Reporting safety equipment malfunctions requiring a critical command

Detected safety deviations had been systematically left unreported. For at least twelve months before the accident, there had been repeated trailing notifications. The only reaction they elicited was returning the turnout under monitoring using the critical VAP command; they were not reported to the control centre. For this reason, the maintenance provider had not been notified either. When the VAP command is used before someone visits the location, it is impossible to observe any opening in a switch lock. Proactive risk identification and the reporting of all deviations, as emphasised in the safety management systems and in instructions, are not being realised in practice.

The Finnish Transport Agency should establish a system to ensure that the reason and justification for using a critical command are recorded. This justification will be used to show that no actual flaw remains in the system after the command has been used.

Before the VAP command is given, the actual state of the turnout should be checked by visiting the spot and checking the positions of the switch lock and the detectors. It has become habitual to leave trailing notifications caused by the passage of trains unreported due to their being so common and, on the other hand, because maintenance personnel have been unable to determine the cause of the trailing notifications. No interventions had been made in this practice, which has been allowed to develop as such. The Railway traffic control manual clearly obliges traffic controllers to report all safety device malfunctions and disruptions to the control centre, and all communications and monitoring disruptions to the maintenance provider.

Detected safety deviations had been systematically left unreported. For at least twelve months before the accident, there had been repeated trailing notifications. The only reaction they elicited was returning the turnout under monitoring using the critical VAP command; they were not reported to the control centre. For this reason, the maintenance provider had not been notified either. When the VAP command is used before someone visits the location, it is impossible to observe any opening in a switch lock. Proactive risk identification and the reporting of all deviations, as emphasised in the safety management systems and in instructions, are not being realised in practice.