Tank Wagons Accident-Finland Issues Investigation Report


The Safety In­ves­ti­ga­tion Au­thor­ity, Fin­land, has com­pleted its in­ves­ti­ga­tion and safety rec­om­men­da­tions on the tank wagon ac­ci­dent at the Kinni sta­tion in Mänty­harju on 7 April 2018.

In the ac­ci­dent, 50 tank wag­ons began mov­ing of their own ac­cord, rolled 145 me­tres and col­lided with a buffer stop. The first two wag­ons were de­railed. A hole was made in the tank of the first wagon, from which 35,000kg of Methyl tert-butyl ether (MTBE) used as an ad­di­tive in petrol, leaked into the en­vi­ron­ment. The chem­i­cal caused se­ri­ous dam­age and harm to the nearby en­vi­ron­ment, res­i­dents and busi­nesses.

The Safety In­ves­ti­ga­tion Au­thor­ity, Fin­land is­sues six new rec­om­men­dations, and re­peats one pre­vi­ous one, on man­ag­ing track ca­pac­ity for the trans­port of dan­ger­ous goods (RID sub­stances), im­prov­ing the safety of the tem­po­rary stor­age and trans­port of tank wag­ons, the de­vel­op­ment of res­cue op­er­a­tions, the pre­ven­tion of sim­i­lar ac­ci­dents, and dam­age con­trol.

The Safety In­ves­ti­ga­tion Au­thor­ity em­pha­sises that ac­ci­dent in­ves­ti­ga­tions con­ducted on the basis of Sec­tion 1 of the Safety In­ves­ti­ga­tion Act (525/2011) are not per­formed in order to at­tribute re­spon­si­bil­ity.

The Safety In­ves­ti­ga­tion Au­thor­ity rec­om­mends that rail­way op­er­a­tors, the Finnish Trans­port Agency, and the com­pe­tent au­thor­i­ties de­velop means of pre­vent­ing con­ges­tion among trans­ports of dan­ger­ous goods that have ar­rived in Fin­land from Rus­sia. The ac­qui­si­tion and use of pre­dic­tive in­for­ma­tion must be de­vel­oped. In­for­ma­tion on the num­ber of trans­ports en­ter­ing Fin­land was not used for the man­age­ment of rail­way net­work ca­pac­ity and the re­stric­tion of RID traf­fic com­ing from Rus­sia. Ac­cord­ing to their own in­ter­pre­ta­tions, the Finnish Trans­port Agency and VR had no means of re­strict­ing traf­fic. For their part, the Finnish Trans­port Safety Agency (Trafi) and the Min­istry of Trans­port and Com­mu­ni­ca­tions lacked in­for­ma­tion on the safety risk posed by con­ges­tion.

Sec­ondly, the Safety In­ves­ti­ga­tion Au­thor­ity rec­om­mends that rail­way op­er­a­tors and in­fra­struc­ture man­agers per­form a risk as­sess­ment of the tem­po­rary stor­age of RID wag­ons in lo­ca­tions other than des­ig­nated RID rail­way yards, and en­sure that the due care and at­ten­tion re­quired under law be ob­served.

– The safety of tank wag­ons con­tain­ing dan­ger­ous goods is dra­mat­i­cally      re­duced when they are stored out­side RID rail­way yards. The risks as­so­ci­ated with tem­po­rary stor­age out­side RID rail­way yards has not been clearly recog­nised. The iden­ti­fi­ca­tion and man­age­ment of rail traf­fic risks must be given much more de­tailed at­ten­tion in all op­er­a­tors’ safety man­age­ment sys­tems and risk man­age­ment should be im­ple­mented in every­day ac­tiv­i­ties, em­pha­sises Veli-Pekka Nurmi, Ex­ec­u­tive Di­rec­tor of the Safety In­ves­ti­ga­tion Au­thor­ity, Fin­land.

Thirdly, the Safety In­ves­ti­ga­tion Au­thor­ity rec­om­mends that rail­way op­er­a­tors and the Finnish Trans­port Agency de­velop the iden­ti­fi­ca­tion and man­age­ment of risks re­lated to nor­mal rail traf­fic in their safety man­age­ment sys­tems. The in­ves­ti­ga­tion has found that the Finnish Trans­port Agency’s rail­way safety man­age­ment sys­tem is fo­cused on the man­age­ment of risks in rail­way in­fra­struc­ture man­age­ment and con­struc­tion pro­jects. In VR’s safety man­age­ment sys­tem, the as­sess­ment of change-re­lated risks is em­pha­sised, while less at­ten­tion is given to risks re­lated to daily traf­fic.

The Safety In­ves­ti­ga­tion Au­thor­ity also rec­om­mends that the Finnish Trans­port Agency draw up guide­lines on en­sur­ing that wag­ons re­main sta­tion­ary in the Finnish state rail net­work. Tests car­ried out on so-called stop blocks demon­strated that the Safety In­ves­ti­ga­tion Au­thor­ity’s cal­cu­la­tions on their in­suf­fi­cient hold­ing power were cor­rect.

– The rail­way op­er­a­tor’s guide­lines on the num­ber of stop blocks failed to take ac­count of the weight of the wag­ons or the lon­gi­tu­di­nal gra­di­ent of the track. The guide­lines over­es­ti­mate the hold­ing power of the stop blocks. The wag­ons began mov­ing as their rolling re­sis­tance de­creased due to warmer weather, and a re­duc­tion in the hold­ing power of the stop blocks due to mois­ture on the rails. The guide­lines should be drawn up by the in­fra­struc­ture man­ager in order to en­sure their con­sis­tency in a multi-actor en­vi­ron­ment. The num­ber of stop blocks must take ac­count of the lon­gi­tu­di­nal gra­di­ent of the track, the weight of the wag­ons and the true hold­ing power of the stop blocks, com­ments Esko Värttiö, in­ves­ti­ga­tor-in-charge.

The Safety In­ves­ti­ga­tion Au­thor­ity, Fin­land rec­om­mends that the Finnish Trans­port Agency in­forms all stake­hold­ers of its role and scope of re­spon­si­bil­ity. Not all stake­hold­ers are aware of the changed roles and re­spon­si­bil­i­ties or op­er­a­tors in the rail­way sec­tor. Nei­ther prac­ti­cal pro­ce­dures nor the par­ties re­spon­si­ble for en­vi­ron­men­tal dam­age in the event of rail ac­ci­dents have been de­fined with suf­fi­cient clar­ity. The guide­lines on no­ti­fy­ing the res­cue au­thor­ity of the wag­ons’ tem­po­rary stor­age were un­clear. The role of the Finnish Trans­port Agency’s rail­way ac­ci­dent res­cue team should also be clar­i­fied.

The Safety In­ves­ti­ga­tion Au­thor­ity rec­om­mends that the Finnish Trans­port Safety Agency en­sure the im­ple­men­ta­tion of the five above-men­tioned safety rec­om­men­da­tions.

Res­cue ser­vice co­op­er­a­tion, safety and lead­er­ship should be de­vel­oped

The Safety In­ves­ti­ga­tion Au­thor­ity rec­om­mends that the Res­cue De­part­ment of the Min­istry of the In­te­rior en­sure that res­cue op­er­a­tions de­fine prin­ci­ples for re­mote man­age­ment and the com­mu­ni­ca­tion of the sit­u­a­tional aware­ness of the scene of the ac­ci­dent, and draw up guide­lines for re­mote man­age­ment. The com­mu­ni­ca­tion of a re­al­is­tic sit­u­a­tional aware­ness is very im­por­tant in re­mote man­age­ment sit­u­a­tions. No qual­i­ta­tive re­quire­ments have been drawn up on the con­tent and de­vel­op­ment of the sit­u­a­tional aware­ness. It would also be im­por­tant to iden­tify sit­u­a­tions for which re­mote man­age­ment is un­suit­able.

The res­cue op­er­a­tion dur­ing the tank wagon ac­ci­dent at Mänty­harju was led re­motely. No use was made of the sup­port func­tions of the res­cue co­op­er­a­tion body, the East­ern Fin­land Sit­u­a­tion Cen­tre. The in­ter­pre­ta­tion of the sit­u­a­tion did not match the sit­u­a­tion at the scene of the ac­ci­dent, and the sit­u­a­tional aware­ness did not de­velop suf­fi­ciently. Emer­gency med­ical ser­vices only joined the op­er­a­tion on the day after the ac­ci­dent. The risks pre­sent at the scene of the ac­ci­dent were not sys­tem­at­i­cally as­sessed, and in­suf­fi­cient ac­count was taken of oc­cu­pa­tional safety and the dan­ger of fur­ther ac­ci­dents.

The Safety In­ves­ti­ga­tion Au­thor­ity, Fin­land also re­peats its safety rec­om­men­da­tion given with re­gard to the ac­ci­dent in­volv­ing four fa­tal­i­ties at the Skogby level cross­ing in Raase­pori on 26 Oc­to­ber 2017, ac­cord­ing to which the Min­istry of the In­te­rior must en­sure that op­er­a­tional area com­mand (OAC) is es­tab­lished for long-term or ex­cep­tional multi-au­thor­ity tasks.

The res­cue au­thor­i­ties and other par­tic­i­pants did not or­gan­ise res­cue op­er­a­tions and after-care for the tank wagon ac­ci­dent. Co­op­er­a­tion was in­ad­e­quate and no use was made of res­cue equip­ment and re­sources suit­able for the sit­u­a­tion. The issue of post-ac­ci­dent pre­ven­ta­tive mea­sures was left open after the res­cue op­er­a­tion had ended. This was partly due to lack of clar­ity about what would be in­volved in plac­ing the scene of the ac­ci­dent under the re­spon­si­bil­ity of the Finnish Trans­port Agency. In ex­ten­sive ac­ci­dents re­quir­ing co­op­er­a­tion be­tween sev­eral op­er­a­tors, an op­er­a­tional area com­mand would cre­ate a basis for bet­ter and more ef­fec­tive co­op­er­a­tion

Signed

Veli-Pekka Nurmi, Ex­ec­u­tive Di­rec­tor
Värttiö Esko, Chief Rail Safety In­ves­ti­ga­tor

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