1. No category

PRELIMINARY INVESTIGATION REPORT INTO
PRASA RAIL REAR-END COLLISION AT DENVER
STATION
OPERATOR
PRASA
PERMIT NUMBER
ASP0002NTS
INVESTIGATION SUBJECT
PRASA Rail Denver Station rear-end collision
DATE OF OCCURRENCE
28 April 2015
REFERENCE NUMBER
Head of Occurrence
Investigations
Preliminary Investigation Report
RSR/20150428/011
Thanduxolo Fumbata
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CONTENTS
1.
ABBREVIATIONS ........................................................................................ 3
2.
STATEMENT OF INTENT ........................................................................... 3
3.
OBJECTIVE ................................................................................................. 3
4.
SCOPE OF THE INVESTIGATION ............................................................. 3
5.
BACKGROUND TO THE INVESTIGATION ................................................ 4
5.
GEORGE GOCH SIGNAL CABIN FACT FINDING ..................................... 5
6.
CONCLUSIONS .......................................................................................... 6
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1.
ABBREVIATIONS
BOI
Board of Inquiry
CTC
Centralised Traffic Control
Km/h
Kilometers per hour
OHTE
Overhead Traction Equipment
Perway
Permanent Way
PRASA
Passenger Rail Agency of South Africa
RIC
Rail Incident Commander
RSR
Railway Safety Regulator
TCO
Train Control Officer
2. STATEMENT OF INTENT
This investigation has been conducted in accordance with section 38 of the Railway
Safety Regulator Act, Act 16 of 2002 (as amended) and is conducted with the
objective of determining the facts of the occurrence, the immediate cause and of
making recommendations thereof.
3. OBJECTIVE
The preliminary investigation’s objective is to collect and understand the factual data
relating to this occurrence to assist the Board of Inquiry process.
4. SCOPE OF THE INVESTIGATION
This preliminary investigation included the following:
(a)
Analysis of the occurrence site
(b)
Facts gathered from the Denver signal Control office
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5. BACKGROUND TO THE INVESTIGATION
5.1 On the 28th April 2015 at approximately 07h12 PRASA Rail Business Express
Train number 1602 collided into the rear of the Metro Plus Train number 0600
which had stopped at the platform at Denver Station. Both trains had departed
from Pretoria Station at different times and were enroute to Park station when
the collision occurred.
5.2 It was reported by the Train Control Officer at Signal Cabin that the driver of
Train number 0600 stopped at the platform in Denver station because he could
not confirm the signal DN11 aspect.
5.3 Train number 1602 coming from Cleveland direction collided into the rear of a
stationary Train number 0600. The collision occurred in the morning under clear
weather conditions. Extensive damage was caused to railway infrastructure and
rolling stock.
Figure 1 Showing damage to the collided trains
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Figure 2 Showing damage to the collided trains
5. GEORGE GOCH SIGNAL CABIN FACT FINDING
5.1.
The method of train control in the section from Cleveland station to Denver
station is automatic colour light signals.
5.2.
There were no faults reported in Denver on the day of the collision in relation
to the colour light signalling.
5.3.
According to the TCO at the Signal Cabin Metro Plus Train number 0600
passes Denver station at 07h09 and the Business Express Train number 1602
at 07h19. However neither of the trains was scheduled to stop at Denver
Station.
5.4.
There was a power outage at George Goch signal cabin which started at
01h30 on 28 April 2015. Upon investigation it was also established that the
two way radio communication was not working.
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5.5.
As a result of the outage the driver of Train number 0600 could not establish
direct communication with the signal cabin to confirm the signal aspect
because their communication lines were down; the driver called Operations
Control Centre in Braamfontein who then relayed the message to the TCO at
George Goch signal cabin.
5.6.
The Signal Technician estimated that Metro Plus Train number 0600 was
stationary at the platform for approximately 5 minutes. During this period
Business Express Train 1602 collided into the rear of the Metro Plus Train
number 0600.
5.7.
Metro Plus Train number 0600 was protected by Signal DN2 which was at
danger (Red Signal). Signal DN1 which precedes DN2 was displaying a
caution aspect (Yellow Signal).
5.8.
However the Business Express Train number 1602 passed the Signal DN2 at
Danger (Red Signal).
6. CONCLUSIONS
6.1. The preliminary investigation suggests that:
6.1.1 The driver of Business Express Train number 1602 passed the signal at
danger (Red Signal).
6.1.2 The communication system including the two way radio system was not
working.
6.2. The RSR will conduct an independent Board of Inquiry into the circumstances
that led to this collision. The BOI will amongst other things scrutinize the
following:
6.2.1 The adequacy, effectiveness and personnel knowledge of the relevant
procedures and training.
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6.2.2 Background regarding activities pertaining to adherence to, specifically
applicable train operating procedures by the train drivers and the TCO
concerned as set out in local instructions, General Appendix and other
applicable directives.
6.2.3 The adequacy and effectiveness of maintenance systems and procedures for
signals, perway and rolling stock.
6.2.4 The effectiveness of the implementation of RSR previous recommendations
issued to the operator regarding similar type of occurrences; and
6.2.5 The risk profile of the train crew and previous occurrence history.
6.2.6 And any other information that will be relevant to the BOI.
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