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Author Topic: Six children killed in collision between train and school bus in France - 14 Dec 2017  (Read 7279 times)
stuving
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« Reply #15 on: January 20, 2018, 11:02:51 pm »

Thanks for posting that update, Stuving.  A very sad and distressing incident.  I wonder if the level crossing has an event recorder (data logger)?  Not seen one mentioned in the reports you have linked to so far.

Initially, I understood SNCF (Societe Nationale des Chemins de fer Francais - French National Railways)'s comments on whether the level crossing operated properly to be based on recorded remote monitoring. However, I have not seen any clear statement of that; just references to what witnesses said. My assumption was based on the notion that keeping the crossing safe needs remote monitoring, at least of its power supply (including backup batteries, since there are press reports of thefts of those). Otherwise how can train drivers be told to proceed at caution?

The level crossing closure is triggered by the train at a treadle, as is its opening. I can't fathom quite how these are positioned, given the number of crossings, often close to stations. For example, on leaving Millas (where all trains stop) there is a crossing after 150 m, then the site of the accident after a further 740 m. The train, by the way, was Z 7369 - a 2-car EMU (Electric Multiple Unit) built in 1980-1984 by Francorail-ANF (now Bombardier). I also went searching for any safety-related text, e.g. a report or regulation, about on-board video recorders. I found none!

The line's signalling is very French - you might not recognise it as signalled at all. Information on this single track line is contradictory, but it's most likely to be CT (cantonnement téléphonique) updated to CAPI-95 (Cantonnement assisté par informatique). That means each block has a control point at each end (almost always a station), with a single signal controlling access to the block,  and also interlocked with the points exiting a passing loop. Here, there is no loop from the junction at Le Soler to Ille-sur-Tet, and as I can see no signals I assume this is one block of nearly 20 km.

The operators (probably chefs de gare) exchange messages to request the block, notify that a train has entered it, and confirm all of it has left at the other end. CT has just a telephone link, and a log book to record events, while CAPI has screens for the operators and a datalink, and records all transactions automatically. It (as CAPI-95, an update) also has a train detector that replaces the human eyeball component, and can stop a train entering without permission. The signals are not interlocked with CAPI!

So while you might expect some remote monitoring, most likely at the next station, it doesn't look as if there is any system that would record it.
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stuving
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« Reply #16 on: October 05, 2018, 09:57:25 am »

Le Parisien is reporting what's in a report (expertises techniques) prepared for the juge d’instruction, which is a leak not a publication. As we perhaps expected, the evidence all points to the barrier being down in time but coach driver having braked too late to stop before it.

The report is really a collection of separate experts' analyses of the evidence, including witness statements, but the one called "automobile" uses the full detail of the bus's tachograph. That shows that "after her delicate manoeuvre onto the D612, and having accelerated to 12 km/hr, the driver became aware of an obstacle in front of her and stamped on the brake pedal. The only possible obstruction at that point is the barrier of crossing PN25. By the time she had decided to brake, the coach was already too close to the closed  barrier to stop before it, and it went onto the railway line bending the barrier out of the way." (Remember, it is only 17 m from that junction to the crossing.)

The main subject of comments is now the medicines the driver was taking, in particular hypnotics. (No English report so far.)
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stuving
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« Reply #17 on: July 02, 2019, 10:34:40 pm »

The BEA-TT report into the Millas accident was released on 17th May. I'm surprised to have missed it then, but looking back it got surprisingly little mainstream media coverage, for such a high-profile incident. It is the usual highly detailed, technical, dispassionate, document providing an interpretation of the events as close  to the truth as is possible. maybe that's just not what news is made of.

My summary of the report has got a bit long - it'll be the next post - but these are the key points from the report's introduction:

  • the crossing worked correctly
  • the direct cause was that the bus didn't stop despite the barrier, lights, and bell
  • the most likely explanation is that the driver just did not see or notice the warnings

The factors found to have played a role include:

  • the side road the bus arrived along was very close to the crossing
  • the visibility of the warning lights from that side road was poor
  • the bell stopped once the barrier was down, so wasn't a back-up to the lights
  • the turn into the main road was very demanding of the driver's attention
  • these factors were not included in risk assessments of the crossing




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stuving
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« Reply #18 on: July 02, 2019, 10:39:23 pm »

More on that BEA-TT report:

There were always just two possible narratives: either the school bus (really a coach) drove through the barrier after it came down, or the crossing wasn't closed when it should have been. The driver's conviction that the crossing was open, combined with the (sometimes noisy) support from her neighbours, never looked like good evidence given how traumatic her experience had been. The driver and passenger in the light van waiting at the barrier on the other carriageway had a much clearer view and said all along that the crossing close sequence happened just as it should and the coach did drive through the barrier. So it's no surprise that the BEA-TT adopt that as highly likely to be the case.

They dismiss the idea (which had so excited the press previously) that being a long-term user of sleeping pills affected the driver's performance; reporting that only normal therapeutic traces were found, of medicines for which no warnings about driving were required. But they did need to explain how she could have driven up to the closed crossing and through the barrier without noticing. As always, it's a story of many small contributory factors. The two tachographs both recorded the impact, so the events could be reconstructed working backwards. There was no CCTV (Closed Circuit Tele Vision) at the crossing or in the train's cab, and fitting more of these is one of the recommendations.

The barrier was down when the coach reached the junction, 20 m south of the crossing. The bell isn't audible inside a vehicle from there, and in any case had stopped once the barrier was down. There were three flashing lights, one of which was aimed down to be seen by pedestrians. The other two were aimed along the nearly straight main road, and the far one would have been out of its main beam. The last one, on the near side, could have been hidden behind a pole (for domestic power and/or telephone wires) - its presence was never picked up in assessments. The first light was also hidden from exactly the same viewpoint. Of course the pole blocking a driver's sightline just when they look had a low probability, but even such unlikely things can and do happen.

The main element of the narrative was based partly on the driver's evidence about turning into the main road. The road at that point was rebuilt in 2000/01, when the D612 was upgraded to a designated "route avoiding  Perpignan", so as to have two single-lane carriageways with raised kerbs at each side and at the central island (which is unusual for French rural roads). Getting a coach to turn into this narrow (3.1 m) slot, only just long enough for it, required a lot of attention and looking in the mirror to check the offside read wheel was off its kerb (the nearside front wheel being invisible). The theory was that this task so occupied the driver that she didn't look with attention at the barrier until it was so low down in front of the coach she was unsighted. The nearest flashing light might have been seen, just, once the coach was straight but its hood came so far down at the sides as to block that view. The barrier arm itself was designed to bend easily enough that the effect on the coach wouldn't be felt.

A minute examination of the regulations finds a number of gaps, and contradictions between the railway and road rules. The performance of warning lamps isn't clearly specified, not in brightness nor in angle. The pointing of the lights is defined as if there is only a single road to consider, and while junctions are considered (e.g. in the review checklist), that is mainly for queueing back.

The school (Christian Bourquin) at Millas was built only in 2015, so the route this bus took - and the demanding turn manoeuvre at PN25 - was not used by such large vehicles before that. The road from the school (Chemin du Ralet) was widened at the time specifically for school buses. There wasn't a review of the crossing safety triggered by that, but from the comments it probably wouldn't have considered this aspect anyway. In fact, these reviews are clearly seen as inadequate - the 2009 assessment that the crossing was far enough from any junction or other noteworthy point being labelled "manifestly wrong". That 2009 national review programme of level crossing risks was, of course, itself a response to the Allinges accident in 2008.

There's no mention of the other point sometimes made about single flashing lights, that a quick look may only see them dark between flashes. Presumably that's the rationale for the twin lights of a wig-wag, though I've not seen proof of that. If looks are never that quick, so single lights are not an issue, then twin ones would avoid the "post in the way" problem - but the superiority of wig-wags isn't mentioned either.

One final point that surprised me is that the railway line has never been reopened since the accident, eighteen months ago, being replaced by buses throughout its length.
« Last Edit: July 03, 2019, 11:33:34 am by stuving » Logged
SandTEngineer
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« Reply #19 on: July 03, 2019, 10:38:26 am »

Thanks for that excellent summary.  I too missed the issue of the report.  I'll have a good read over the coming weeks as there are always lessons for everybody when an accident like that happens.
« Last Edit: May 22, 2020, 09:45:05 am by SandTEngineer » Logged
stuving
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« Reply #20 on: May 21, 2020, 11:34:07 pm »

The line through Millas reopened today - well over two years on from the accident. Most of that time it was a court's decision (which closed the road as well), lifted last October, followed by works to the crossing (inevitably extended by YKW). Further up, part of the line is closed due to storm (Gloria) damage, and buses will fill in until that is fixed.

The rework hasn't touched one of the key factors specific to this crossing: the side road, very close to the track, that the bus came out of. If you remember, it was only just possible to turn the bus in the space, which left very little time with a clear straight-ahead view of the barrier and lights before reaching them. 

Feelings are, not surprisingly, still rather raw, notably among the parents of children who still make that trip by bus every day. The train times have been changed, and some kind of warning to the school of late running provided, so as to avoid a train and a bus being close to coinciding at the crossing. But it probably didn't help anyone's nerves that only a few days ago the barriers failed to rise after a train had passed. Failed safe, but still ...
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stuving
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« Reply #21 on: September 19, 2022, 01:16:35 pm »

The only trial to come out of this accident, of the coach driver, starts this morning in Marseille. Views on on whether she did drive through the barrier or not are still divided as they always were, notwithstanding the BEA-TT report. Nothing new of any significance has emerged since. For some, the trial will finally decide, but no doubt some will never be convinced.

The trial itself is huge - 123 "civil parties" (or more), with a right to legal representation. It's the first trial to be shown by CCTV (Closed Circuit Tele Vision) in another room (in Perpignan), following a change in the law. In some ways it's a surprise it's only scheduled to last three weeks.

SNCF (Societe Nationale des Chemins de fer Francais - French National Railways) are not directly involved, except as witnesses. Their request to be a "civil party" has not been accepted, but of course the court's decision could in effect find them at fault.
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broadgage
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« Reply #22 on: September 20, 2022, 02:55:09 pm »

What I find surprising is that neither the train, nor the bus, nor the crossing were equipped with CCTV (Closed Circuit Tele Vision) and recording.
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A proper intercity train has a minimum of 8 coaches, gangwayed throughout, with first at one end, and a full sized buffet car between first and standard.
It has space for cycles, surfboards,luggage etc.
A 5 car DMU (Diesel Multiple Unit) is not a proper inter-city train. The 5+5 and 9 car DMUs are almost as bad.
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« Reply #23 on: November 18, 2022, 03:57:43 pm »

The bus driver has been sentenced to five years in prison, of which four suspended. But she is still in hospital, having collapsed in the court a few weeks ago.
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