Recommendation: 2019004-03

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Ref # 2019004-03
Status Open / In progress
Occurrence Road Rail Vehicle occurrences on Iarnród Éireann Network
Occurrence Date 24 September 2015

Basis for Recommendation

The RAIU made some findings in relation to RRV Plant requirements, as follows:

  • ACD – It is noted that while EN 15746 does not specifically mandate the use of ultrasonic devices or ACDs, the RAIU consider that had ACDs been installed on the RRVs involved in the RRVs in at least five accidents involving the collision of RRVs with other RRVs and other objects; these accidents may have been prevented where a device was fitted;
  • Speedometers – The RAIU found that not all RRVs are fitted with speedometers that operate in both directions in rail mode; the RAIU deem that speedometers are necessary to allow RRVs maintain the speeds outlined in the IÉ Rule Book (paragraphs 449 - 450);
  • Brake Testing – In terms of the brake testing, requirements are set out in I-PLM-5001; and in terms of stopping distance requirements, the requirements of I-PLM-5001 are the same as EN 15746. All RRVs, with two exceptions, had the required EAC, meaning that they met the braking requirements at time of certification. However, no brake tests were carried out after any of the incidents, despite there being loss of control of RRV accidents, where the brakes would not stop the RRV before colliding with other RRVs. In addition, these RRVs were allowed back into service without any assurances that the RRVs were working correctly;
  • Braking Performance – The RAIU noted that WSP or sanders were not fitted to any of the RRVs involved in the occurrences reviewed by the RAIU which may have improved the braking performance of the RRVs in areas where there was low rail adhesion and/ or poor rail head conditions;
  • Warning Systems – The only warning systems available to RRVOs in the event of an emergency, such as the loss of control of an RRV, is through the use of flashing headlights and/or sounding the horn (paragraphs 456 - 458). Given that RRVs: are large plant; which work on noisy worksites (weather or work related noise); where it is normally dark (during night possessions); and there are personnel on-track (e.g. RRVCs) the RAIU consider that consideration should be given to appropriate warning systems in the event of an emergency to be able to warn staff to go to a place of safety or to provide safe with portable ACDs;
  • Communications between work positions – There was no communication between Operators of RRVs/RRVOs and other Operators of RRVs/RRVOs or PICs/RRVOs through the use of intercoms, for example, in any other of the sixteen occurrences identified in this report. EN 15446 does require communication, through use of intercom, etc, between work positions. The RAIU consider that there should be a better means of communication between work positions, in particular, when travelling in convoy;
  • Post-accident performance review of RRVs - It is noted from all the occurrences reviewed by the RAIU that data recorders are not fitted to the RRVs, as a result the braking capabilities, speeds and actions of the RRVOs cannot be reviewed post occurrence.
  • It should be noted, that EN 15746 standards have been adopted by several other European countries, either directly or indirectly, meaning it has been deemed to be best practice in these countries; and, the NSAI transposed EN 15746-1 and EN 15746-2, into standards: I.S. EN 15746-1 and I.S. EN 15746-2 in July 2018. For these reasons and the reasons outlined in paragraphs 520 to 523 the RAIU make the following safety recommendations related to the introduction of improved CCE Plant and Machinery Standards:

Recommendation

IÉ-IM should review and improve its current CCE Plant and Machinery Standards; attention should be given to best international practice in RRVs; and, as a minimum, the following should be considered for inclusion:

  • Applying the requirements set out in the EN 15746/ I.S. EN 15746 standards such as controls & indicators, visibility from the cab, warning systems & communications between work positions, etc. Where, due to a technical impossibility, the design specifications of EN 15746 cannot be met in full, control measures to address these deficiencies should be clearly identified, risks assessed, and suitable controls implemented;
  • The installing of an appropriate emergency warning system, which, when activated in emergency, can produce a suitably loud audible alarm and/or visual alarm. In cases, where this is not possible, as a result of a technical impossibility, control measures to address this deficiency should be clearly identified, risk assessed, and suitable controls implemented;
  • Installing WSP and/or sanders on RRVs;
  • Installing of ACDs on RRVs for the prevention of collisions with other RRVs, rolling stock, infrastructure and staff (through the provision of portable ACDs fitted to staff) on the IÉ network. In cases, where this is not possible, as a result of a technical impossibility, control measures to address this deficiency should be clearly identified, risk assessed, and suitable controls implemented;
  • Introducing an appropriate means of communication between work positions, whereby the RRVOs and RRVCs can communicate while on-tracking, travelling on the railway and at worksites;
  • Installing of data recorders on RRVs;
  • The suitability of the current braking system on Type 9B RRVs where an indirect rail wheel braking system is in place; consideration should be given for the requirement to have all RRVs fitted with direct rail wheel braking systems.