Nuits - English Summary

On June 23, 2023, the temperature in Paris exceeded 34 degrees Celsius. Around 10 p.m., an OSLO passenger train from Paris to Lyon stopped due to a locomotive breakdown. The stopping point was on platform 1, 1,000 meters upstream from Nuits-sous-Ravières station in the Yonne department (89).

Due to a lack of air conditioning since departure, the temperature on board exceeded 40 degrees Celsius. The 700 passengers were affected by the situation. Up to 400 exited the carriages. Some required medical attention on site, while others were taken to hospital. Thirty firefighters and two gendarmerie patrols were dispatched to the scene. Their intervention took place within the railway rights-of-way without any protective measures having been put in place to ensure safety.

The resumption of normal operations on platform 2 led to the passage of three trains, endangering emergency services and the gendarmerie officers, and the ongoing evacuation of a passenger on a stretcher.

The primary cause of the near miss was a lack of rigor in complying with defined rules. This slackness was due to the majority of those involved in managing the emergency situation of the passenger train on the track, both remotely and on the ground.

The more specific causes identified as having led to the endangerment of emergency services operating on railway rights-of-way without protective measures include :

- the fragility of the OSLO company’s design and its strategy for managing the emergency situation of its train ;
- the illegitimacy of the intervention of the TER Bourgogne Franche-Comté on-call staff ;
- the failure of the regional and national levels to comply with crisis management rules and SNCF Reseau & SNCF Voyageur’s commitments ;
- the individual behavior of regional crisis managers ;
- the lack of coordination between Traffic Agents and the regulator in handling the incident ;
- a partially adapted documentation for handling the incident ;
- a failure to comply with the SNCF group’s first rule of thumb ;
- a failure by emergency services to comply with the rules governing intervention in railway environments.

Each of these points is the subject of a recommendation.

Other weaknesses were identified, concerning :
- the conditions for obtaining the single safety certificate by the OSLO train company ;
- the "chief of operations" mission belonging to the train companies ;
- the organization of the rescue and the skills of the SNCF Reseau (network manager) EIC on-call teams ;
- the ergonomics of the SNCF Reseau DC 1503 document ;
- the knowledge of the SNCF Reseau, SNCF Voyageurs, and OSLO responders ;
- the presence of the mayor of the municipality within the railway rights-of-way.

Each of these points is the subject of an invitation.