Saint-Romain-en-Gier english summary
Report on the technical investigation into the April 5th 2004 railway accident at Saint-Romain-en-Gier, France
This report(format PDF - 1.7 Mo) presents the sequence of events, analyses and recommendations of the technical investigation ordered by the Minister of Transport following the railway collision on April 5th, 2004, between an empty high speed train and a works train on the main line between Lyon and Saint-Etienne.
The accident was due to track works between the cities of Rive-de-Giers and Givors, in a railway section equipped with reverse signalling. The works carried out on the night of the 4th to 5th of April took longer than expected, and consequently the works trains were behind schedule on their return journey. The ballast works train return journey conflicted with the first commercial morning run between Lyon and Saint-Etienne. Due to a series of errors, these two trains were running in opposite directions but moving towards each other on the same track and a head-on collision could not be avoided. Two people were injured and there was considerable damage done to rolling stock.
The analysis of this operating accident concluded to no fault due to either the technology (material means) or the procedures as such ; the accident was due to a series of human errors starting with the planning of the works, all the way through to the carrying out of the works. Also, each department involved in the various operations contributed its own share of errors.
The works instruction sheet drawn up in advance to identify all conditions under which the project would be carried out, was not specific enough as to works train movements and the need to set the direction of the train route ; signalling for the egress route was not set in the correct direction.
Concerning driving the works train and determining the boundaries of its scope of action, failings in reading certain markers and signals (particularly those turned off at night) prevented the two converging trains from stopping on time.
Both the night and morning traffic agents failed to share sufficient information with each other, to the extent that the morning traffic agent had an erroneous mental picture of the situation (in fact the picture of previous works sessions) and unduly set a route by manoeuvring buttons through attention support devices.
Also, the investigation brought out the fact that the planners from « Operations » and « Rolling Stock » had not indicated on the works instruction sheet that the work site covered two intervals running counter to each other. They had also failed to indicate the direction in which traffic was to run inside these intervals.
In order to improve the level of safety and successfully carry out such a project, the following recommendations were made at the end of the investigation :
Improve training and awareness of all infrastructure departments - operations and rolling stock - to the problems involved when lines equipped with reverse signalling.
Prior to any job, improve the description of all works train movements, so that field operators will have a set of clear and unambiguous instructions.
Ensure that safety operators have indeed taken the time to study all works programmes beforehand and that they have clearly laid out all their procedures when works begin.
When outside safety operators from a different centre are brought in as reinforcement, it is important that they familiarise themselves with the layout of the area and with the infrastructure they will be using.
Give the works train agents the signalling diagram of the line section where they will be expected to discharge their duties.
In summary, documents given to field agents for the execution of their work should be subject to no interpretation whatsoever. Also, the SNCF’s internal auditing system should focus on highlighting any possible procedural deviation in order to maintain the high level of safety of the railway network.