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Author Topic: Train crash at Br^tigny-sur-Orge - multiple fatalities - 12 July 2013  (Read 35338 times)
stuving
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« Reply #45 on: September 27, 2013, 12:21:07 am »

There was a TV report on SNCF (Societe Nationale des Chemins de fer Francais - French National Railways)'s and RFF's maintenance standards tonight (Envoy^  Sp^cial, F2). Largely familiar - my favourite line to Saint-Gilles-Croix-de-Vie featured again, which everyone agrees is overdue for rebuilding, plus other lines with severe speed restrictions. Not very much directly about Br^tigny sur Orge, where the journos seemed unable to cope with the boss of SNCF saying it was almost certainly down to maintenance, and so their fault, but not admitting that it definitely was. Of course that's simply because the investigations are still underway.

Similarly, a point was made that after a low-speed derailment at Lyon two weeks earlier (26th June) SNCF instructed staff not to use the D-word. The accident is listed by BEA-TT (French for RAIB (Rail Accident Investigation Branch)) as an ongoing investigation, so it's hardly a secret. It was apparently due to a wheel breaking up, and the programme reported that a batch of 236 wheelsets had to be traced and recalled as they were assembled using the wrong torque (on its wheel-fixing bolts, I think). That was not the cause at Lyon, after which another batch of wheelsets had to be checked.

So the picture is building up that the safety culture and organisation had slipped below the required standards. And Guillaume Pepy (SNCF boss) is already talking about pre- and post-Br^tigny eras, much as Hatfield marked a radical change of priorities here.
« Last Edit: November 17, 2015, 07:49:48 pm by Four Track, Now! » Logged
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« Reply #46 on: October 11, 2013, 08:56:19 am »

RFF and SNCF (Societe Nationale des Chemins de fer Francais - French National Railways) Infra announced on Tuesday an urgent programme of accelerated inspection and replacement of track, concentrated on the most heavily used S&C (Settle and Carlisle ), called "Vigirail". This is a direct result of the Br^tigny-sur-Orge accident, and they warn that the extra possesions for the work will lead to some disruption. This follows on from the emergency work immediately after the accident, in which they claim to have inspected 5000 crossings, 100,000 fishplates, and 520,000 rail clamps in two weeks.

There is no new railway money involved, just collecting an extra ^410M according to SNCF) over four years from other budgets. Most of this is planned to double the number of replacements to 500 per year, and to recruit more staff to do it. Small amounts go on digitising the maintenance records and management, and on some new survey trains using HD video to inspect tracks.

SNCF info at http://debats.sncf.com/bretigny-sncf-et-rff-lancent-vigirail/#.UlevWFCkpcg, and full text at: http://www.rff.fr/?page=ajax_view&real_action=download&file_url=IMG/pdf/DP-Bretigny-sur-Orge_Point-presse-N6.pdf
« Last Edit: November 17, 2015, 07:52:58 pm by Four Track, Now! » Logged
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« Reply #47 on: January 09, 2014, 08:24:34 am »

Advance news (in French) on RTL of the results of the enquiries. The first report is due out tomorrow - I think that's the interim technical report from the BEA-TT.

RTL concentrate more on the (leaked) prosecutors' report, which seems to be heading for a criminal prosecution as well as a civil liability case. The news item talks about missing bolts in fishplates that no-one is bothered about, and maintenance that was both random and not thorough enough. The other theme, which is obviously going to have political implications, is the confused relationship between RFF and SNCF (Societe Nationale des Chemins de fer Francais - French National Railways), and how this clouds the responsibility for maintenance standards.

All sounds rather familiar, doesn't it?
« Last Edit: November 17, 2015, 07:56:41 pm by Four Track, Now! » Logged
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« Reply #48 on: January 10, 2014, 12:15:50 pm »

BEA-TT produce reports very similar in style and thoroughness to RAIB (Rail Accident Investigation Branch)'s. The interim report on the Br^tigny-sur-Orge accident is no exception. Of course that means it will take a while to read through (and no English text at the moment) ... but here's an initial appreciation:

The technical explanation is in line with what we heard earlier, but with more detail. The key facts, I think, are:
  • There were cracks running along a cast piece of rail, passing through the hole for a fishplate bolt.
  • This rail was part of the cast central crossing*, attaching it to the plain rail on the "upstream" side.
  • The cracks reached the end of this rail, where a piece broke off, leaving the fishplate free to deflect under the load of wheels.
  • This bolt (No.3 in the direction of travel) must have broken months before the accident.
  • The rest of the successive failures probably took place after the last inspection 8 days before the accident.
  • Movement unscrewed or broke three of the bolts, each failure placing more load on those remaining.
  • Finally only bolt No. 4, was left at the downstream (inner) end.
  • The nut unscrewed of this bolt, and then the outer fishplate fell off.
  • The bolt had too little clearance to come out, but the inner fishplate was now free to rotate and twist.
  • The fishplate was then flipped up under a train ,bent and hammered into the flangeway, and derailed its last four carriages.

The report comments that this trackwork is particularly complex and needs a lot of maintaining:
  • There is a diagonal link track across all five running tracks, with a double slip crossing with each.
  • This is now rare, in France as here, and scheduled for replacement but not before 2025.
  • The close spacing of the rails and other parts means the visibility of the underside of the trackwork was poor, and the initial fault - cracks and one broken bolt - was missed.

The country-wide inspection of similar crossings after the accident showed up a lot of deficient single fixings, though no immediate serious risks. Of course there is enough redundancy that it takes more than one bolt to fail before it causes an accident. They did find:
  • 4% of examples had vertical play of > 10 mm
  • 0.2% of bolts missing and 5.1% loose
  • from 1.7% to 4% of fixing bolts (rail to seat and seat to sleeper) were missing or loose.

The report notes the similarity of this track failure and resulting accident to Southall (2002) and a Danish accident (Farris,  2012), but not Grayrigg (2007). In all cases they observe there were specific technical issues, as well as poor maintenance.

The immediate recommendations are as you would expect:
  • Technical: to look at materials, procedures for tightening, locking of threads etc.
  • Inspection: to identify areas of track that need extra attention;
  • Procedures: to clarify the rules for follow-up time limits etc.

*I'm not sure what this piece is specifically called - but I now believe it is an obtuse crossing.
« Last Edit: January 11, 2014, 12:18:00 am by stuving » Logged
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« Reply #49 on: January 10, 2014, 08:29:15 pm »

The report notes the similarity of this track failure and resulting accident to Southall (2002) and a Danish accident (Farris,  2012), but not Grayrigg (2007). In all cases they observe there were specific technical issues, as well as poor maintenance.


I find there drawing a parallel with Southall strange, my recollection was not a track failure, it was Railtrack signaller / route control crossing a freight train from Southall Down West yard across to the UP Relief, which meant crossing over the DN and UP Main and DN Relief in front of a class 1 passenger train which was compounded by the ATP (Automatic Train Protection) not functioning correctly and the drive "packing his bag" 

I do think Network Rail are in a much better place than they were at the time of Grayrigg in 2007 I cannot speak for maintenance, in projects the process, procedures and checking that has to be done before, during and after any work is exceedingly onerous.
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« Reply #50 on: January 10, 2014, 09:38:14 pm »

The report notes the similarity of this track failure and resulting accident to Southall (2002) and a Danish accident (Farris,  2012), but not Grayrigg (2007). In all cases they observe there were specific technical issues, as well as poor maintenance.


I find there drawing a parallel with Southall strange, my recollection was not a track failure, it was Railtrack signaller / route control crossing a freight train from Southall Down West yard across to the UP Relief, which meant crossing over the DN and UP Main and DN Relief in front of a class 1 passenger train which was compounded by the ATP (Automatic Train Protection) not functioning correctly and the drive "packing his bag" 

I do think Network Rail are in a much better place than they were at the time of Grayrigg in 2007 I cannot speak for maintenance, in projects the process, procedures and checking that has to be done before, during and after any work is exceedingly onerous.

Wrong derailment.  That was the 19 September 1997 one.  The one similar to the French one is that at Southall that occured on 24 November 2002 http://www.hse.gov.uk/press/2003/e03027.htm and http://www.rssb.co.uk/LEARNING/Documents/Southall%20East%20Junction%20summary.pdf
« Last Edit: January 10, 2014, 10:02:16 pm by SandTEngineer » Logged
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« Reply #51 on: January 10, 2014, 10:02:20 pm »

The report notes the similarity of this track failure and resulting accident to Southall (2002) and a Danish accident (Farris,  2012), but not Grayrigg (2007). In all cases they observe there were specific technical issues, as well as poor maintenance.


I find there drawing a parallel with Southall strange, my recollection was not a track failure, it was Railtrack signaller / route control crossing a freight train from Southall Down West yard across to the UP Relief, which meant crossing over the DN and UP Main and DN Relief in front of a class 1 passenger train which was compounded by the ATP (Automatic Train Protection) not functioning correctly and the drive "packing his bag" 

I do think Network Rail are in a much better place than they were at the time of Grayrigg in 2007 I cannot speak for maintenance, in projects the process, procedures and checking that has to be done before, during and after any work is exceedingly onerous.

Wrong derailment.  That was the 19 September 1997 one.  The one similar to the French one is that at Southall that occured on 24 November 2002 http://www.hse.gov.uk/press/2003/e03027.htm
Ah yes strikingly similar
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« Reply #52 on: July 07, 2014, 08:17:36 am »

The next step in the process following this accident is not the final BEA-TT report, but the release of two reports done for the prosecutors' office. One is the metallurgical examination of the track components, mentioned in the BAA-TT interim report as not finished. The other is an overall report by their own appointed expert engineers. These were both delivered to the prosecutors by June, and some kind of announcement is expected today, as well as publication. However, as is usual it has already been leaked to the press - and no one seems to find this odd.

In this case Le Figaro had the story. Obviously the purpose of the main report is to allocate blame, and so it is not as studiously neutral in tone as the BAE-TT one. SNCF (Societe Nationale des Chemins de fer Francais - French National Railways) and RFF have already said they dispute the findings (also an entirely routine part of the legal process). Basically, the report is reported to say the poor state of maintenance was unprecedented, and due to deficiencies throughout the maintenance branch, including training. SNCF point out the inherent contradiction in that - doesn't it mean maintenance is overall good and quite adequate (as the accident record shows)? And just who are these experts anyway? More will appear soon, no doubt.
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« Reply #53 on: July 07, 2014, 10:01:19 pm »

To clarify:

 
Quote
A year after the disaster, the conclusions of reports commissioned by the judges in charge of the investigation are instructive for the SNCF (Societe Nationale des Chemins de fer Francais - French National Railways) and its maintenance procedures.

Findings:

Rail disaster 12 July 2013 last Bretigny-sur-Orge (Essonne), which killed seven people and wounded thirty, is definitely due to a maintenance problem. It is telling that the railway and metallurgical expertise has procured reports whivh  Le Figaro and the prosecutor Evry shall make public on Monday. In these extremely severe reports for the SNCF, sent to judges on June 25, expert engineers (Court of Appeal of Douai) and Pierre Michel Dubernard Henquenet note that "metallurgical examinations were made possible to establish that we are not in the presence of a malicious act, and the process that led to the complete disintegration of the assembly is quite the opposite over several months and involved the entire assembly failing, from which were recorded over 200 anomalies of varying degrees of criticality. Most of these abnormalities were known from the railway company or its agents, but were not adequately remedied. The conclusion of the experts is final and evokes "dilapidation never seen elsewhere." He added: "imfrastructure perished by fatigue, vibration, beat, defects tightening, wear, etc.. Damages relating to the quality of maintenance. "
Number 3657 Intercity train consisted of seven cars Reef. There were 385 passengers on board. The train had left the Gare d'Austerlitz to 16 h 53. At 17 h 11, as it prepared to cross Br^tigny station vi platform 1, passengers felt a shock when crossing a double junction crossing . The train derailed and separated into two parts between cars 4 and while traveling at 137 km / h. the authorized speed limit on this road being 150 km / h. Due to the state of the network, the experts appointed by the judges noted in their report that "it would be desirable to limit to 100 km / hour speed trains approaching the station Br^tigny."
Inadequate monitoring network

It further notes that "current maintenance requirements" for sleepers at double junctions are "inadequate because insufficient." Currently, SNCF dismantles the spliced ​​connections to check every three years because they are classified as "comfort items". Experts advise strongly to dismantle every year to inspect. According to them, the tour audits on channels should lead agents to "the immediate compliance", which is not the case today. The network status Br^tigny "would logically have led the SNCF to increased surveillance, and especially adapted," they write.
Experts are clearly involved in the railway maintenance organization: "There is also important to say that the SNCF staff responsible for implementation of track maintenance and equipment should be chosen according to the first criteria for solid training in engineering and in addition have received extensive specialized training. "an allusion to the youth of the agent who made the last inspection tour July 4, 2013, eight days before the accident. It was a railwayman 25, freshly graduated from an engineering school. In February 2013, he became leader of nearby lanes Br^tigny. He framed 19 agents responsible ways to do maintenance on the rail network in the industry. At the last inspection, no abnormality was reported.
Abnormalities inadequately considered

"The maintenance requirements of the SNCF, complex, difficult to interpret or apply by field workers were not fully met (...). This has led to a lack of consideration and processing of errors encountered; It should be noted in this regard that many observations made ​​during the monitoring tours found themselves carried from one operation to another, sometimes to eventually disappear without us was sure they were treated . "And experts conclude by holding the top three factors that led to the accident by improper maintenance" repositories large maintenance superabundant, sometimes inadequate or contradictory so against-productive. "
Finally judicial engineers who conducted the inspection lane January 28 rounds alert on the status of network station of Noisy-le-Sec (Seine-Saint-Denis). They consider disturbing.

I speak French, but have used Google Translate for speed, tidied up to make sense for the the first half of the article. I'll translate further, as time allows, but the gist is that it was a Potters Bar incident, down to poor inspection and maintenance. I don't think the report was to allocate blame, the tenor of the report being largely similar to that of a report by the AAIB (Air Accident Investigation Branch) or RAIB (Rail Accident Investigation Branch) - what happened, why it happened, what should be done to stop it happening again. There is reference to the judicial process, something which would not happen in the UK (United Kingdom), although the relevant inspector could be summonsed to the criminal court proceedings, and indeed to any civil proceedings for damages.

We do not have
Quote
les ing^nieurs judiciaires
or judicial engineers in the UK, and therefore rely on legal experts to listen to two sides of the argument about what went wrong.

We find it common for everyone to blame everyone else at time like this, unlike the days before rail privatisation, when if it wasn't sabotage, it was down to British Rail. France has a similar dilemma, but it ends up as a decision as to which pocket gets dipped to pay for the repairs.

J'offre mes condolednces aux familes touch^s par cet accident. C^tait vraiment tragique.
« Last Edit: July 08, 2014, 05:24:14 pm by Four Track, Now! » Logged

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« Reply #54 on: July 08, 2014, 09:52:54 am »

SNCF (Societe Nationale des Chemins de fer Francais - French National Railways) have put their side of the arguments in their "newsroom" (all in French, obviously).

They do have an obvious problem, both legally and as PR (Public Relations), in that the accident was caused by inadequate maintenance, which they admitted almost immediately. Worse, they identified a lot of similar pointwork in need of renewal, and set up a major programme to do that. In that context, they are trying to resist the conclusions that the whole system (or at least the non-LGV (Large Goods Vehicle) part) has been allowed to deteriorate and hence is, in general, less safe than it ought to be (i.e. "unsafe" in headline terms).

The procedure appears to be that the legal opinions ("expertises*") of the "experts*" are only published on paper, made available to the press and maybe waved at a camera in a press conference. SNCF/RFF do not get to see them in advance of publication, so are playing catch-up at this point. They have put some extracts of the latest report on-line, essentially the conclusions.

One point worth thinking about in a British context is in the translated version posted yesterday, where it refers to "the maintenance requirements of the SNCF, complex, difficult to interpret or apply by field workers..." Their point is that there is just too much written material about doing maintenance: instructions, working methods, standards, reference documents. They reckon much of it is also not suitable for it purpose, confusing, and contradictory.

There was another such expert report in June, just about the state of that specific section of track, that got a lot less attention. It was not mentioned in the BEA-TT interim report, but I think the examination was done together (i.e. this was the prosecutors' report of that examination). BEA-TT's mission is the same as the RAIB (Rail Accident Investigation Branch)'s and their reports contain a similar warning not to use them to allocate legal liability.

There is another bit of French railway bureaucracy you don't much hear about - the safety authority EPSF - answering to that part of the ORR» (Office of Rail and Road formerly Office of Rail Regulation - about).

They are credited with the attached little picture, which SNCF quite like as it puts them ahead of the Germans.

The head of SNCF has been saying, Rice-Daviesly, that the system is "safe". Worse, the head of RFF said it was the safest in Europe. Given that the picture is based on data to 2012, that seems hard to justify.

*Note that expert does not have the same primary meaning in French as in English when used as a noun (it does as an adjective). It means someone asked for advice or an opinion, such as the experts judiciaires in this case, and expertise has the primary meaning of an opinion, legal or otherwise. The English senses of these words are also known too, by leakage.
« Last Edit: July 08, 2014, 09:50:04 pm by stuving » Logged
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« Reply #55 on: July 12, 2014, 04:11:03 pm »

Following some passing comments in the latest reports, there is now confirmation (via Mediapart) that previous internal reports into maintenance elsewhere in the Paris region have been pretty poor. Specifically, at and around the Gare du Nord in 2010, an audit noted procedures not followed, the wrong tools, mistakes in rail condition monitoring, inspections not planned and scheduled and sometimes not done at all, among other things.

SNCF (Societe Nationale des Chemins de fer Francais - French National Railways) have fallen back on "explanations" such as: not following the rules doesn't mean it's unsafe, audits only report deficiencies so what do you expect?, if we got no deficiencies reported then we'd be worried, we started a recovery programme and some things have improved since then, etc.

Sound familiar?
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« Reply #56 on: September 16, 2014, 01:58:07 pm »

RFF have been formally "mis ex examen", which is an earlier stage than a formal charge would be here. The offence is "homicides et blessures involontaires", a purely accidental kind of manslaughter, rather than the "mise en danger de la vie d'autrui" - which involves reckless conscious acts - and which some victim groups had been calling for.

The same thing will happen to SNCF (Societe Nationale des Chemins de fer Francais - French National Railways) on Thursday, though possibly not on the same charge. SNCF infra actually maintains the infrastructure, which RFF only manages. That will change with the the fusion of RFF and SNCF, recently voted by parliament, but not coming into effect until January 2015.
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« Reply #57 on: February 19, 2015, 11:43:48 am »

From 1st January 2015, the old RFF has been transformed into SNCF (Societe Nationale des Chemins de fer Francais - French National Railways) R^seau. The idea is to integrate ownership and management of rail infrastructure (RFF) with the engineering activity (SNCF Infra), at least while talking to French Socialists. This new entity has to be kept at arms length from the operating divisions of SNCF (SNCF Mobilit^s), at least while talking to European Commissioners.

However, despite well over a year's notice, neither web site yet reflects the new structure any more than the new logo and one paragraph of text on the old rff.fr site, promising a new version. I suspect that there was the predictable tug-of-war between RFF and SNCF Infra about which would take over the other, and RFF lost. The SNCF site does include the report of yesterday's meeting of a new safety oversight committee.

This new structure doesn't create any new bodies (unusually), as there already was the EPSF (cf. the safety-related bits of ORR» (Office of Rail and Road formerly Office of Rail Regulation - about)) and BEA-TT (RAIB (Rail Accident Investigation Branch)). It gives SNCF a central r^le in writing rules for the industry. The communiqu^ has been reported in quite different ways (no English reports, that I can see).

The headline news is that the starts of a number of big projects are being deferred, notably new LGVs (Large Goods Vehicle) (these would be regional links, mostly), station revamps, and resignalling. This is to permit resources to be shifted to the backlog of renewals work on the "classic" network. In effect, a two-year moratorium on new starts.

One TV report this morning refers to the Br^tigny-sur-Orge accident, of course, and to a report from the year before on the state of (dis)repair of the network. It suggests that money is the main consideration - a km of new line costs ^15 M against ^1 M for renovation.

This AFP report also refers to Br^tigny-sur-Orge, and the survey report done after it - plus another done in 2005 which (it says) had already led SNCF to make maintenance its priority. That does sound odd. It also says the main limited resource is specialist staff, rather than money, citing signals testers in particular - "we can't train them in two or three years, the job takes twenty years of experience"!

The following summary of the scale of thus year's renewals programme may be of interest:

- a budget of ^2.3 Bn for maintenance and ^2.6 Bn ;
- the renewal of 1,000 km of track, 400 items of S&C (Settle and Carlisle ), and 450 km contact wire ;
- the replacement of 788 points,  280,000 sleepers, 15,000 welded track inserts (precautionary against breakages), 3,600 km of catenary as planned renewal and 563 million m^ of vegetation dealt with ;
- verification of 37,000 signaling "centres" (not sure what level that represents) in 8 months.
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« Reply #58 on: November 17, 2015, 09:04:57 am »

BEA-TT published their final report on this accident in September. It didn't get much reported, as it doesn't really change anything in the interim report, so I for one missed it at the time.

BEA-TT have a page of brief summaries of their reports in English, but have not added any new ones for several years. In this case RAIB (Rail Accident Investigation Branch) have put a summary in English on line. This emphasises the caveat that investigations for the prosecutor's office are proceeding, and were not all made available for this report. However, there is no obvious sign of a shortage of information, so that is perhaps just the formal position.

The story line of how the accident happened is still that a cracked frog on a double slip led to the bolts on a fishplate failing one at a time, until it was free to flip up under a train and jam in a flangeway. This chain of events is reconstructed in great detail by reference to the marks and indentation on the wheels and bogie components. While that might not seem entirely necessary, it was important to make sure that no other cause, even a minor one, contributed to the derailment.

The rest of the report looks at the inspection and measurement (by "Mauzin" trains) of this track, whether the faults were detected, and if so why they were not fixed. A lot of this sounds very familiar.

A couple of things are missing from the report. One is a clear statement of the impact of the restructuring of SNCF (Societe Nationale des Chemins de fer Francais - French National Railways) and RFF into a single organisation, which happened betwen the accident and this report. This should be slight, as SNCF did all the actual maintenance work anyway, but surely worth recording. The other is about what led to the 1500V DC (Direct Current) power being turned off, and whether that was a fault current due to the accident, and if damaged live wires constituted a danger. This was raised by comments elsewhere, before being commented on in this forum, but is not mentioned in the report. Presumably it was not in fact an issue at all.
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« Reply #59 on: November 17, 2015, 07:54:08 pm »

Advance news (in French) on RTL of the results of the enquiries. The first report is due out tomorrow - I think that's the interim technical report from the BEA-TT.

RTL concentrate more on the (leaked) prosecutors' report, which seems to be heading for a criminal prosecution as well as a civil liability case. The news item talks about missing bolts in fishplates that no-one is bothered about, and maintenance that was both random and not thorough enough. The other theme, which is obviously going to have political implications, is the confused relationship between RFF and SNCF (Societe Nationale des Chemins de fer Francais - French National Railways), and how this clouds the responsibility for maintenance standards.

All sounds rather familiar, doesn't it?
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