The derailment of the Alfa Pendular train, in the village of Soure, district of Coimbra, in July 2020 , which caused two deaths and 44 injuries, was due to human error, but the investigation also blames Infraestruturas de Portugal (IP).
The conclusions are contained in the final report of the Office for the Prevention and Investigation of Accidents with Aircraft and Railroad Accidents (GPIAAF), which the Lusa agency had access today, which it reveals that “the direct material costs of the accident were around 11 million euros and the economic impact of the delays resulting from the accident amounts to around 575 thousand euros”.
The train, with 212 passengers and heading south-north, bound for Braga, derailed in the afternoon of July 31, 2020, after colliding with a catenary conservation vehicle (VCC), which had entered the road, seconds before, near the town of Matas, causing the death of the two workers of IP, who were in the VCC, and 44 injured, three of which were serious.
“The accident was not due to any technical anomaly , having established as the most likely explanation for the undue overrun of signal S5 by the VCC, an error by the crew in the identification of the signal that related to the line the train was on, having understood that the S3 signal with a green appearance was applied to them for the passage of fast train No. 133 [Alfa Pendular]” , concluded the GPIAAF.
In addition to the “probable error” in the interpretation of the signal by the VCC, the investigation also points out as a contributing factor to the accident, among others, the fact that this maintenance vehicle is not equipped with the automatic speed control system (CONVEL).
In July 2018, IP committed to installing CONVEL in the VCC, but the measure, “subject to financial commitment”, until the date of the accident, has never progressed.
The IP commitment is contained in the response sent to the GPIAAF, after this body warns of the risk of these vehicles circulating without CONVEL, after one of them “unduly” passes a red light at the Roma- Areeiro, in Lisbon, in January 2016.
The final report also lists several factors contributing to the accident, namely “the limited knowledge of the location by the VCC crew, having passed the station de Soure, in the north-south direction, on average, once a year”, as well as “the reduced proficiency of the crew provided by the organization of their work and functions”.
“The monitoring of the function of driving special motor vehicles [VME – como o que provocou o acidente] was not ensured by the infrastructure manager [IP], as provided for in its obligations”, underlines the investigation, denouncing that “the internal recommendation to improve the identification” of the signs installed at the accident site (S3 and S5) was not implemented by IP
“The history of SPAD [sigla em inglês de passagem não autorizada de um sinal vermelho] that occurred with VME was not integrated in the process of learning and monitoring the risks of the infrastructure manager [IP]; the infrastructure manager did not carry out the reassessment of the risk of the circulation of VME on an open road for exploitation, recommended by the GPIAAF in 2018 to the national safety authority [IMT – Instituto da Mobilidade e dos Transportes]”, highlights the investigation.
The GPIAAF also reveals the “insufficient supervision by the national safety authority regarding the infrastructure manager’s SPAD”.
“It appears that many of the causal and contributory factors determined in the investigation are systemic factors, that is, of an organizational, management, societal or regulatory nature likely to affect future similar or related occurrences in the future, on which a decided action by the organizations involved is essential, since that is the only way to prevent future accidents”, warn the investigators.
The GPIAAF makes in this report ten safety recommendations to the IMT, so that it is attentive to the performance of IP, the machinists and the cont roll of the risk of train circulation without CONVEL supervision on equipped lines.
This body recalls that “most systemic factors were identified in 2018″ and are included in the report to the accident involving a VCC at the Roma-Areeiro station, in Lisbon, in which “addresses improper overtaking of closed signals by vehicles of the infrastructure manager”.
“The history of events of this type well illustrates the so-called Heinrich pyramid, which postulates that a major accident is preceded by several smaller events of increasing gravity, with pre-conditions common”, stresses the GPIAAF.
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