Investigation Body for Railway Accidents and Incidents

May 2015

Safety investigation reportSafety investigation reportDEATH OF A SHUNTING AGENT WHILE UNCOUPLING MOTOR COACHESJEMELLE - 15 NOVEMBER 2009

DEATH OF A SHUNTING AGENT WHILE UNCOUPLING MOTOR COACHESJEMELLE - 15 NOVEMBER 2009

Any use of this report with a different aim than of accident prevention - for example in order to attribute liability, individual or collective blame in particular - would be a complete distortion of the aims of this report, the methods used to assemble it, the selection of facts collected, the nature of questions posed, and the concepts mobilising it, to which the notion of liability is unknown. The conclusions which could be deduced from this would therefore be abusive in the literal sense of the term. In case of contradiction between certain words and terms, it is necessary to refer to the French version.

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CONTENTS PAGE

1. Description of the event 5

2. Initial facts 62.1. The event2.2. The circumstances of the event2.3. Human losses, injuries and material damage

3. Report of investigations and enquiries 83.1. Rules and regulations3.2. Uncoupling operation3.3. Portable radios3.4. Risks of the uncoupling operations3.5. Train operations

4. Analysis and conclusions 144.1. Final report on the chain of events4.2. Conclusions

5. Measures taken 16

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1. DESCRIPTION OF THE EVENTOn Sunday 15 November 2009, at Jemelle station, the train operating the link Liers-Jemelle (E 5570) was received in track VII. It was made up of two motor coaches.After its arrival, the 2 train sets constituting the train were to be uncoupled: one train set was to stay in Jemelle station until Monday morning, the second was to depart for Liège at 22:22 (E5593).To carry out this uncoupling, a shunting agent was positioned between the two train sets, track VII. The convoy departed, knocked the agent onto the rails, resulting in his death.

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2. INITIAL FACTS2.1. THE EVENT2.1.1. THE DECISION TO OPEN AN INVESTIGATIONThe accident that occurred on 15 November 2009 at Jemelle station meets the definition of a serious accident according to Directive 2004/49 and the Law on Railway Operational Safety of 19 December 2006.The Investigation body called upon SNCB/NMBS Holding and specifically its Safety and Environ-ment service to conduct the investigation on the accident site.According to the available elements, the investigation body decided to prepare a restricted report.

2.2. THE CIRCUMSTANCES OF THE EVENT2.2.1. PERSONNEL CONCERNED2.2.1.1. THE INFRASTRUCTURE MANAGER: INFRABEL

Head assistant station manager 14/22Head assistant station manager 22/6

2.2.1.2. RAILWAY UNDERTAKING: SNCB/NMBS

Shunting agent 14/22Shunting agent 22/6Train driverAssistant station manager 14/22Assistant station manager 22/6

2.2.2. ROLLING STOCK INVOLVED2.2.2.1. TRAIN E5570

The train received on track VII was made up of two motor coaches, type AM 73 and AM 74, num-bers 694 and 757.

2.2.3. EXTERNAL CIRCUMSTANCESThe accident occurred during the night, visibility was good between 50 and 100m, the tempera-ture was 9°C, a slight breeze with no precipitation.

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2.2.4. DESCRIPTION OF INFRASTRUCTURE

The “passenger” service installations are made up of:•direct passenger main running lines V and VI with a platform alongside each;•main reception tracks I to IV with a platform alongside each.

The Jemelle station installations include amongst others, 3 sidings (Lamsoul, Wamme and Mari-time), as well as access to the “LHOIST” connecting track.The tracks I to IV and VII are intended for:

• reception and stabling of passenger trains;• short term stabling of freight trains when the freight sidings are saturated.

The tracks V and VI are used for:•passage of non-stop passenger trains and those stopping for a short time;• the direct passage of freight trains.

At the time of the accident, the tracks I, II and III are cul-de-sacs in the direction of Marloie (Namur) due to works.

2.3. HUMAN LOSSES, INJURIES AND MATERIAL DAMAGES2.3.1. PASSENGERS AND THIRD PARTIES, PERSONNEL, INCLUDING CONTRACTORSThe incident resulted in the death of an employee from the railway undertaking: the shunting agent.

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3. REPORT OF INVESTIGATIONS AND ENQUIRIES

3.1. RULES AND REGULATIONS3.1.1. APPLICABLE PUBLIC COMMUNITY AND NATIONAL RULES AND REGULATIONSSNCB/NMBS PROCEDURAL MANUAL

•Manual II Passenger trains•Part 1 Formation of trains• Folder 1 Trains composed of motor coaches

Local instruction 11/1 of the VN zone of Jemelle- Revision of 27 February 2008

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3.2. UNCOUPLING OPERATIONThe train E5570 Liers - Jemelle is made up of two motor coaches (AM757 and AM694) and was received in track VII to allow passengers alighting. The two motor coaches were then to be uncoupled:

•one of the two motor coaches was to leave to Liège at 22:22 with the No. 5593,• the other was to go from track VII to track III to stay in Jemelle station until Monday morning.

The uncoupling operation at Jemelle station had been in operation since 1 November 2009. This was a provisional phase, prior to definitive adoption in the new timetable foreseen on 13 December.

This operation had already been carried out twice, on Sundays 1 and 8 November. On these dates, the uncoupling operation was carried out on track III. It was also possible to carry out the operation on track VII, as foreseen in the local instruction 11/1 of the VN zone of Jemelle.

3.2.1. UNCOUPLING IN TRACK IIIIf the choice is for an uncoupling in track III, here are the consecutive steps.The train arrives in track VII.It leaves in the direction of Libramont and comes into track III where it is uncoupled. Following the works at Jemelle station, tracks I, II and III are dead-end tracks in the direction of Marloie (Namur).A train set stays in track III and remains there until Monday morning; the other leaves in the di-rection of Libramont and returns to Jemelle station to depart at 22:22 towards Liers (train L5593).In this uncoupling, the driver does not leave the convoy, they change driving cab.

3.2.2. UNCOUPLING IN TRACK VIIIf the choice is for an uncoupling in track VII, here are the consecutive stages.The train arrives in track VII where it is uncoupled.The driver parks the train set in track III: it remains there until Monday morning.The driver leaves his cab and goes on foot to the second train set still in track VII. It is this train set which goes to Liers with the train number 5593.This method of uncoupling requires the driver to leave his cab in track III to go, on foot, to his cab in track VII.

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3.2.3. ORGANISATION OF THE OPERATIONSAccording to internal procedures, the general organisation falls to the assistant station manager of the railway undertaking. The operations to be carried out are communicated to the regulator1 and the shunting personnel:

• verbally for the specific operations not foreseen for passenger trains;• in the timetable documents available from the dispatcher and the duty card of the shunting

agent for the operations foreseen.

The assistant station manager manages the local service manoeuvres. He checks the organisation and safety of operations for trains as well as the correct application of the procedures provided.The shunting agent is responsible for the correct and prompt execution of the train operations.He scrupulously applies the requirements in the Procedural Manual I-Manoeuvres and the 11/1 instruction for the VN Jemelle zone.

3.2.4. END OF SERVICEThe accident happened during a shift change. The functions of shunting agent, assistant sta-tion manager and head assistant station manager are carried out during the 14-22 shift or the 22-6 shift.At the end of service, in accordance with regulations, the duty agent informs his replacement of the situation and in particular the operations underway, which is what the shunting agent 14-22 and his colleague from the 22-6 shift were doing on their way to the cloakroom. The shunting agent 14-22 communicated that an uncoupling operation of the train 5570 was to be carried out in track VII on the train arriving at Jemelle station at 21:40.The shunting agent 22-6 suggested that agent 14-22 finish his service and he would carry out the uncoupling in track VII himself. The two shunting agents left each other in the car park.

3.2.5. MODIFICATION OF THE OPERATIONSThe assistant station manager 22-6 decided that the uncoupling would take place in track III and not track VII for the two following reasons:

• less distance to travel for the shunting agent;• the train driver could leave his possessions in the same motor coach.

He informed the Infrabel assistant station manager verbally, the movement manager in post 60, of the change to the uncoupling area at around 21:35.The assistant station manager 22-6 carrying out the night service tried to contact the shunting agent by radio, but in vain.

1 The function of regulator is carried out by the Infrabel movement agent from the signal box (block 60) of Jemelle, the assistant station manager

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3.3. PORTABLE RADIOSThe agents carrying out the manoeuvres should have a portable radio, if foreseen in the local instruc-tions 11/1.The local instructions 11/1 provide for the use of portable handsets with three different channels:

•No 1 for the station (general);•No 2 for Jemelle operations;•No 3 for Marloie station.

Five portable handsets are used by:• the block dispatcher;• the assistant station manager;• the zone manager;• the shunting agent.

For the command of operations, the local instruction 11/1 in zone VN of Jemelle advocated the use of radios in a triangle. The driving personnel carrying out the manoeuvre, the shunting agent control-ling the manoeuvre and the assistant station manager monitoring the manoeuvre were in contact with the dispatcher I-R (from the infrastructure manager) who blocks the routes to be operated on.

3.3.1. QUALITY AND LINK UP TESTA quality and link up test should be carried out when the radio is put into service, when the channel or user is changed. The assistant station manager 22-6 carrying out the night service tried to contact the shunting agent 22-6 by radio, but in vain. We have not had the information concerning portable radio channels from the shunting agent and the assistant station manager. When radio links are not certain, the radio should be replaced or abandoned. He went to meet the shunting agent in the car park to inform him verbally of the change to the place of uncoupling, this being done in track III instead of track VII.

The assistant station manager returned to his office while waiting for the arrival of train 5570 in track VII.The assistant station manager 22-6 went to track VII when the train 5570 arrived at 21:40 to inform the train driver that the operation would be carried out in track III.

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3.4. RISKS OF THE UNCOUPLING OPERATIONSA risk was identified by the railway undertaking for uncoupling by shunting agents, this is why the agent in charge of uncoupling was required to:

• request and take possession of the RIC key for all locomotives coupled to the train set before the beginning of operations;

• ensure that the situation would not be altered during the whole length of the operation;• retain the key(s) as long as the heating cable has not been removed and returned to its rest

box.

However, in the case of the accident, it was not a locomotive but a motor coach. This procedure is not applicable. There was no RIC key.The RIC key is requested to avoid the risk of electrocution in the coupling and uncoupling of pas-senger cars and a locomotive. This does not guarantee the immobilisation of the convoy.To help the personnel, various sheets for organisation of the service manoeuvres were available ac-cording to the stock involved, etc.The procedure for the uncoupling of motor coaches equipped with a “Henricot” attachment is des-cribed in sheet 502. The uncoupling involves removing the bellows, lifting the ramp, placing safety bars, locking the frame end doors, disconnecting the electric couplers, the pneumatic links and the sound coupler. Manipulation of the electric coupler between 2 motor coaches is subject to the lowering of all the pantographs on the train set. The agent called to manipulate the couplers should visually check this has been done.The lowering of the pantographs is a precautionary measure to prevent damage to the stock (elec-tric arcs on the contacts, amongst others). An incorrect manipulation (with pantographs raised) does not present a danger of electrocution on this type of motor coach.The elements in our possession do not confirm or negate whether the pantographs were lowered.

The Operating Manual foresees that during coupling and uncoupling, the “presence” of the as-sistant station manager is required on the platform, except for urgent reasons.

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3.5. TRAIN OPERATIONSAt around 21:44, the train was driven from track VII to track III. The driver received authorisation to depart via the opening of the signal TXD: the train departed. It moved towards the sidings and the driver then changed cab to return to the platform of track III. He then noticed the brakes were stuck on the second motor coach. He informed the signal box and carried out an inspection of the stock. He verified the position of the brake valve in the driving cab that he’d just left and noticed that the CFA was at 0 bar. He tried to resolve the problem so as not to block the main running lines. He then noticed that an electric connection was disconnected. He reconnected it and left in the direction of Libramont to park the train in track III. He did not look for the reasons for the discon-nection of the electric connection.He did not consider the risk that the shunting agent was in the process of uncoupling the motor coaches: for the driver, in accordance with the instructions he had received from the assistant sta-tion manager 22-6, the manoeuvre was to take place in track III and not in track VII.We are not in possession of elements concerning an investigation of the braking system. The train set 5570 arrived in track III where the driver waited for agent 22-6. When the latter did not arrive, the driver informed the assistant station manager 22-6, who attempted to contact the agent 22-6. After several unsuccessful radio calls, they went to look for the shunting agent in track VII. At around 21:55, they discovered the body of the agent and found him to be deceased.

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4. ANALYSIS AND CONCLUSIONS4.1. FINAL REPORT ON THE CHAIN OF EVENTSThe shunting agent carrying out the service 22-6 arrived at Jemelle station at around 21:22 on train 2119. Prior to starting service, he went to the office of the assistant station manager at around 21:23, and met his colleague from the 14-22 shift as well as the 2 assistant station managers for respectively 14-22 and 22-6 shifts.

The train E5570 Liers - Jemelle was made up of two motor coaches (AM757 and AM694) and was re-ceived in track VII to allow passengers to get off. The two motor coaches were then to be uncoupled:

•one of the two motor coaches left towards Liège at 22:22 with the number 5593,• the other was intended to go from track VII to track III and stay in Jemelle station until Monday

morning.

The uncoupling operation in track VII had been planned in the afternoon by the station manager 14-22 who informed the shunter 14-22 in writing.On their way to the cloakroom, the shunting agent 14-22 informed his evening colleague that an uncoupling operation of train 5570 was to be carried out in track VII arriving in Jemelle station at 21:40 according to the daily report. The shunting agent for shift 22-6 suggested that the other agent finish his service and he would carry out the uncoupling in track VII himself. The two shunting agents split up in the car park.The assistant station manager for 22-6 decided that the uncoupling would take place in track III and not in track VII for the following two reasons:

• shorter distance to be covered by the shunting agent;• the driver of the train could leave his personal effects in the same motor coach.

The assistant station manager 22-6 carrying out the night service tried in vain to contact the shun-ting agent by radio. At around 21:35, he went to meet the shunting agent and saw him in the car park. He verbally notified him that the uncoupling area had been changed and would take place in track III instead of track VII. He returned to his office and awaited the arrival of the train to inform the driver.The assistant station manager 22-6 went to track VII when train 5570 arrived at around 21:40 to in-form the driver that the manoeuvre would take place in track III. He did not see the shunting agent.He confirmed verbally to the main assistant station manager from Infrabel, movement manager at post 60, of the change to the area of uncoupling at around 21:45.The shunting agent was not seen again.

At around 21:44, the train was manoeuvred from track VII to track III. The driver received authorisa-tion to depart via opening of the signal TXD and the train departed. It moved towards the sidings, the driver changed driving cab to return to the platform in track III, when he noticed the brakes were stuck. He went to check the position of the brake valve in the driver’s cab that he had just left and noted that the CFA was at 0 bar. He tried to resolve the problem so as to not block the main running lines. He noticed that the electrical connection was disconnected. He reconnected it and departed in the direction of Libramont to park the train set in track III. He did not look for the reasons for the electric link being disconnected. The train set 5570 arrived in track III where the driver was waiting for the shunting agent 22-6.

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4When the latter did not arrive, the driver informed the assistant station manager 22-6 who arrived around 2 minutes later and tried to contact the shunting agent 22-6. After several unsuccessful ra-dio calls, they went to look for the shunting agent by going to track VII. At around 21:55, they found the body of the shunting agent and found him to be deceased.

4.2. CONCLUSIONSAccording to the declarations and elements in our possession, the agent started the uncoupling of the motor coaches in track VII without the presence of the assistant station manager and the driver This way of working does not provide any safety barrier.

In the case of a change in the operations via a verbal communication, the monitoring procedure by the assistant station manager should be reviewed and reinforced. When communications involving tasks that involve several operators each with a well-defined role to play, agreement beforehand, understanding and visual contact between them should be a requirement.

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5. MEASURES TAKEN5.1. MEASURES TAKEN BY THE SNCB/NMBSTo prevent the shunting agent starting operation without the consent of the driver, the current regulations do not provide for any reinforcement of the following preventive measures:

•A prior verbal agreement with the driver is imposed on all shunting agents taking part in the uncoupling of the two motor coaches.

• In the absence of the driver, it is strictly prohibited to start uncoupling operations.

The Operating manual, Chapter IV, Part 3, section 4.1 foresees that when coupling and uncou-pling, the “presence” of the assistant station manager is required on the platform, except for ur-gent reasons.To raise the awareness of agents with regard to their responsibilities, we suggest modifying the term “presence” by “supervision”.

The procedure has been recalled and sent to all the regional managers and advisors in the pre-vention safety cell, who are responsible for transmitting this to the agents concerned.

Extract of the communication

2) Reminder of instructions based on propositions featured in the report

Major principles to be respected in the uncoupling of motor coaches equipped with a Henricot attachment:

• The manipulation of the electric coupler situated between 2 motor coaches is subject to the lowering of all pantographs on the train set. The agent called to manipulate these couplers visually checks this. The covers on the rest boxes are lowered. When manipulating and putting the coupler back in place, twisting should be avoided (Manual II, Part 1, Folder 1).• SNCB Mobility 2 requires that all shunting agents taking part in an uncoupling operation between mo-tor coaches carry out a prior verbal communication with the driver. In the absence of the driver, it is strictly PROHIBITED to start uncoupling operations.• The presence of the assistant station manager (excluding urgent reasons) is required on the platform during coupling and uncoupling operations of the MC equipped with a Henricot coupling.

As time has gone on, the Henricot type couplings have started to disappear, replaced by automa-tic couplings.In the absence of this, stock planning is carried out to minimise the number of uncouplings of stock operations equipped with this type of coupling.

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Extract HLT II.B.5

2 Means of carrying out manoeuvres

2.1 Prior conditions for the transmission of the authorisation to departThe agent ordering the movement ensures beforehand that this can be carried out in total safety.

2.2 Position of the driver during the carrying out of manoeuvre movementsThe driver:

• stands if possible on the side of the agent commanding the manoeuvre movement;

•occupies the head cab with regard to the direction for a pulling movement;

•occupies the head or tail cab for a push back movement;

• stands at the head of the movement if the traction unit is controlled from the portable remote control. If they cannot stand at the head the movement is considered to be a push back.

2.3 Position of participants for accompanied manoeuvre movementsDuring a push back movement the commanding agent positions himself in the place where he can completely observe, alone or with the assistance of several agents, the track to be operated on.

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