Updating the risk assessment on the removal of train personnel from the Dm12 rail buses
Implemented
Rail R
Accident
4.5.2022
2022-S12
Suosituksen perustelu
The risk assessment on the removal of train personnel from the Dm12 rail bus rolling stock was carried out at a time when the rolling stock had just undergone a basic overhaul, and no fires had occurred for several years. Therefore, a fire and the resulting evacuation of passengers was not considered to be a major risk, and no measures were taken because of it. A situation, in which the train driver was incapacitated, or the passengers would need to exit the train unit on their own initiative for some other reason, was not recognised as a significant risk, either. In the cases investigated, the successful evacuation of the passengers and avoidance of personal injuries was based on the driver being able to act and, moreover, acting in an exceptionally systematic and effective manner.
Recommendation
VR-Yhtymä Oy updates the risk assessment concerning the effects of removing train personnel from the Dm12 rolling stock and takes the risks of fire and the potential inability of the driver to function into account in it in particular
Suosituksen tarkennus
Based on the observations during the investigation, the emergency signs on the doors that are important for the independent exit of passengers also require further clarification. Passenger safety, such as in situations, in which the driver has been incapacitated, can be improved by returning the train personnel back to the units especially in Dm12 trains that operate with more than one unit.
Toimenpide-ehdotukset
The risk assessment on the removal of train personnel from the Dm12 rail bus rolling stock was carried out at a time when the rolling stock had just undergone a basic overhaul, and no fires had occurred for several years. Therefore, a fire and the resulting evacuation of passengers was not considered to be a major risk, and no measures were taken because of it. A situation, in which the train driver was incapacitated, or the passengers would need to exit the train unit on their own initiative for some other reason, was not recognised as a significant risk, either. In the cases investigated, the successful evacuation of the passengers and avoidance of personal injuries was based on the driver being able to act and, moreover, acting in an exceptionally systematic and effective manner.