-5289 Occurrence Summary What Location Date of occurrence 28-03-17 Location name Ciolpani Local time 21:05 Latitude 44:14:40 North Event type Railway vehicle movement events Train derailment Longitude 25:27:45 East Description Direct Cause descrip the 3-rd wagon (loaded with grain) from the freight train no.30559-2 derailed on the track no.4 in the railway station Ciolpani The direct cause of the accident is the fall between the rails of the right wheels from the second bogie of the third train wagon, on the line 4 for reception-dispatching, in the railway station Ciolpani. It happened because the increase of the track gauge over the accepted tolerances, following the lateral movement of the rail from the outside track of the curve under the action of the dynamic forces transmited to the track by the rolling stock in running. Contributing factors:? keeping in operation of unsuitable wooden sleepers in the curve, after the switch no. 10, their condition leading to the decrease of the fastening system effectiveness and allowing the displacement to the outside of the track of the ensemble rail metallic plate, under the dynamic forces of the rolling stock;? supply with insuficient quantities of normal wooden sleepers for the performance of line maintenance and repair in the railway station Ciolpani;? lack of the polyamide lining at the centre casting of the bogie II (the second bogie in the train running direction) from the wagon no. 33530823183-6, it leading to the increased rigidity of the ensemble bogie wagond body, generating the increase of the lateral guiding force and implicitly to the decrease of the curve negicoation. Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo RI PDF 1786 2/11 Ciolp File 7607 /201 ani 8 28 10:2 03 2:38 2017 AM CR trans mis.p df 0 ERAIL-REP PUBLIC 1 Thursday, June 13, 2019
-5289 What Title Train derailment, 28-03-17, Ciolpani (Romania) Occurrence type Railway vehicle movement events Train derailment Occurrence Class Accident Date of occurrence 28-03-17 Local time 21:05 Events Railway vehicle movement events - Train derailment Descriptions Language English Translation provider Information providers own translation Description the 3-rd wagon (loaded with grain) from the freight train no.30559-2 derailed on the track no.4 in the railway station Ciolpani Location name Ciolpani Railway System type Railway Country Romania Location type Station Border Country Line type Double track Line number Allowed line speed Km number Latitude 44:14:40 North Longitude 25:27:45 East Location description Ciolpani railway station Additional location in on the Craiova railway county, in the south of Romanian railway county Location type details Fixed installations Occurrence details Railway vehicles Movement type Freight train Train number 30559-2 RU Romania Wagons overturned No DB SCHENKER RAIL MÂNIA Train speed at mom Passengers onboard No Vehicle description covered wagon for bulk agricultural goods Other objects involved in the occurrence Other objects Parties involved ERAIL-REP PUBLIC 2 Thursday, June 13, 2019
-5289 IM Involved Romania - National Railway Company "CFR" S.A. RU Romania - DB SCHENKER RAIL MÂNIA Passengers Staff Level crossing users Unauthorised persons Others Total Material consequences Material Damage Damage description Fatalities Serious injuries Minor injuries Infrastructure Estimated total mate < 150 000 Rolling stock minor damage to the line and wagon Images Name Description Type Size Last modified Organization Repository 0 Causation Causes Language English Translation provider Information providers own translation Direct Cause description The direct cause of the accident is the fall between the rails of the right wheels from the second bogie of the third train wagon, on the line 4 for reception-dispatching, in the railway station Ciolpani. It happened because the increase of the track gauge over the accepted tolerances, following the lateral movement of the rail from the outside track of the curve under the action of the dynamic forces transmited to the track by the rolling stock in running. Contributing factors:? keeping in operation of unsuitable wooden sleepers in the curve, after the switch no. 10, their condition leading to the decrease of the fastening system effectiveness and allowing the displacement to the outside of the track of the ensemble rail metallic plate, under the dynamic forces of the rolling stock;? supply with insuficient quantities of normal wooden sleepers for the performance of line maintenance and repair in the railway station Ciolpani;? lack of the polyamide lining at the centre casting of the bogie II (the second bogie in the train running direction) from the wagon no. 33530823183-6, it leading to the increased rigidity of the ensemble bogie wagond body, generating the increase of the lateral guiding force and implicitly to the decrease of the curve negicoation. ERAIL-REP PUBLIC 3 Thursday, June 13, 2019
-5289 Underlying and root causes description Underlying causes? infrigement of the provisions of art.25, paragraphs (2) and (4) from Instruction of norms and tolerances for the line construction and maintenance, lines with standard gauge no.314/1989, concerning the failures that impose the replacement of the wooden sleepers and non-acceptance of unsuitable neighbour wooden sleepers in the track;? infringement of the provisions from point.2.4.4., letter h) from Railway technical norm "Railway vehicles. Technical provisions for the repair of bogie frames that equipped the wagons and caoches no. 81-005:2006" concerning the non-acceptance in operation of polyamide linings between the centre castings of the wagon with the thick under 6mm. Root cause? non application of all provisions from the operational procedure code PO SMS 0-4.07 Compliance with the technical specifications, standards and requirements relevant for the whole life cycle of the lines in maintenance process (including the annexes), part of the safety management system of the railway public infrastructure manager CNCF CFR SA, concerning the coordination of the line maintenance. Language Romanian Translation provider Original version Direct Cause description Cauza directa Cauza directa a producerii accidentului feroviar o constituie caderea între firele caii a ro?ilor din partea dreapta ale celui de-al doilea boghiu de la al treilea vagon din compunerea trenului, pe linia 4 primiri-expedieri a haltei de mi?care Ciolpani. Acest lucru s-a produs în conditiile cre?terii valorii ecartamentului caii peste toleran?ele admise, ca urmare a deplasarii laterale a?inei de pe firul exterior al curbei sub ac?iunea for?elor dinamice transmise caii de catre materialul rulant în mi?care. Factori care au contribuit:? men?inerea în exploatare a traverselor de lemn necorespunzatoare pe curba de dupa schimbatorul de cale numarul 10, starea acestora slabind eficacitatea sistemului de prindere?i permi?ând deplasarea spre exteriorul caii a ansamblului?ina-placa metalica, sub ac?iunea for?elor dinamice exercitate de materialul rulant;? aprovizionarea cu cantita?i insuficiente de traverse de lemn normale pentru executarea lucrarilor de între?inere?i reparare a liniilor din HM Ciolpani;? lipsa garniturii din poliamida de la crapodina boghiului II (al doilea boghiu în sensul de mers al trenului) de la vagonul nr. 33530823183-6, fapt ce a sporit gradul de rigiditate al ansamblului boghiu cutie vagon, conducând astfel la marirea for?ei laterale de ghidare si implicit la scaderea capacita?ii de înscriere a vehiculului în curba. Underlying and root causes description ERAIL-REP PUBLIC 4 Thursday, June 13, 2019
-5289 Cauze subiacente? nerespectarea prevederilor art.25, alin.(2)?i alin.(4) din Instruc?ia de norme?i toleran?e pentru construc?ii?i între?inerea caii pentru linii cu ecartament normal nr.314/1989, referitoare la defectele care impun înlocuirea traverselor de lemn si la neadmiterea traverselor necorespunzatoare vecine în cale;? nerespectarea prevederilor pct.2.4.4., lit. h) din Norma tehnica feroviara "Vehicule de cale ferata. Prescrip?ii tehnice pentru repararea cadrelor de boghiuri ce echipeaza vagoanele de marfa?i calatori nr. 81-005:2006" referitoare la neacceptarea în exploatare a garniturilor de poliamida dintre crapodinele vagonului cu o grosime mai mica de 6mm. Cauza primara? neaplicarea tuturor prevederilor procedurii operationale cod PO SMS 0-4.07 Respectarea specificatiilor tehnice, standardelor si cerintelor relevante pe întreg ciclul de viata a liniilor în procesul de întretinere (inclusiv a anexelor), parte a sistemului de management al sigurantei administratorului de infrastructura feroviara publica CNCF CFR SA, referitoare la coordonarea activita?ilor de între?inere a liniilor de cale ferata. Causation classification Railway vehicle movement events - Train derailment 1 - Plain line track 1 - Maintenance of infrastructure 2 - Wagons 1 - Maintenance of rolling stock Recommendations Recommendation Issuing information Recommendation title Deraierea vagonului 33530823183-6, al 3-lea din compunerea trenului de marfa nr.30559-2 s-a produs... Recommendation REC-000059 End implementer IM Status Addressee NSA Issue date Recommendation texts Language Romanian Translation provider Original version Recommendations text ERAIL-REP PUBLIC 5 Thursday, June 13, 2019
-5289 Deraierea vagonului 33530823183-6, al 3-lea din compunerea trenului de marfa nr.30559-2 s-a produs în principal pe fondul mentenan?ei necorespunzatoare pe curba de dupa schimbatorul de cale numarul 10, cu acces spre linia 4 a haltei de mi?care Ciolpani dar?i pe fondul cre?terii gradului de rigiditate al ansamblului boghiu cutie vagon cu consecin?e asupra înscrierii acestuia în curba. În cursul ac?iunii desfa?urate, comisia de investigare a constatat faptul ca managementul administratorului de infrastructura la nivel central?i regional a identificat dar nu a gestionat riscurile generate de nerealizarea mentenan?ei liniilor CF, pentru a putea dispune în consecin?a solu?ii?i masuri viabile în vederea tinerii sub control a pericolului deraierii. Astfel, administratorul de infrastructura feroviara publica, daca ar fi aplicat propriile proceduri ale sistemului de management al siguran?ei, în integritatea lor, precum?i prevederile codurilor de practica, parte a SMS, ar fi putut sa men?ina parametrii tehnici ai geometriei caii în limitele toleran?elor impuse de siguran?a feroviara?i sa previna producerea acestui accident. De asemenea, comisia a constatat ca la nivelul operatorului de transport managementul de vârf nu a identificat?i gestionat riscurile generate de absen?a/deteriorarea în exploatare a garniturilor de poliamida dintre crapodinele vagonului având ca?i consecin?a o înscriere necorespunzatoare a vehiculului în curba, deci nu a putut lua masurile în vederea?inerii sub control a acestor riscuri. Având în vedere aspectele prezentate comisia de investigare recomanda ASFR: 1. sa solicite administratorului infrastructurii feroviare publice: - revizuirea "Registrului propriu de pericole"; - gestionarea eficace a riscurilor generate de nerealizarea mentenan?ei liniilor CF, prin reevaluarea masurilor de?inere sub control a acestor riscuri. Language English Translation provider Information providers own translation Recommendations text Safety recommnedations The derailment of the wagon no. 33530823183-6, the 3rd of the freight train no.30559-2 happened because the unsuitable maintenance in the curve after the switch no. 10, with access to the line 4 of the railway station Ciolpani and following the increase of the rigidity of the ensemble bogie wagon body, with consequences for the curve negociation. During the investigation, the investigation commission found out that the management of the infrastructure manager, at its central and county level, identified but did not managed the risks generated by the non-performance of line maintenance, in order to dispose, consequently, viable solutions and measures, for the control of the derailment hazards. Thus, the public infrastruture manager, if it had applied the own procedures of the safety management system, completely, as well as the provisions of the practice codes, part of the Safety Management System SMS, it could keep the technical paramenters of the track geometry between the tolerances imposed by the railway safety and to prevent the occurrence of this accident. The commission, also found out that the top management of the railway undertaking did not identify and manage the risks generated by the lack/deterioration in operation of the polyamide linings between the centre castings of the wagon, leading to the unsuitable curve negociation, so it could not take the measures for the control of these risks. Taking into account the presented issues, the investigation commission recommend Safety Authority ASFR: 1. to ask railway public infrastructure manager: - review "Own register of dangers"; - effective management of the risks generated by the non-performance of the line maintenance, re-assessing the measures for those risk control. ERAIL-REP PUBLIC 6 Thursday, June 13, 2019
-5289 Implementation information Implementation status Implementation date NSA Response NIB Comment Recommendation Issuing information Recommendation title Recomandari de siguranta Deraierea vagonului 33530823183-6, al 3-lea din compunerea trenului de... Recommendation REC-000061 End implementer Status Sent to adressee Addressee Issue date 13-12-17 Recommendation texts Language Romanian Translation provider Original version Recommendations text Recomandari de siguranta Deraierea vagonului 33530823183-6, al 3-lea din compunerea trenului de marfa nr.30559-2 s-a produs în principal pe fondul mentenan?ei necorespunzatoare pe curba de dupa schimbatorul de cale numarul 10, cu acces spre linia 4 a haltei de mi?care Ciolpani dar?i pe fondul cre?terii gradului de rigiditate al ansamblului boghiu cutie vagon cu consecin?e asupra înscrierii acestuia în curba. În cursul ac?iunii desfa?urate, comisia de investigare a constatat faptul ca managementul administratorului de infrastructura la nivel central?i regional a identificat dar nu a gestionat riscurile generate de nerealizarea mentenan?ei liniilor CF, pentru a putea dispune în consecin?a solu?ii?i masuri viabile în vederea tinerii sub control a pericolului deraierii. Astfel, administratorul de infrastructura feroviara publica, daca ar fi aplicat propriile proceduri ale sistemului de management al siguran?ei, în integritatea lor, precum?i prevederile codurilor de practica, parte a SMS, ar fi putut sa men?ina parametrii tehnici ai geometriei caii în limitele toleran?elor impuse de siguran?a feroviara?i sa previna producerea acestui accident. De asemenea, comisia a constatat ca la nivelul operatorului de transport managementul de vârf nu a identificat?i gestionat riscurile generate de absen?a/deteriorarea în exploatare a garniturilor de poliamida dintre crapodinele vagonului având ca?i consecin?a o înscriere necorespunzatoare a vehiculului în curba, deci nu a putut lua masurile în vederea?inerii sub control a acestor riscuri. Având în vedere aspectele prezentate comisia de investigare recomanda ASFR: 2. sa solicite operatorului de transport revizuirea sistemului de management al siguran?ei prin identificarea?i gestionarea tuturor riscurilor relevante generate în activitatea de exploatare. Language English Translation provider Information providers own translation ERAIL-REP PUBLIC 7 Thursday, June 13, 2019
-5289 Recommendations text The derailment of the wagon no. 33530823183-6, the 3rd of the freight train no.30559-2 happened because the unsuitable maintenance in the curve after the switch no. 10, with access to the line 4 of the railway station Ciolpani and following the increase of the rigidity of the ensemble bogie wagon body, with consequences for the curve negociation. During the investigation, the investigation commission found out that the management of the infrastructure manager, at its central and county level, identified but did not managed the risks generated by the non-performance of line maintenance, in order to dispose, consequently, viable solutions and measures, for the control of the derailment hazards. Thus, the public infrastruture manager, if it had applied the own procedures of the safety management system, completely, as well as the provisions of the practice codes, part of the Safety Management System SMS, it could keep the technical paramenters of the track geometry between the tolerances imposed by the railway safety and to prevent the occurrence of this accident. The commission, also found out that the top management of the railway undertaking did not identify and manage the risks generated by the lack/deterioration in operation of the polyamide linings between the centre castings of the wagon, leading to the unsuitable curve negociation, so it could not take the measures for the control of these risks. Taking into account the presented issues, the investigation commission recommend Safety Authority ASFR: 2. to ask the railway undertaking to review its safety management system identifying and managing all the relevant risks generated by the operation. Implementation information Implementation status Implementation date NSA Response NIB Comment Causation links Railway vehicle movement events - Train derailment Subsystem - Infrastructure - Plain line track Causal factors - Maintenance - Maintenance of infrastructure Subsystem - Rolling stock - Wagons Causal factors - Maintenance - Maintenance of rolling stock ERAIL-REP PUBLIC 8 Thursday, June 13, 2019
-5289 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 - (a) the seriousness of the accident or incident -5289 National investigatio Occurrence creation 02-04-17 07:55:04 Investigator in charge Decision to investigate 31-03-17 Declaration date 02-04-17 Date of IM/RU notific 29-03-17 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 17867607 2/11/2018 Ciolpani 10:22:38 28 03 AM 2017 CR transmis.p df ERAIL-REP PUBLIC 9 Thursday, June 13, 2019