INDEX
- SUMMARY.. 3
B - INTRODUCTION.. 3
C - ORGANIZATION.. 5
E - INQUIRIES.. 8
F - RECOMMENDATIONS.. 12
G - CONCLUSIONSCONCLUSÔES.. 18
ANNEX 1 - Inquiries that had transited for 2008
- SUMMARY
The present report looks for to answer to the constant in point 3 of the Article 23.º of the DirectiveDirectiva 2004/49/CE of 29 of April, in which if it relates that the Responsible Entity for the Inquiry of Accidents must present until end of September of each year a Report contends referring information to the performedefectuadas inquiries, the recommendations of security and the developed actionsshares in accordance with the recommendations, and that they had been carried through during the previous year (2007)
Thus the main constant aspects in this Report are the following ones:
- Presentation of the current organization
- Description of the used procedures
- Identification of the type of inquiries carried through in 2007
- Synthesis of the concluded inquiries
- Efectuadas Recommendations issued
B - INTRODUCTION
In 2007 onein accordance with was givengave to continuity to the procedures of inquiry of railway accidents and railroad incidents in accordance with the application of the methodology followed in the last years.
In 31 of December of 2007 the Organic Law was published (Decree n.º 394/2007) that it partially transposes for the internal jurisprudence the Directivea n.º 2004/49/CE, of the European Parliament and the CouncilAdvice, of 29 of April, relative to the security of the railways of iron of the Community, and that it modifies the Directivea n.º 95/18/CE, of the CouncilAdvice, of 29 of July, relative to the distribution of capacity of the railways infrastructure railroad employee, the application of taxes of use of the railways infra one--railroad structure and to the certification of safetysecurity guard.
This Decree creates the Cabinet of Inquiry of Safetyecurity and Railway AccidentsAcidentes Ferroviários (GISAF), defining its scope, attributions and abilities.
Currently the GISAF doesn’t havenot yet makes use ofown staffpersonnel so is if not finding in full functioning in accordance with its attributions.
In 2007 it was aggravated this situation of human lack of half technician resources and it was not having been possible to conclude the processes of inquiry in the time secular limits imposed by taxes for the Directivea (12 months after the opening of the inquiry process), having itself given to immediate reply to the situations of bigger gravity and tried to shorten looked to colmatar the delays of processes of previous years.
With the creation of the GISAF and respective structure of functioning and endowment of an adjusted staff personnel, it’s one expectedsinside that this situation can thus be exceeded and, if of the possible one, to give fulfilment to the stated periods of conclusion of the Reports
However, during 2007, it had they had been developed and put in ranks in practiceal all the relative procedures relative to the gathering together retraction and treatment of the referring technical data technician relative to the circumstances where if they had verified the occurrences not only want as for the rolling stock circulating material as well as to the infrastructures.
Complementarily to the processes they had been also collected and registeredados the direct and indirectospersonnel testimony certifications of the witnesses of the occurrences.
The previous approachesorientaçõeshave continued during 2006 namely regarding how much toto the application of the criteria of opening of inquiry processes had been remained nominated,, structure of the Final Reports, relationships with the companies of the rail sector and information to the ERAAGE of the occurrences that had been objecto of opened investigationinquiry opening.
In the absence of the Authority of the RailwaysroadSafety AuthoritySecurity to whom the constant Recommendations of the Final Reports must be addressed, the procedure that has been adoptede has been of the presentation to the operators and to the manager of the infrastructure of the draft version reportsversion and of and further posterior integration or not, of the respective commentaries will be pronounced on the final.
C - ORGANIZATION
During the year of 2007 the services of Inquiry of Accidents Investigation had been remained integrated in a dependent Department of the RailwaysroadInspection Inspecção of the INTF.
During this period the services had had the following personnel:
1 - Director of Department
1 - Superior technician
1 - Administrative technician
These services had organicly continued organicly integrated in the structure of the dependent INTF in directdependence of the BoardAdvice of Administration, keeping however functional autonomy face to the capacity of proposal of decision for opening of inquiry processes, its development and the presentation of the conclusions and recommendations which are of the exclusive responsibility of the services of Inquiry of Accidents.
The institucional relationship with the services of the Manager of Infra-estrutura (REFER) and with the main operator of railwaysroad transport (CP) is has been donneefectuadodirectly directamente through the President and Technician of the Commissions of Inquiry having aimed at the order of all the technical documentation necessary technique for the continuation of the inquiry processes.
Figure 1 - Diagram of Institucional Relationship
D - PROCEDURES
In 2007 Tthe same procedures of 2006 had been followed that in 2006: 2007:
1.Information received from the operators or the manager of the infrastructure (written, or verbal) on the occurrences.
2.Decision on the procedures to take face to the gravity of the occurrence (opening or not of Process of Inquiry).
3.RetractionGathering of the first information on the circumstances of the occurrence (human and material damages, safety security of the traffic circulation, etc.).
4.SeenVisit to the place of the occurrence accompanied by folloied for the Manager of the Infrastructure - characterization of the circumstances of the occurrence, photographic register.
5.Procedures of opening of the Technical Process Technician of Inquiry - Justification of the opening of the procedure and proposal of constitution of the Commission of Inquiry, information to the Infrastructure Manager, Operators and State Ssecretary of the Transports of the decision and of the constitution of the Commission of Inquiry.
6.Identification and systematization of the technical information technique to be requested to the companies on the involved rolling stock circulating material and the infrastructure.
7.Marking of the auditions hearings to the crew of the trainconvoy or other witnesses.
8.Accomplishment of the interviews.
9.Reception and verification of the requested technical data technician.
10.Identification of eventual complementary information to be requestedto the companies.
11.Elaboration of the first version of the Report of the occurrence in accordance with the constant structure of Annex V of Directivea 2004/49 of 29 of April.
12.Analysis and discussion quarrel of the first version of the Report.
13.Introduction of alterations and signature of the Final Report.
14.Sending of the Final Report for the companies for the purpose of contradictory argumentation.
15.Analysis and validation of the comments made for the companies to the Final Report.
16.Introduction of eventual alterations to the Final Report.
17.Sending of the Final Report to the companies and the State Ssecretary of the Transports.
18.AccompanimentFollow up of the recommendations.
E - INQUIRIES
In 2007 12 processes of inquiry had been opened and had been concluded 6 processes, being 1 referring onethe processes opened in 2005, referring 3 reports are of 2006 and referring 2 reports are referred tothe 2007;,; transiting 29 processes of inquiry have transited for 2008 and they are late reports referring ones to the years of 2005, 2006 and 2007, which meeting in course the necessary inquiries are still in course.
To relate that of the 12 opened processes of inquiry opened in 2007, 8 correspond the accidents in Tickets of Level Crossings, the 2 are derailments and the last 2 are persons caught by rsmharvested ones.
TYPE OF CORRÊNCIA / v.a. / %Derailments / 2 / 17
Tickets of Level Crossings / 8 / 66
Persons c. by rsmHarvested / 2 / 17
Total / 12 / 100
Picture 1 - Type of occurrences objecto of Inquiry (2007)
[Note: tickets of level is a bad translation of “passagem de nivel” which means level crossing;
Harvested should be “colhidas”, which means persons caught by rsm]VR
Figure 2 - Type of occurrences objecto of Inquiry (2007)
In Picture 2 containsit consists the identification of the processes that had been opened in 2007 and respective date and hour.
In Picture 3 containsit consists the syntheses of the 6 processes concluded in 2007.
ASSIGNMENT / DATE / HOURAccident with the convoy n.º 5679 in the PN(Level Crossing) type D to Pk(Kilometric point) 149,695 of the Line of the Beira BaixaSide Low / 01.02.07 / 14h08
Temporary derailment convoy n.º 6205, Pk 6,900 of the Line of TuaYours / 12.02.07 / 18h25
Accident with the convoy n.º 133 in the PN type, to Pk 203,378 of the Line of the North / 21.03.07 / 18h41
Accident with the convoy n.º 803 in the PN type B to Pk 122,032 of the Line of the West / 28.03.07 / 16h50
Accident with the convoy n.º 96509 PN 5.ª Cat., Pk 37,969 of the Line of the South / 04.04.07 / 17h43
Accident with the convoy n.º 6458 in the PN type D, sita to the Pk143,998 of the Line of the West / 12.05.07 / 17h30
Accident with the convoy n.º 4109 in the PN type, in the sita one to the Pk59,270 of the Line of the Douro / 02.06.07 / 15h31
Accident with the convoy n.º 77631 in way D, to the Pk218,190 of the Line of the North / 13.06.07 / 01h40
Accident with the convoy n.º 5679 in the Line of the Beira BaixaSide Low, to Pk 140,650 / 01.08.07 / 15h48
Accident with the convoy n.º 5714 in the PN type B, sita to the Pk370,183 of the Line of the Algarve / 05.08.07 / 12h16
Accident with the convoy n.º 5718 in the PN type D, sita to Pk 347,716 of the Line of the Algarve / 18.08.07 / 14h13
Derailment of the convoy n.º 69611 to Pk 231,300 of the Line of the North / 17.08.07 / 02h57
Picture 2 - Inquiries initiated in 2007
[convoy means “comboio” or train]VR
Date of the Incident Accident/:
14 ofJaneiroof 2005
Date of the Report:
22 of November of 2007 / Line of the Beira AltaHigh Side in the PN type D, sita to PK 207,273 / In day 14 of January of 2005 for 16H45, a light road vehicle fastautomobile of goodsmerchandises, was clashed harvested by the convoy (train) of passengers nº 5427, in the ticket of levellevel crossing of the type D, sita to Pk 207,273, in the Line of the Beira AltaHigh Side. The collision occurred when the conductor of the road vehicle fast automobile of merchandises lost the control of itthe viatura after an brusque braking, having entered in the PN, of the right for the left side relatively to the direction of the march of the convoy, having the conductor been seriously wounded and the companion with lightfast wounds.
Date of the Incident Accident/:
21 of June of 2006
Date of the Report:
15 of January of 2007 / Lisbon - Ascensor of the BicaPipe / In day 21 of June of 2006, for 20h50m, the vehicle n.º 2 of the installation by cable for handle for transport for of people public transport assigned by Ascensor of Bicathe Pipe, explored for Companhia Carris de Ferro de Lisboa, s.a. (Carris), it struck in the back of an automobile vehicle automobileforof glass garbage collectionretraction, ontto the service of the City council of Lisbon (CML), the collision occurred when the vehicle was doingefectuava the last trip of the day, circulating in the ascending direction, and the vehicle of the CML wasstopedif it found motionless next to n.º 42 of the Street of the BicaPipe Duarte Belo.
Date of the Incident Accident/:
6 of September of 2006
Date of the Report:
3 of April of 2007 / Line of the North - incident with the convoy nº 66951 to Pk 87,400 / In day 06 of September of 2006 the convoy nº 66951 that it circulated with 22 wagons of TEJO ENERGIA s.a. loaded with coal, with origin in the station of Port of Sines and destination to the station of Electrical Power Central office of Pego, stoppeding efectuou, atfor 03H50, in the neighborhoods of Pk 087,428, betweenenters the stations of Valley of Figueira and Mato Miranda, of the Line of the North, due to which had damages it of the rollings of a box of axle of one of twirled of the wagon placed in 7.thªthe position of the composition of the convoy, in the direction of marches. The box of axle of the right wheel, of the first one twirledset of, the rear bogie of rear, on the interiorthe side of the line,seedindistinctly, of the wagon nº UIC 83 94 933 0 037-1, placed in 7.ª position of the composition of the convoy, in the direction of the march, had heated sobreaquecido abnormally.
Date of the Incident Accident/:
20 of December of 2006
Date of the Report:
23 of June of 2007 / Line of the North - Derailment of wagon 64311 to Pk 235,140 / In day 20 of December of 2006 for 04H35, in the convoy of merchandises nº 64311 pulledtraccionado by two locomotives and 18 cistern wagons watering hole of loaded with cement of the company TRANSFESA, when it circulated in the Pampilhosa direction - Aveiro, of the Line of the North, derailed the front wheel set twirled one of the front of the back bogie of the wagon, in the direction of the march, the wagon that followed in the 13 position to count of the locomotive, in the PK 235,140, having the wagon circulated derailed until the convoy has been if to have immobilized in the PK 238.412.
Date of the Incident Accident/:
1 of February 2007
Date of the Report:
27 of December of 2007 / Line of the Beira BaixaSide Low in the PN type D, sita to PK 149,695 / In day 1 of February of 2007 for 14H08, a light passenger vehicle fast automobile vehicle of passengers, was clashed by the passenger train nº 5679 was harvested by the convoy of passengers, in the Ticket of Level cross of type D, sita to Pk 149,695, between enters the station of Fundão and the apeadeiro of Alcaria, in the Line of the Beira BaixaSide Low.
The collision of the convoy with the vehicle automobile occurred when the vehicle automobile entered in the Ticket of Level cross of the left tofor the right in the direction of the circulation of the convoy, having the conductor of the vehicle automobile, its only occupant, been jailed inside of the vehicleviatura and this after to have been dragged about 200metros until the a immobilization of the convoy
Date of the Incident Accident/:
12 of February of 2007
Date of the Report:
19 of March of 2007 / Line of TuaYours - Derailment of the convoy of passengers to the o Pk 6,900 / In day 12 of February of 2007 for 18H25, in the line of TuaYoursbetweenit enters the stopsapeadeiros of Talhariz and Castanheiro, the regional convoy of passengers n.º 6205 that it circulated in the direction of TuaYours - Mirandela, derailed in the neighborhoods of Pk 6,900 and fell to the river TuaYours.
The derailment of the convoy occurred due to a landslide of rocks of the hillside of the right side of the direction of circulation of the convoy that damaged the railway line.
Of the derailment and fall of the convoy it resulted, in the death of the 3 members of the crew of the convoy: Operator of Systems of Railwaysroad Transports, Operator of Revisionsão and SalesVendas and the Operator of the station of TuaYours. They had been also wounded with gravity two passengers, who had been projectedados of the convoy for the rocks when this was in fall, having been rescued byof helicopter for because of the place where if they found wasto be ofof difficult access, having been carried to the Hospital of Vila Real Village.
Picture 3 - Synthesis of the inquiries concluded in 2007
F - RECOMMENDATIONS
Of the total of the 26 Recommendations issuedefectuadas in the concluded processes of inquiry concluded in 2007, 9 had been addressed directedto the Manager of Railways Infra-estrutureas Ferroviárias (REFER), 11 to National Railwaysroad Operator C.P. e 6 to other entities. (Figure 3)
Figure 3 - Recommendations for Entity
TFor type of recommendationhe most important of the types of recommendations are the the ones that are associates to the fFulfilment of the Regulation or Legislation, Training Shares of Formation of the Staff and Instalation or refurbishment of Alteration or Equipment or material Installation , as most significant are outstanding. (Picture 4 and AppearsTable 4)
Category of Recommendation / N.º / %Actions of training of Shares of Formation of the Staff / 6 / 23
Equipment alteration or Installation / 4 / 15
Fulfilment of the Regulation or Legislation / 8 / 31
Maintenance of Circulating Material (rs) / 3 / 12
ActionsShares of Fiscalization / 3 / 12
Organization of the Services / 2 / 8
Total / 26 / 100
Picture 4 - Category of Recommendations (2007)
PictureFigure 4 - Category of Recommendations (2007)
In Picture 5 are represented the the recommendations consist that had been donneefectuadas in the scope of the concluded processes of inquiry in 2007.
Picture 5 - Recommendations of the processes concluded in 2007
OCCURRENCE / Accident with the convoy of passengers nº 5427 in the PN Type D, sita to Pk 207,273 of the Line of the Beira AltaHigh Side, occurred in day 14 of January of 2005IT DATES REPORT / 22 of November 2007
N.º / RECOMMENDATIONS
1 / It will have the REFER as managing entity of the railwaysroad infrastructure, to promote togethernext withto the City council of Guarda to placetherank of advanced vertical road signalling, in the approach to the related PN (LC), on both sides of the way-railway lineone.
2 / It must the REFER in the characterization fiches of the level crossings tickets to promote the historical of the existing fixed road signalling in its accesses.
OCCURRENCE / Accident with the elevator of the BicaPipe in 21 of January of 2006
IT DATES REPORT / 15 of January of 2007
N.º / RECOMMENDATIONS
1 / It will have the Carris, as exploring entity of the Ascensor of the BicaPipe, to promote togethernext with to the City council of Lisbon:
- the alteration of the schedule of collection retraction of solid residues, including glass, for that the takeout be doneretraction is efectuada outside of the period of commercial exploration of the transport installation;
-the prohibition to carry outthrough loads and discharges during the period of commercial exploration of the transport installation;
-the implementation of severe restrictions to the transit automobile traffic in the Street of the BicaPipe Duarte Belo during the period of commercial exploration of the Ascensor of the BicaPipe, including to crosscover the way of circulation of the Ascensor, to stop on the way and to cross the street. In case that it is viable, automobile traffic in the Street of the BicaPipe will have to be forbidden in the street to the traffic total Duarte Belo during the period of functioning of the it Ascensor of the BicaPipe, with exception of with priority vehicles.
In the case of the crossingatravessamento of the Street of the BicaPipe Duarte Belo with the for Travessa do Sequeirothe Crosspiece of the Dry land, a color light semaforização semaphore system will be able to be developed to that hinders the road crossing atravessamento during the trips of theit Ascensor.
To note One notices that this recommendation strengthens identical recommendation that had been transmitted for the INTF to the Carris, in the scope of the process of attainment of the authorization for continuation in service of the Ascensor of the BicaPipe, in the sequeênceia of the identification of the risks and dangerous situations taken the handled for the Analysis of SafetySecurity carried through for the entity CATIM.
2 / The Carris will have to communicate to the INTF, immediately, any alterations that come to verify themselves, in what says respect to its structure of responsible on the exploration and maintenance of the Ascensor of the BicaPipe, including alterations of the companies and the employees who play activities related with the conduction and the maintenance of the installation.