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publié le 15 fĂ©vrier 2006 (modifié le 9 avril 2008)

Technical inquiry report on the tramcar accident which occurred in Rouen (Seine-Maritime) on the 30th of August, 2004

The Rouen tramcar system in partially underground, which is equipped with a block signalling system similar to that of the metro. On the morning of August 30th, 2004, when passenger presence was still limited, a tramcar rake which had so far operated normally, passed a closed signal at danger and did a rear-end shunt into a rake stopped underground. The stopped rake had been waiting for clearance to enter the next block. The driver’s safety device on the rear rake was functioning and apparently still activated, but was insufficient to prevent the accident from occurring.
One person was seriously injured and 7 others slightly injured. The damage was limited to the rolling stock and both rakes were badly damaged.

Human failure was at the origin of the accident. A sudden indisposition of the driver was alleged at the beginning of the investigation then discarded. The driver’s lack of alertness as he began to doze off appears far more likely. The driver had resumed work that morning, returning from his summer leave. He had a definite lack of sleep because of taking up his position early in the morning ; he had skipped breakfast and was most likely under the influence of an anti-depressant drug prescribed after he had been attacked two year earlier.

A first recommendation was sent to the management of the Rouen Public Transport System, for it to study how to match drivers’ living patterns and work patterns, particularly for drivers under medical treatment or under medical monitoring for partial unfitness at their usual job position. The management should hence study the allocation of worked days in order to reduce the risk of lack of alertness when returning after a leave of absence.

The report also recommended that the tunnel signalling system of the Rouen underground network as well as the rakes be fitted with devices to control passing at danger. Such arrangements should be included in the "Guided Transport" baseline document which would then progress on the matter of passive resistance of rakes (compliance with Euro-standard EN 12.663).

Another recommendation also suggested that during the next upgrade of the Rouen tramcars IT traffic management system, which processes the exchange of information between tramcar drivers and the Main Control Centre, new features would include permanent location of all tramcars and monitoring of block occupancy. Voice radio links should be unbroken wherever the driver is, inside his cab or outside of it when he is troubleshooting.

Links with rescue services should also be improved.
Finally, various improvements should be introduced to the rakes and to the tunnel to improve lighting in degraded situations, and to make it easier for passengers to evacuate on their own.