Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo Rapo PDF /20 rt File 559 /201 A18 7 Dziar 10:3 now 2:48

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1 Occurrence Summary What Location Date of occurrence Location name Dziarnowo Local time 07:34 Latitude 52:46:52 North Event type Railway vehicle movement events Level crossing event Level crossing accident (Level crossing serious accident) Longitude 18:10:46 East Description The passenger long-distance train No 7501 going in relations Poznan Glówny - Gdynia Glówny operated by RU - PKP Intercity collided with the passenger car Audi A4 Kombi at the levle crossing category A. The barriers of the level crossing were opened. The car was passing the level crossing when the train approached and hit the car at the level crossing as a consequence of which two level crossing users from the car were killed. Direct Cause descrip A rail vehicle hitting a road vehicle (passenger car, Audi A4 WAGON), which entered the level crossing with opened gates, directly in front of the approaching train No. EIE 7501, owned by the PKP Intercity S.A. carrier. Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo Rapo PDF /20 rt File 559 /201 A18 7 Dziar 10:3 now 2:48 o AM ver.3.18 (osta t).pdf 0 What Title Level crossing accident, , Dziarnowo (Poland) Occurrence type Railway vehicle movement events Level crossing event Level crossing accident Occurrence Class Serious accident Date of occurrence Local time 07:34 ERAIL-REP PUBLIC 1 Saturday, January 27, 2018

2 Events Railway vehicle movement events - Level crossing event - Level crossing accident (Level crossing serious accident) Descriptions Description The passenger long-distance train No 7501 going in relations Poznan Glówny - Gdynia Glówny operated by RU - PKP Intercity collided with the passenger car Audi A4 Kombi at the levle crossing category A. The barriers of the level crossing were opened. The car was passing the level crossing when the train approached and hit the car at the level crossing as a consequence of which two level crossing users from the car were killed. Location name Dziarnowo Railway System type Railway Country Poland Location type Station Border Country Line type Double track Line number 353 Allowed line speed 120 km/h Km number 65,669 Latitude 52:46:52 North Longitude 18:10:46 East Location description The level crossing A category is operated from the signalbox of the station - junction post Dziarnowo by the traffic manager. Additional location in The level crossing was operated by the traffic manager of the station Dziarnowo which is under management of the IM PKP Polskie Linie Kolejowe local brench in Bydgoszcz. Location type details Level Crossing Fixed installations Infrastructure Occurrence details Railway vehicles Movement type Passenger train Train number 7501 RU Poland Wagons overturned No PKP Intercity S.A. Train speed at mom 100 km/h Passengers onboard Yes Vehicle description Other objects involved in the occurrence Other objects The train consisted of the locomotive type EU07A and paseenger coaches. Road vehicle Parties involved IM Involved Poland - PKP Polskie Linie Kolejowe S.A. RU Poland - PKP Intercity S.A. ERAIL-REP PUBLIC 2 Saturday, January 27, 2018

3 Passengers Staff Level crossing users Unauthorised persons Others Total Material consequences Material Damage Damage description Fatalities Serious injuries Minor injuries Infrastructure 3rd party Rolling stock Estimated total mate < The car Audi A4 was totally demaged. The locomotive and the infrastructure were slightly demaged. Images Name Description Type Size Last modified Organization Repository 0 Causation Causes Direct Cause description A rail vehicle hitting a road vehicle (passenger car, Audi A4 WAGON), which entered the level crossing with opened gates, directly in front of the approaching train No. EIE 7501, owned by the PKP Intercity S.A. carrier. Underlying and root causes description ERAIL-REP PUBLIC 3 Saturday, January 27, 2018

4 I. Underlying:? 1) failure to preserve extreme caution by the driver of Audi A4 WAGON, especially entrance to the level crossing with significant speed, without making sure whether a rail vehicle is approaching or not, against provisions of Art. 19 para 1 of the Act of 20 June 1997 Traffic Law - (uniform text OJ Dz.U. 2012, item 1137, as amended) 2) driving a road vehicle under influence of alcohol (above 0,2 ). 3) giving the C½ signal did not depend on closing of the level crossing s gates, 4) deconcentration and distraction of the train dispatcher Mr. K.W. from current technical and operational situation caused by: malfunction of radio communication with the train on the Dziarnowo level junction, and on the route between the Janikowo station and the Dziarnowo level junction - failure of automatic crossing signaling devices at the cat. B level crossing located at kilometer point, before the level crossing, where the accident took place; the failure occurred after the C½ signal, was given, allowing the train No. EIE 7501 to proceed to the area of the Dziarnowo level junction, - a few attempts to establish radio communication with the train to inform the train driver of cat. I failure. II. Root causes:?1) leaving the gates opened by the train dispatcher on the Dziarnowo level junction before giving the S2 signal, proceed, for the train No. EIE 7501, on the C½ home signal.?2) giving the S2 signal, proceed, on the C½ signal, not having made sure whether the level crossing s gates are closed. III. Systemic causes: 1. The infrastructure manager and its executive unit failed to carry out the safety management system s procedures, including: - failure to carry out the change management process, determined in the SMS-PR-03 procedure named Change management - rev. 1 issued in , as regards the planned increase of timetable speed of train in the Janikowo - Dziarnowo level junction section (including the level crossing situated in kilometer point), recommended because of conditions occurring in the workplace of the train dispatcher operating the gates. It should have been treated as wrong ergonomics of the train dispatcher s workplace, among others, no information on gates position that would be displayed on the control panel. Increase of trains speed on the Janikowo - Dziarnowo level junction section reduced the time of travel and allowed to preserve the time intended for operation of the devices by the train dispatcher in case temporary overlap of needs (e.g. failure of the control and signaling system or radio communication with a train). The above-mentioned circumstance should force an analysis of the train dispatcher s workplace ergonomics. - failure to carry out actions intended to minimize or reduce dangers, stipulated in Procedures SMS-PW-01 called Maintaining a railway line in a technically and organizationally effective condition - SMS-PR-02 called Identification and evaluation of technical risk, including failure to carry out the risk assessment or to make the possibility to give signals to proceed (note: in Dziarnowo level junction) dependent on closure of the gates, and as a consequence, failure to undertake adequate corrective and preventive actions compliant with the procedure SMS-PD-05 Corrective and preventive actions in response to the existing threat of an accident on a level crossing. 2. Inefficient direct supervision over safety conditions on the level crossing carried out by the infrastructure manager, including inspections performed in an insufficiently detailed manner, not identifying the emerging threats within the SMS, i.e. the possibility to give the signal allowing to proceed was not dependent on closing the gates (note: Dziarnowo level junction). ERAIL-REP PUBLIC 4 Saturday, January 27, 2018

5 Causation classification Railway vehicle movement events - Level crossing event - Level crossing accident (Level crossing serious accident) Recommendations Recommendation Issuing information Recommendation title Inspections on employees in the scope of presence of substance with similar influence to alcohol Recommendation REC End implementer RU IM Status Sent to adressee Addressee NSA Issue date Recommendation texts Recommendations text Infrastructure managers and railway undertakings will intensify inspections on employees in the scope of presence of substance with similar influence to alcohol in their organisms, or if there are no such inspections, they will develop and implement internal systems of random inspections on employees that have direct influence on railway traffic safety. Implementation information Implementation status Implementation date NSA Response NIB Comment Recommendation Issuing information Recommendation title verify documentation in terms of provisions related to irregularities in operation of train radio communication systems Recommendation REC End implementer IM (PKP Polskie Linie Kolejowe) Status Sent to adressee Addressee NSA Issue date ERAIL-REP PUBLIC 5 Saturday, January 27, 2018

6 Recommendation texts Recommendations text PKP K S.A., within the scope of supervision, will verify documentation in terms of provisions related to irregularities in operation of train radio communication systems, and will undertake appropriate preventive measures. Implementation information Implementation status Implementation date NSA Response NIB Comment Recommendation Issuing information Recommendation title SMS-related recommendations Recommendation REC End implementer IM (PKP Polskie Linie Kolejowe) Status Sent to adressee Addressee NSA Issue date Recommendation texts Recommendations text ERAIL-REP PUBLIC 6 Saturday, January 27, 2018

7 In relation to the Safety Management System, PKP Polskie Linie Kolejowe S.A. will undertake the following actions: a) as regards the PKP K S.A. scale, to accelerate identification of cat. A level crossings operated by train dispatchers or other operators of signal boxes and technical posts, and to undertake appropriate actions intended to successive subordination of the possibility to give the signal allowing to proceed on the position of the gates; the above should be realized on the basis of performed risk assessment as regards accidents on those level crossings, and if necessary, undertake appropriate corrective or preventive actions, b) enter the following threat identified during the investigation carried out by the accident investigation team, i.e. failure to make the signal dependent on closure of the gates for cat. A level crossings, operated from signal boxes and technical posts to the Hazard Register, and carry out necessary further actions, including those resulting from the SMS employed by the infrastructure manager. c) carry out an extraordinary comprehensive inspection of the SMS again, checking implementation of corrective and preventive actions that result from the comprehensive audit in the Railway Lines in Bydgoszcz, especially in the scope of SMS procedures: PR-02, PW-01, PR-03, PG-01 i SMS-PD-05 and to undertake appropriate corrective actions, if necessary; the repeated comprehensive audit should also cover the Exploitation Section in Inowroclaw; d) efficiently monitor and analyze data related to the occurred dangerous events and situations, especially on cat. A level crossings, and to initiate adequate preventive actions with consideration of previous recommendations proposed by the National Railway Committee (PKBWK) and railway commissions investigating the circumstances and causes of accidents on level crossings of this category. Implementation information Implementation status Implementation date NSA Response NIB Comment Causation links Railway vehicle movement events - Level crossing event - Level crossing accident (Level crossing serious accident) Investigation details Legal Basis Other reason descrip National rules imposed by implementing of the Safety Directive 2004/49/EC - in light of Article 19, 1 of SD Reporting Body National investigatio PKBWK Occurrence creation :29:22 Investigator in charge NIB_-REPORTER Decision to investigate ERAIL-REP PUBLIC 7 Saturday, January 27, 2018

8 Declaration date Date of IM/RU notific 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 Raport PDF File /20/2017 A18 10:32:48 Dziarnowo AM ver.3.18 (ostat).pdf ERAIL-REP PUBLIC 8 Saturday, January 27, 2018