Reporting Body RO Romanian Railway Investigation Body ID RO-5579 Occurrence Summary What Location Date of occurrence Location name Suceava Lo

Transcriere

1 -5579 Occurrence Summary What Location Date of occurrence Location name Suceava Local time 05:05 Latitude 47:39:48 North Event type Other Other event Longitude 26:16:24 East Description the both pantographs of the locomotive EC 126 that hauled the passenger train no have broken Direct Cause descrip Cauza directa a producerii incidentului feroviar (EC126 de la trenul de calatori R nr.5454) o constituie desprinderea si ridicarea necomandata a pantografului de la postul B, pantograf care nu era în actiune, iar la impactul cu linia de contact a produs dereglari ale geometriei acesteia, fapt care a avut repercusiuni asupra pantografului de la postul A care era activ; Comisia de investigare a identificat urmatorii factori care au contribuit la producerea incidentului: ruperea (sectionarea) izolatorului de tractiune a cilindrului de actionare a pantografului inactiv; fisuri vechi existente în corpul izolatorului, în special în sectiunea de rupere. Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo RI PDF /2/ Suce File ava 10:3 01 7:21 01 PM 2018 CR trans mis.p df 0 ERAIL-REP PUBLIC 1 Monday, August 5, 2019

2 -5579 What Title Other event, , Suceava (Romania) Occurrence type Other Other event Occurrence Class Other Date of occurrence Local time 05:05 Events Other - Other event Descriptions Description the both pantographs of the locomotive EC 126 that hauled the passenger train no have broken Location name Suceava Railway System type Railway Country Romania Location type Station Border Country Line type Double track Line number 500 Allowed line speed Km number Latitude 47:39:48 North Longitude 26:16:24 East Location description Suceava railway station Additional location in in the North of Romanian railway network, on the Iasi railway county Location type details Fixed installations Occurrence details Railway vehicles Movement type Passenger train Train number 5454 RU Romania Wagons overturned No National Company for Passenger Railway Transport "CFR-Calatori" S.A. Train speed at mom Passengers onboard Yes Vehicle description electric locomotive EC type (4 axles) Other objects involved in the occurrence Other objects ERAIL-REP PUBLIC 2 Monday, August 5, 2019

3 -5579 Parties involved IM Involved Romania - National Railway Company "CFR" S.A. RU Romania - National Company for Passenger Railway Transport "CFR-Calatori" S.A. Passengers Staff Level crossing users Unauthorised persons Others Total Material consequences Material Damage Damage description Fatalities Serious injuries Minor injuries Infrastructure Estimated total mate < Rolling stock damages to the locomotive and to the catenary wire Images Name Description Type Size Last modified Organization Repository 0 Causation Causes Language Romanian Translation provider Original version Direct Cause description Cauza directa a producerii incidentului feroviar (EC126 de la trenul de calatori R nr.5454) o constituie desprinderea si ridicarea necomandata a pantografului de la postul B, pantograf care nu era în actiune, iar la impactul cu linia de contact a produs dereglari ale geometriei acesteia, fapt care a avut repercusiuni asupra pantografului de la postul A care era activ; Comisia de investigare a identificat urmatorii factori care au contribuit la producerea incidentului: ruperea (sectionarea) izolatorului de tractiune a cilindrului de actionare a pantografului inactiv; fisuri vechi existente în corpul izolatorului, în special în sectiunea de rupere. Underlying and root causes description ERAIL-REP PUBLIC 3 Monday, August 5, 2019

4 -5579 Cauze subiacente Având în vedere nomenclatorul de lucrari la pantografe si izolatori din Specificatia Tehnica cod ST , elaborata de SC RL Brasov, puteau fi depistate fisurile existente la izolatorul de tractiune al cilindrului de actionare al pantografului. Comisia apreciaza ca lucrarile de aspectare a suprafetei exterioare a izolatorilor la revizia tip Pth3 (si urmatoarele) si de curatirea suprafetei exterioare a izolatorilor la reviziile tip RT (si urmatoarele) nu au fost executate si implicit verificate prin: nerespectarea în totalitate a continutului lucrarilor obligatorii de executat cu ocazia reviziilor tip Pth3, RT si urmatoarele, prevazute în Specificatia Tehnica cod ST , cap.5 Nomenclator de lucrari, la partea electrica pct.2. Pantografe si izolatori, fila 9; Direct Cause description Direct cause of the railway incident (EC126 from the passenger train R no.5454) was the detachment and lifting non-ordered of the pantograph from the driving cab B, a non-working one, and at its impact with the contact line generated changes of its geometry, it having consequences on the pantograph from the driving cab A which was working; The investigation commission identified the next contributing factors: breakage (sectioning) of the traction insulator of the cylinder for the operation of the non-working pantograph; old cracks existing in the insulator body, especialy in the breakage section. Underlying and root causes description Underlying causes Taking into account the schedule of the works at the pantographs and insulators from the Technical Specification code 3ST , drafted by SC RL Brasov, one could identify the cracks existing at the traction insulator of the cylinder for the operation of the pantograph. The investigation commission considers that the works for the view of the exterior surface of the insulators during the inspection type Pth3 (and the next ones) and for the cleaning of the exterior surface of the insulators during the inspections type RT (and the next ones) were not performed and implicitly checked through: non-meeting completely of the content of the works, compulsory to be performed during the inspections type Pth3, RT and the next ones, stipulated in the Technical Specification code ST , chapter 5 Work schedule, at the electric part point 2. Pantographs and insulators, page 9; Root causes None. Causation classification Other - Other event 1 - Maintenance of rolling stock ERAIL-REP PUBLIC 4 Monday, August 5, 2019

5 -5579 Recommendations Recommendation Issuing information Recommendation title Luând în considerare precizarile facute în cap. C.6.3. Analiza si concluzii privind modul de... Recommendation REC End implementer NSA Status Sent to adressee Addressee NSA Issue date Recommendation texts Language Romanian Translation provider Original version Luând în considerare precizarile facute în cap. C.6.3. Analiza si concluzii privind modul de producere a incidentului, partea referitoare la cazurile de defectari ale locomotivelor EA305 si EA078 în circulatia trenurilor de calatori IR nr.1654 si nr.1766 din noaptea de 16/ , AGIFER recomanda ASFR sa se asigure ca: 1. produsul pantograf tip EP3 încadrat ca produs feroviar critic la clasa de risc 1B, a caror defectare determina grave perturbatii în exploatarea feroviara, daca va fi utilizat la echiparea locomotivelor care vor fi introduse la modernizare prin reparatii de tip RG sau RK, sa fie supus omologarii tehnice, în baza unei documenta?ii tehnice de referin?a; Taking into account the stipulations from the Chapter C.6.3. Analysis and conclusions on the incident occurrence, part concerning the failures at the locomotives EA305 and EA078 in the running of the passenger trains IR no.1654 and no.1766 from the night 16/ , AGIFER recommends ASFR be sure that: 1. the protduct pantograph type EP3 classified like railway critical product at the risk class 1B, whose failure generates the serious interruptions in the railway operation, if it will be used in the endowment of the locomotives that will be submitted to the modernization through repairs type RG or RK, be submited to the technical homologation, upon on a reference technical documentation; Implementation information Implementation status Implementation date NSA Response NIB Comment ERAIL-REP PUBLIC 5 Monday, August 5, 2019

6 -5579 Recommendation Issuing information Recommendation title Luând în considerare precizarile facute în cap. C.6.3. Analiza si concluzii privind modul de... Recommendation REC End implementer IM Status Sent to adressee Addressee NSA Issue date Recommendation texts Language Romanian Translation provider Original version Luând în considerare precizarile facute în cap. C.6.3. Analiza si concluzii privind modul de producere a incidentului, partea referitoare la cazurile de defectari ale locomotivelor EA305 si EA078 în circulatia trenurilor de calatori IR nr.1654 si nr.1766 din noaptea de 16/ , AGIFER recomanda ASFR sa se asigure ca: 2. administratorul de infrastructura feroviara publica Compania Na?ionala de Cai Ferate CFR S.A. va inventaria sectiile de cale ferata electrificata pe care pot fi admise locomotive echipate în prezent cu pantografe tip EP3 si sa comunice aceste informatii catre toti factorii interesati. Taking into account the stipulations from the Chapter C.6.3. Analysis and conclusions on the incident occurrence, part concerning the failures at the locomotives EA305 and EA078 in the running of the passenger trains IR no.1654 and no.1766 from the night 16/ , AGIFER recommends ASFR be sure that: 2. the railway public infrastructure manager CNCF CFR S.A. shall make an inventory of the electrified track sections on which the locomotives provided with the this pantographs EP3 can be accepted and shall notify this information to all interested factors. Implementation information Implementation status Implementation date NSA Response NIB Comment ERAIL-REP PUBLIC 6 Monday, August 5, 2019

7 -5579 Causation links Other - Other event Causal factors - Maintenance - Maintenance of rolling stock Investigation details Legal Basis Other reason descrip National rules imposed by implementing of the Safety Directive 2004/49/EC - in light of Article 19, 2 of SD - (c) its impact on railway safety on a Community level National investigatio 249 Occurrence creation :14:25 Investigator in charge Decision to investigate Declaration date Date of IM/RU notific Report Type Final report Workflow Status Validated Report Version 2 Investigation Status Closed Other Attachments Name Descriptio Type Size Last Organizati Repositor 0 Final Report Name Descriptio Type Size Last Organizati Repositor RI PDF File /2/2019 Suceava 10:37: PM 2018 CR transmis.p df ERAIL-REP PUBLIC 7 Monday, August 5, 2019