Date of occurrence Location name Chitila Local time 21:02 Latitude 44:29:00 North Railway vehicle movement events Train derailment

Transcription

1 -5044 Occurrence Summary What Location Date of occurrence Location name Chitila Local time 21:02 Latitude 44:29:00 North Event type Railway vehicle movement events Train derailment Longitude 25:59:33 East Description Direct Cause descrip the rear two wagons from the freight train derailed in the Chitila railway station Cauza directa a producerii accidentului o constituie pierderea capacitatii de ghidare a caii în zona km pe linia curenta firul II dintre Ramifica?ia Rudeni?i sta?ia CFR Chitila. Factori care au contribuit: - mentenan?a defectuoasa a suprastructurii caii. Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo Micro PDF /24 soft File 574 /201 Word 7 - acc 1:48: Chitil 35 a PM 2016 CR trans mis.p df 0 What Title Train derailment, , Chitila (Romania) Occurrence type Railway vehicle movement events Train derailment Occurrence Class Accident Date of occurrence Local time 21:02 Events Railway vehicle movement events - Train derailment Descriptions ERAIL-REP PUBLIC 1 Saturday, March 9, 2019

2 -5044 Language English Translation provider Information providers own translation Description the rear two wagons from the freight train derailed in the Chitila railway station Location name Chitila Railway System type Railway Country Romania Location type Station Border Country Line type Single track Line number Allowed line speed 15 km/h Km number Latitude 44:29:00 North Longitude 25:59:33 East Location description Chitila railway station Additional location in on the Bucharest railway county in the south of Romanian railway network Location type details Plain track Fixed installations Occurrence details Railway vehicles Movement type Freight train Train number RU Romania Wagons overturned No DB SCHENKER RAIL MÂNIA Train speed at mom Passengers onboard No Vehicle description flat wagon Laagrss type Other objects involved in the occurrence Other objects Parties involved IM Involved Romania - National Railway Company "CFR" S.A. RU Romania - DB SCHENKER RAIL MÂNIA Passengers Staff Level crossing users Unauthorised persons Others Total Fatalities Serious injuries Minor injuries ERAIL-REP PUBLIC 2 Saturday, March 9, 2019

3 -5044 Material consequences Material Damage Damage description Infrastructure Rolling stock Estimated total mate damages to the track, wagons and overhead line Images Name Description Type Size Last modified Organization Repository 0 Causation Causes Language Romanian Translation provider Original version Direct Cause description Cauza directa a producerii accidentului o constituie pierderea capacitatii de ghidare a caii în zona km pe linia curenta firul II dintre Ramifica?ia Rudeni?i sta?ia CFR Chitila. Factori care au contribuit: - mentenan?a defectuoasa a suprastructurii caii. Underlying and root causes description Cauza subiacenta Nerespectarea prevederilor Instruc?iei de norme?i toleran?e pentru construc?ia?i între?inerea caii-linii cu ecartament normal nr.314/1989, referitor la modul de alcatuire a caii cu joante. Cauze primare 1. Neaplicarea prevederilor Instructiei de întretinere a liniilor ferate nr.300/2003, document asociat al procedurii operationale cod PO SMS Respectarea specificatiilor tehnice, standardelor si cerintelor relevante pe întreg ciclul de viata a liniilor în procesul de întretinere, parte a sistemului de management al sigurantei al CNCF CFR SA, referitoare la dimensionarea personalului Districtului de Linii nr.5 Chitila din cadrul Sectiei L2 Bucure?ti, în raport cu volumul de lucrari. 2. Neidentificarea pericolelor generate de aprovizionarea insuficienta cu unele materiale necesare realizarii mentenan?ei caii (respectiv a traverselor normale de lemn). Language English Translation provider Information providers own translation Direct Cause description Direct cause of the accident is the lost of the guiding capacity of the track at km 1+985, on the running line, track II, between the branch line Rudeni and the railway station Chitila. Contributing factors: - unsuitable maintenance of the track superstructure. ERAIL-REP PUBLIC 3 Saturday, March 9, 2019

4 -5044 Underlying and root causes description Underlying cause Infringement of the provisions from the Instruction of norms and tolerances for the construction and maintenance of the track line with standard gauge no. 314/1989, concerning the composition of the welded track. Root causes 1. Non-application of the provisions from the Instruction for the maintenance of the lines no.300/2003, document associated to the operational procedure code PO SMS Compliance with the technical specifications, standards and requirements relevant for the whole life time of the lines in the maintenance process, part of the safety management system of CNCF CFR SA, for the sizing of the staff from Line District no.5 Chitila, within Track Section L2 Bucure?ti, in relation to the works. Causation classification Railway vehicle movement events - Train derailment 1 - Plain line track 1 - Maintenance of infrastructure Recommendations Causation links Railway vehicle movement events - Train derailment Subsystem - Infrastructure - Plain line track Causal factors - Maintenance - Maintenance of infrastructure Investigation details Legal Basis Other reason descrip National rules imposed by implementing of the Safety Directive 2004/49/EC - in light of Article 19, 2 of SD - (a) the seriousness of the accident or incident National investigatio 194 Occurrence creation :10:35 Investigator in charge Decision to investigate Declaration date Date of IM/RU notific Report Type Final report Workflow Status Validated Report Version 2 Investigation Status Closed Other Attachments ERAIL-REP PUBLIC 4 Saturday, March 9, 2019

5 -5044 Final Report Name Descriptio Type Size Last Organizati Repositor Microsoft PDF File /24/2017 Word - 1:48:35 acc Chitila PM 2016 CR transmis.p df ERAIL-REP PUBLIC 5 Saturday, March 9, 2019