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Zoufftgen english report

publié le 19 novembre 2010

On Wednesday 11 October 2006, extensive track works on the French network required one of the two tracks of the Thionville-Bettembourg section of international line to be neutralised from 8h50 to 16h30. Consequently, trains in both directions were using the other track under the Wrong-track Working Fixed Equipment (WWFE) system.
While an SNCF freight train was travelling on this track from Thionville to Bettembourg, a Regional Express Train (RET) was travelling in the opposite direction on the same track via Bettembourg station.
These two trains collided head on at around 11h44, on French territory at about ten metres from the border, near Distance Marker (DM) 203.700 (Commune of Zoufftgen).

As a result of this accident, six people died, one was seriously injured and fifteen others had minor injuries.
The first of the three carriages of the Luxembourg RET was totally destroyed ; the other two were badly damaged. The French locomotive of the freight train was totally destroyed and the first eight wagons were totally destroyed or badly damaged.

The direct and immediate cause of the accident was human error : the Traffic Controller of the Bettembourg Central Control Post mistakenly issued the driver of the RET an order to pass through the "danger" signal protecting the section of track on which the freight train was travelling.

The other causes and factors that contributed (or could have contributed) to this accident can be classified into four groups :
- direct causal factors relating to mistakenly issuing the pass-through order, and which concern the Bettembourg Central Control Post (CCP) : the incorrect staff handover procedure just before the accident, the high frequency of signal faults, the poor ergonomics of the available documentation, and the ergonomics of the Visual Control Panel which could be improved ;
- direct causal factors relating to the failure of attempts to rectify the situation : incorrectly pressing the radio warning button (or failing to press this button), delay in implementing the traction power cut-off procedure, failing to transmit the warning to the Thionville Control Post, and the limited capacity of the telephone system at the Bettembourg CCP ;
- underlying causes regarding staff skills : insufficient knowledge by the CCP staff of the procedures to be followed, particularly for issuing pass-through orders or for handling emergency situations, and the absence of practical training in emergency procedures ;
- organisational causes regarding the Safety Management System and the regulatory framework of Luxembourg Railways (CFL) : unrealistic division of tasks between the Bettembourg CCP staff, lack of encouragement to gain experience and laissez-faire approach to monitoring staff and implementing management control.

Furthermore, the investigation highlighted several factors that, although they did not play a part in the development of the accident, would have compromised the effectiveness of any attempts to rectify the situation that should normally have been made : the hidden fault on the ground-train radio at the Bettembourg CCP, the fault on the ground-train radio of the freight train, the lack of continuous radio warning transfer near the border, and the lack of a direct connection between the Bettembourg CCP and the East-France Substation Unit.

This investigation makes twenty-two recommendations. They relate to preventive actions focused on the following objectives :
- to remind staff finding themselves in the position of issuing an order to pass through a signal set at "danger" that they must not do so until they are sure that the reason for the signal remaining in "danger" position is really the consequence of a fault in the equipment ;
- to take the necessary steps to reduce the number of faults in the signalling equipment ;
- to provide documents to help in the decision-making process ;
- to improve the legibility of the Visual Control Panel at the Bettembourg CCP ;
- to re-train the Bettembourg CCP staff ;
- to review the consistency of the safety regulations at CFL and the role of the traffic controllers ;
- to improve the reliability of the communication and warning equipment and procedures, particularly the cross-border aspects ;
- to ensure that the systems made available to the staff work properly ;
- to improve the protocol for staff handover and its implementation ;
- to train staff in the emergency procedures that are most likely to occur ;
- to review the experience feedback scheme ;
- to ensure that checking and monitoring of staff by the management is as thorough as possible.