The investigation team believes that the accident involves problems or abnormalities at individual levels such as personnel operations, operating procedures, mechanical equipment and organizational management, and coincidentally passes through each loophole in protective measures

2018-11-26 16:11 | China News Network

On October 21, the scene of the 6432nd train of the Taiwan Railway, Puyouma train overturned and derailed. Visual China Picture

According to Taiwan's United Daily News, the "10.21 Railway Accident Administrative Investigation Team" of Taiwan's administrative department announced the preliminary investigation results of the 6432nd Puyouma train derailment accident at Xinma Station on October 26th. The investigation team believes that the accident involves problems or abnormalities at individual levels such as personnel operations, operating procedures, mechanical equipment and organizational management, and coincidentally passes through each loophole in protective measures at the same time. As long as the problem or abnormality can be effectively dealt with when it occurs, the accident will not happen.

On the afternoon of October 21, the 6432nd train of the Taiwan Railway was overturned and derailed while passing through the SuaoXinma Station in Yilan County, causing 18 deaths and more than 200 passengers to be injured.

Wu Zecheng, convener of the "10.21 Railway Accident Administrative Investigation Group", Taiwan's administrative department, said on November 26 that he will further explore potential problems in depth on various facts and the causes of the accident, and study and propose improvement measures. The

investigation team said that after inspection and verification, all important evidence, including relevant surveillance images, train control and monitoring system (TCMS) records, automatic train protection system (ATP) recording units, communication records, relevant standard operating procedures and regulations, routes and vehicle maintenance records, etc., have five important facts found on the day of the accident on October 21.

First, the main air pumps of the two groups of the accident train were forced to shut down before departure and did not operate normally, causing the train to have 10 total air cylinder pressures from 15:39:12 seconds, and the power is sometimes not available, and the machine is temporarily stopped and the machine is not active.

Second, the driver isolates the ATP system at 16:17:55; the driver communicates at 16:47:59:59: "Closing ATP now", and the locomotive dispatcher replied: "Will it be okay to lock up ATP?"

Third, the ATP remote monitoring system for the accident train was not online, resulting in no alarm message being issued.

Fourth, the accident train departed from Luodong Station at 16:44:51, and the speed handle was placed at 140 km/hour. At 16:46:58, the train speed reached 140 km/hour. Starting from 16:46:57, the driver communicated with the locomotive dispatcher and the inspector of the Taipei Locomotive Depot (the call time is 2 minutes and 09 seconds in total), trying to eliminate abnormal train conditions, did not operate the brake handle, the train did not slow down and entered the curve, and the speed was 141 kilometers per hour, exceeding the critical speed of the curve overturning, and the train derailed; at 16:49:28, the final record showed that the speed handle was placed in the OFF position, and the speed was 135 kilometers per hour.

Fifth, personnel certificates and pre-district inspections, track status of accident sections, ATP software and hardware, train tilting devices, speed handles, digital speedometers and related equipment (wheels, bogies, etc.), no abnormalities. The

investigation team said that based on the above facts, the cause of the accident is summarized as follows: the

accident train entered the Xinma Station curve with a radius of 306 meters at a speed exceeding the speed limit (75 kilometers per hour) (141 kilometers per hour), causing the wheels on the right side of the first carriage to float up and derail and overturn to the left. Then, the 2nd to 8th carriages also derailed one after another.

Accident train is traveling, due to abnormal main air pump, the train is sometimes not powered by the train, and the stopper acts intermittently. The operation decisions and response actions taken by relevant personnel have not ruled out the abnormal situation. The driver continued to communicate while the train was traveling, trying to eliminate the abnormal situation of the train, and did not slow down according to regulations before entering the curve of Xinma Station.

At the same time, the ATP system is isolated, and the ATP remote monitoring function of the Puyouma train is not online, resulting in the relevant protection measures not being implemented.

Investigation Team believes that this accident involves individual levels of problems or abnormalities such as personnel operations, operating procedures, mechanical equipment and organizational management, such as incidents that happen to pass through each protective measures at the same time. As long as the problem or abnormality can be effectively dealt with when it occurs, the accident will not occur.

Investigation Team stated that as of now, based on the facts obtained from this accident investigation, the cause of the accident should be inferred. However, in order to make the investigation report more scientific and professional analysis and testify, the investigation team will continue to entrust academic or professional institutions to handle critical speed simulation of curve overturning and analysis of car collision behavior after train derailment.

Regarding the review and improvement matters involved in this accident, the investigation team has needed to improve matters immediately during the investigation, including urging drivers not to isolate ATP by themselves and to operate at a slow speed for some time, reviewing the relevant regulations on ATP isolation, completing the ATP remote monitoring of Puyouma trains, finding out the causes of abnormal main air pumps and improving them, and improving the tracks of the Xinma Station after emergency repairs, etc., and the Taiwan Railway Bureau has been required to implement them. In the future, we will conduct in-depth discussions on potential problems on various fact discoveries and the causes of the accident, and study and propose complete improvement measures. The finalization of the investigation report needs to be completed continuously. The

investigation team stated that as of now, 7 committee meetings and 38 working meetings have been held, 31 personnel interviews in 3 batches, 2 actual vehicle simulation tests, and 3 on-site inspections. The Department of Civil Engineering of Taiwan Chenggong University, Taiwan University Rail Science and Technology Research Center, Taiwan Shixi Engineering Consulting Company, and Taiwan Consortium legal person ZTE Engineering Consulting Company assist in the relevant professional analysis or simulation.

(Original title: Taiwan Railway Accident Report is released: There are problems with personnel, operations, equipment, and organization." Editor Xu Ting)