Training and procedures in error situations
Implemented
Rail R
Accident
30.1.2012
C1/2011R/S304
Suosituksen perustelu
Traffic control error situations can have a significant impact on railway traffic safety. Critical commands allow the traffic controller to create a situation in which the technical safety equipment system is unable to ensure traffic safety. The investigation found that, due to communication errors, there had been a major increase in the need for axle counting emergency commands in the month preceding the accident. Procedures should be developed for decision-making in error situations, in order to verify decisions taken by a single person. If error situations are common, users are subject to deteriorating levels of awareness with respect to emergency command use. This makes the reliability of equipment extremely important.
Recommendation
Traffic control personnel should undergo regular training and drills on identifying hazards related to error situations and on applying predefined, safe procedures.
Toimenpide-ehdotukset
Traffic control error situations can have a significant impact on railway traffic safety. Critical commands allow the traffic controller to create a situation in which the technical safety equipment system is unable to ensure traffic safety. The investigation found that, due to communication errors, there had been a major increase in the need for axle counting emergency commands in the month preceding the accident. Procedures should be developed for decision-making in error situations, in order to verify decisions taken by a single person. If error situations are common, users are subject to deteriorating levels of awareness with respect to emergency command use. This makes the reliability of equipment extremely important.
Investigation report
C1/2011R Collision of freight trains in Nurmes on 2 FEBRUARY 2011