At least eleven dead as French TGV test train derails near Strasbourg - 14 November 2015

[whole diary]

[stuving]

SNCF^▸ (Societe Nationale des Chemins de fer Francais - French National Railways) have posted full English transcript of Thursday's press conference. I'd add a couple of notes to it:

These SNCF internal auditors are not accountants, they look at safety, project management, and other operational matters.

The French Plateforme means the trackbed or formation, but has been unidiomatically translated as platform.

Their version of Guillaume Pepy's sentence that I commented on before reads:

Finally, it surely reveals  errors  of  human  behaviour  in  the  driver's  cab  and  in  the communication between the cab and the rest of the trainset, which the investigation will examine.

I have read something about the test manager in the driver's cab being distracted by a long conversation on the intercom, though that doesn't sound very serious. Perhaps it was, and we will hear more about it later.

[SandTEngineer]

I also found this interesting (actually somewhat alarming):
https://ressources.data.sncf.com/explore/dataset/incidents-securite/?tab=table&sort=date

[stuving]

I also found this interesting (actually somewhat alarming):
https://ressources.data.sncf.com/explore/dataset/incidents-securite/?tab=table&sort=date

I'm inclined to agree, though it's hard to judge how alarming this list of accidents and incidents is without something similar from the British railway network to compare it with.

A lot of the incidents are minor, so a total of over 700 during the last year (i.e. 2 per day) may or may not be very high. The fact that more than 30% of them are graded "ESR^▸ (Emergency Speed Restriction )", meaning there was a potential danger to life, is what I find troubling.

[stuving]

BEA-TT issued a short interim report (really just a short note) in February, which I didn't spot. It starts with a restatement of the facts based on on-board recordings.

• The accident occurred where the speed limit comes down from 320 km/h in stages to 160 km/h for the curve that runs over the bridge and joins the old line towards Strasbourg. The test run was meant to happen at +10% overspeed, but the actual target speeds were rounded up a bit. Remember that the speed must be reduced before a lower speed limit (PSR^▸ (Permanent Speed Restriction)), which is what ERTMS^▸ (European Rail Traffic Management System.) (or the equivalent SNCF^▸ (Societe Nationale des Chemins de fer Francais - French National Railways) systems) does. More than that, it compares speed during the deceleration with the nominal speed profile and adjusts the braking to ensure it hits that new PSR at (or just below) its speed. The test was driven with ERTMS off, so the driver needed to do that by eye, based on the plan he had been given. Two other drivers were there to "help" him.
  
  1: normal PSR V320, x1.1 = 352, test planned at 360
  
  2: from km 398.77: normal PSR V300, x1.1 = 330, test planned at 330, actual run 331.2 km/h; planned braking for next PSR at km 400.7.
  
  3: from km 403.809: normal PSR V160, x1.1 = 176, test planned at 176, actual run 265 km/h. Derailment occurred at 243 km/h versus a design figure of 235 km/h.
  
  
• They go on to say that the braking point left very little room for error, and that on that run braking started twelve seconds after that point (1.1 km at 330 km/h).  Those figures imply a deceleration of 0.97 m/s/s over 3109 m, or 1.50 m/s/s over 2009 m. Even the higher figure is within the range of emergency braking in good conditions, at least at lower speeds. However, at this high speed the power flux required may not be feasible, so maximum deceleration would be lower - that depends on the design of these trains. The reasons for the delay in braking were still under investigation.
  
  
• Their final point is to question whether these overspeed tests are still needed, or really a survival from an earlier age. A modern instrumented trails train should pick up track defects at much lower speeds, so the overspeed test adds very little - except a big safety issue in how the trains is to be driven. Ever higher train speeds make the result of getting this safety regime wrong more severe as well.
  
  They note that the trials staff seemed very concerned to run every part of the track at the full V+10%, where possible. That is why the braking was scheduled as late as possible; in effect this practice turns the maximum speed (plus 10%!) into a minimum to be achieved.
  
  They referred this question to other parts of the industry (including the safety regulator EPSF).

[stuving]

In today's Le Parisien (and Aujourd'hui en France, its provincial version) there is a report based on unpublished information from the enquiry (i.e. the customary leak to the press). This says that:

• On the same run three days earlier, the train ran too fast as the driver had difficulty following the trials plan. There was a video made that shows the several drivers and trials managers debating where to start braking, and missing some of the speed targets by a substantial margin (e.g. 298 km/h rather than 230 - but not at a formal speed limit point). What's really of concern is the implication that they were working this out as they went along, rather than sticking to a plan or using some technical help (like a modified ERTMS^▸ (European Rail Traffic Management System.)).
  
  
• The report makes much of the fact that the trials plan had been modified to raise the top overspeed to 360 km/h in place of 352 km/hr. That speed, of course, was not implicated in the accident.
  
  
• The "cadre transport traction" (senior driver, supervising the actual driver), who was standing behind the driver, admitted telling him to brake 1 km later just before the accident. He said this was based on having managed easily on the last run (though I think that was run on the "down" line, while the accident happened when running "wrong road" on the "up" line*). That bears out the concerns in the interim note about being too concerned to reach the full overspeed wherever possible.

(*French railway tracks are not up or down - they are even or odd. I have no idea why, nor how anyone remembers which is which.)

[Chris from Nailsea]

Thank you for your detailed posts, stuving, and for your helpful and reasoned explanations. 

My own schoolboy French certainly isn't up to it. 

[stuving]

Le Parisien / Aujourd'hui en France have got hold of an interim judicial (prosecutors') report on this accident, which adds a little more detail to the earlier explanations. The train did brake too late, for a combination of reasons all related to the conduct of these particularly risky overspeed trials.

The correct braking point would have been km 400.2, but the trials plan had decreed km 401 (the initial BEA-TT report said 400.7), and the senior driver overseeing the run changed that to km 402 on the day. Since the speed monitoring and automatic braking systems were turned off, this offhand way of fixing the speeds is the real culprit.

They have other examples, such as where earlier runs went faster than specified but no-one bothered to investigate why, and one of those was the previous run over this section. Elsewhere, the speed was worked out based on the dynamic limit (i.e. when the train overturns) rather than the signalling system's limit (which determines speeds in service).

Apparently those directly involved on the day are facing prosecution, while SNCF^▸ (Societe Nationale des Chemins de fer Francais - French National Railways) and their trials subsidiary Systra may do too.

[stuving]

BEA-TT has published the final report on the accident to a TGV^▸ (Train a Grande Vitesse) test train on 14th November 2015 at Eckwersheim.  BEA-TT don't seem to do English summaries of their reports any more, even for those important ones that would justify it.

So far there has only been a short note from BEA-TT, and some longer reports from SNCF^▸ (Societe Nationale des Chemins de fer Francais - French National Railways). However, the narrative of the accident has appeared in various leaks to the press, reported above. The final report tells the same story, though in much more detail.

The recommendations look rather anodyne, and in measured language that I find hard to translate exacltly. Most of them produce the response "you mean they really weren't doing that?". Roughly, they are:

  Recommendation R1 (SNCF Réseau and EPSF - the rail safety body)

Conclude the review of the documents and regulations that govern proving trials for new high-speed lines, including the UIC in this.

  Recommendation R3 (SNCF Mobilités, and any other train operators involved)

To provide drivers for test trains, set up a process to select and suitably train them.

  Recommendation R4 (SNCF Mobilités, and any other train operators involved)

Provide tools to support trials teams planning braking. [For overspeed tests - remember the KVB and equivalent train protection systems were disabled for this.]

Give a clear definition of who does what in conducting the test runs, with respect to driving the train.

  Recommendation R5 (Systra, and any other potential trials managers)

Review the reference documents for trials conduct based on what has been learnt from this accident, in particular to ensure:

• that the manager of the trial has suitable qualifations and experience
• that the timetable allows enough time for preparation and debriefing for each run
• that the manager of the trial and the driver manager coordinate their work by direct contact
• that the role of "pilot" is redefined so he is not the communications link between the manager of the trial and the driver manager
• that a realistic division of functions between the manager of the trial and the driver manager is defined

  Recommendation R6 (SNCF Mobilités, and any other train operators involved)

Install recorders for any telephone link between the drivers' cab and the trials team, and for sounds within the cab.

How the driving function is shared among the on-board team was important in the accident. It is also very much based on the SNCF way of doing things, and not likely to match anyone else's. The functions and names of the four key actors perhaps need a bit of explaining.

1. The Chef d'essais bord (my manager of the trial) is in charge on the train. Back at the office, during planing and similar work, he will be part of a team, but during the trial he's in the cab and is The Boss.

2. The Cadre Transport Traction (my driver manager) directs the driver, based on the agreed "script", and is responsible for safety on board and during planning.

3. The pilote traction (my "pilot") provides detailed knowledge of the line, its speed restrictions, etc. On board he monitors whether driving actions happen in the right place, and watches for signals. He can also direct the driver.

4. The conducteur (driver) drives the train, watching the line and the instruments, but not needing to read the script and think about trials issues as well.

5. There is also a chef de train (train manager) who looks after the doors, and whom to allow into the train and where, as directed by the manager of the trial.

[stuving]

According to reports today (initially from F3 Grand-Est) the enquête judiciaire has been finished, and the prosecutors' office has told the families of the results. While the specific details quoted look a bit garbled (they don't tally with the BEA-TT report), the key point is that both SNCF^▸ (Societe Nationale des Chemins de fer Francais - French National Railways) and Systra are almost certain to be prosecuted. That is hardly a surprise, given their lack of clear direction from above. Three employees of the two companies have already been charged with something answering to manslaughter.

[stuving]

As expected, Systra has been mis en examen (roughly charged) and SNCF^▸ (Societe Nationale des Chemins de fer Francais - French National Railways) is expected to follow in a few days. That allows for formal questioning, though how cautioning works with a company I'm not sure.

[stuving]

As expected, Systra has been mis en examen (roughly charged) and SNCF^▸ (Societe Nationale des Chemins de fer Francais - French National Railways) is expected to follow in a few days. That allows for formal questioning, though how cautioning works with a company I'm not sure.

Finally, with all the urgency we've come to expect of the French legal system, the trial of several bits of SNCF, including Systra, began today. Here from RFI:

Trial of deadly 2015 high speed train crash opens in Paris

The French national rail operator, SNCF, along with two of its subsidiaries and three rail workers are due to appear at the Paris criminal court at the start of a two month trial for their role in the accident involving a high speed TGV^▸ (Train a Grande Vitesse) train on a test run in 2014 that left 11 people dead and 42 injured.

Issued on: 04/03/2024 - 11:53

The SNCF and its subsidiaries Systra and SNCF Réseau are on trial for “injury and involuntary homicide” for the 14 November 2015 accident that killed 11 of the 53 people on board the train and injured everyone else.

The defendants are facing 88 civil parties, including survivors who were not employees, but were on board the train anyway.

The crash occurred near Strasbourg, in eastern France, on what was supposed to be the final test run of the new high-speed line connecting the city with Paris.

The train struck a bridge and derailed, breaking in two as it landed in the Marne-Rhine canal.

Systra, the company responsible for railway tests, is being prosecuted for its decision to try a test speed of 330 kilometres – the train’s upper limit - rather than the 187 kilometre per hour operating speed.

A 2017 investigation that lead to the charges against the defendants concluded the train’s drivers had not received the necessary training to carry out such high-speed tests.
Non-employees on board

The three companies are accused of failing to take precautions to prevent “inappropriate actions of the driving team in terms of braking”.

On board the train were employees as well as their guests, including four children, and one of the questions in the trial is why non-employees were on board.

SNCF and Systra, as the test operators, and the project owner, SNCF Réseau, face fines of up to €225,000 if found guilty in the trial that runs through 16 May.

Two SNCF employees, including the train’s driver, and one Systra employee will also be on trial, facing maximum sentences of three years in prison and fines of up to €45,000 each.

During the investigation, the lawyers for all the defendants suggested that they would be pleading for acquittal.

Including the driver in this trial seems particularly harsh, given what he's been through and how responsibility was described in the report as lying mainly with others. No doubt there would have been others but they wel killed in the accident.

Mind you, I don't think (without thoroughly revising the subject) the points picked out in that piece are the key ones. They may of course be present in a much longer legal text.

[stuving]

Two SNCF^▸ (Societe Nationale des Chemins de fer Francais - French National Railways) employees, including the train’s driver, and one Systra employee will also be on trial, facing maximum sentences of three years in prison and fines of up to €45,000 each.

That's a bit misleading; all three of the people who collectively drove the train are on trial. The reports are not using the same terminology as the BEA-TT report (based on SNCF's documents) either. Those three were the hands-on driver, a driver manager who told him what to do and when, and a Systra engineer who handed over the "script" to the other two and then was meant to monitor the trial and answer technical questions.