Donchery english summary

On Monday 14 November 2022 at 6.47pm, regional train n° 840831 stopped at Donchery station in the Ardennes, its last stop before the end of the service. Several people got off the train, including a schoolgirl who found her father waiting for her on the platform. To reach the exit, passengers had to use a level crossing footway through the tracks which was positioned in front of the train. Four people crossed in front of the train, but the father and his daughter waited for the train to leave. A young man did the same.
As the regional train was leaving the station, freight train n° 54084 arrived on the other track. It was coming from Metz and going to Dunkirk. It was travelling at a speed of 88 km/h as it passed the station.
As soon as the regional train cleared the pedestrian crossing, the three pedestrians crossed, the father and daughter first, the young man behind. The freight train, hidden by the regional train, hit the first two pedestrians with fatal injuries. The young girl died instantly from the violence of the impact. The father died a few moments later from the severity of his injuries. The young man who was following them was unharmed.
The level crossing is equipped with lighting signs warning pedestrians that it is forbidden to cross the lanes.

At the end of the investigation, the BEA-TT considers that, in view of the observations and testimonies gathered, the light signal was operating at the time of the accident and that its operation was not a factor in the accident. However, the BEA-TT cannot provide an assurance of this, as this signal is not equipped with a recording function. When the four people first crossed in front of the regional train, the light signal was off, indicating that there was no danger. The signals then turned on to warn of a danger as the train left the station. As the warning signals were located on the opposite side of the tracks from the pedestrians, they were hidden by the regional train. The pedestrians crossed behind this train, without noticing that the warning had lighted on.

The immediate cause of the accident, as identified by the BEA-TT, was the pedestrians’ lack of attention to the signals, which were neither observed nor obeyed.
The accident was not deliberate. The risk of inattention during this type of crossing is well known. It has been highlighted by a series of accidents and confirmed by behavioural studies of passengers in these situations.
Several systemic factors have been identified as having contributed to the accident :
• the visual masking of the signals by the regional train as it leaves the station, as well as the visual and audible masking of the freight passing train to be observed, the attention to be paid to them being disrupted because they are only revealed at the last moment before the accident ;
• the hurry of pedestrians to cross, once the regional train has cleared the way ;
• the lack of redundancy of the warning given to pedestrians in a second way of perceiving the alarm, as well as the absence of an explicit message announcing the arrival of a cross-train, which should increase their attention ;
• the reality of the behaviour of passengers who, as they walk through stations, are the opposite with the absolute vigilance expected of them to ensure their safety when crossing the tracks ;
• passengers are not sufficiently aware of the level of risk they are taking, as their attention is focused on other goals such as leaving the station ;
• the absence of an effective physical barrier blocking the path of pedestrians in the event of a deficit in attention.
Overall, the station track crossing installation does not sufficiently incorporate the behavioural risk of occasional passenger inattention into its design. It justifies improvement efforts in order to provide sufficient warning "power", as well as a catch-up loop or a physical barrier to counteract the natural risk of inattention.

The BEA-TT is issuing 8 recommendations and one invitation to prevent the risk of accident return, in the following areas :
• Implementation of SNCF’s action plan to make level crossings at stations safer ;
• a study of the redesign of the track crossing system, taking full account of passengers’ actual behaviour ;
• as a transitional measure while waiting for the implementation of these developments, the search for operating measures to prevent the risk of accidents ;
• re-examination of police rules and safety requirements, as these are not adapted to the reality of behaviour ;
• seeking funding to give SNCF the means to undertake an ambitious programme to replace or eliminate pedestrian level crossings at stations ;
• in the specific case of Donchery station, the implementation of the underground pathway.
An additional recommendation is devoted to a safety management measure at Donchery station, concerning the large group crossings observed. However, this was not a causal factor in the accident.