on.
• The emergency radio communication was not picked
  up by the trains.
• The current safety cut out was to late to be
  efficient.

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Involvement of the stakeholders

• According to French legislation and following the
  EU directives, each stakeholder is responsible
  for his part of the system related to safety. In
  the present case, the following parties were
  involved
• The CFL from Luxembourg
• The French RU SNCF
• The IM (RFF and SNCF-delegated IM)
• The French accident investigation body (BEA-TT)
• The accident investigation body from Luxembourg
  (EEAI)
• The ministries of Transport from France and
  Luxembourg
• The French NSA (EPSF)
• N.B. Judicial inquiries made in France and
  Luxembourg are out of our present scope.

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Role of the stakeholders and their interfaces (1)

• The accident occured on the French territory but
  both emergency services from France and
  Luxembourg were involved.
• In France, the delegated IM took the first
  protective measures (closing and lifting the
  line), transmitted the advices to the police and
  emergency services, to BEA-TT, EPSF and Ministry
  of Transport and commanded immediately an
  internal technical investigation on the accident
  in coordination with the internal investigation
  of CFL.

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Role of the stakeholders and their interfaces (2)

• The ministry of Transport ordered the BEA-TT to
  proceed to investigation.
• EPSF asked the IM for information about specific
  conditions for traffic re-opening.
• After 5 days, the IM re-started the traffic on
  the line with EPSF approval on the specific
  conditions.
• On October 20th, 9 days after the accident, the
  traffic was normally operated on the line with a
  special focus on the staff in charge of safety
  (EPSF demand). Investigations were still going
  on.

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Role of the stakeholders and their interfaces (3)

• Remarks
• First serious accident since the creation of NSA
  coordination of the new system and information
  transmission are functionning well.
• Considering the important technical damages, the
  re-opening was quick thanks to the diversity of
  safety control levels and to permanent
  cooperation between the entities involved.
• The international aspect of the accident has a
  slight impact on the resolution of the situation.

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Conclusions (1)

• The official conclusions of the BEA-TT and the
  EEAI are not yet published.
• The cooperation between the stakeholders was good
  and efficient, especially between the IM, BEA-TT
  and EPSF, and the responsibilities are well
  defined.
• After the publication of the conclusions from the
  accident investigation bodies (BEA-TT and EEAI),
  the NSA (EPSF) will be in charge of controlling
  the implementation of its recommendations in
  France.

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Conclusions (2)

• In France, this accident shows that the new
  entities in charge of safety (BEA-TT, EPSF) are
  well identified and recognized.
• It also shows that its resolution is quicker and
  safer with an increasing number of entities
  involved.
• However, there was no concerted return on
  experience concerning implementation of emergency
  plans from railway point of view.

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• Thank you for your attention!