-5101 Occurrence Summary What Location Date of occurrence 22-06-16 Location name Telciu-Cosbuc Local time 17:48 Latitude 47:24:17 North Event type Railway vehicle movement events Train derailment Longitude 24:23:16 East Description Direct Cause descrip two wagons loaded with logs from the freight train no.42564 derailed in open line between railway stations Telciu and Cosbuc Direct cause: The direct cause of this railway accident is the loss of the horizontal stability of the group rail-sleepers under the action of the dynamic forces sent by the rolling stock during the train running, it leading to the overclimbing of the active shoulder of the rail head, corresponding to the outside rail of the curve, by the flange of the wheel no.5 from the right side of the first axle from the second bogie, in the running direction, of the wagon no.31535301647-2 (the 31st one of the train), followed by the fall of the left wheel of the same axle between the rails. Contributing factors: - high values of the temperature registered in the rails, taking into account that : the derailment happened in an area with mixed cross section, it leading to the keeping of high temperatures registered in the air and in the rails; when the derailment happened, the temperature registered in rails was between 460C-480C (when the derailment happened it was of about 460C); - the non-welded track at the derailment site was not formed in accordance with the instructions, that is the joints were not on square because for the track construction at the derailment site one used rails of different lengths, and the number of joints from the outside rail of the curve was different from the number of joints from the inside rail of the curve (on the outside rail of the curve there were 6 joints and on the inside one there were 4 joints); - the sizes of the expansion joints, whose values in operation were under the values of the joints accepted in operation; - the shape of the broken stone track bed, that did not comply with the geometry of the broken stone track bed for the current line, route in curve, non-welded track fitted on wooden sleepers; - existence at the derailment site of some track sections with insufficient broken stone; Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo 0 ERAIL-REP PUBLIC 1 Monday, March 11, 2019
-5101 What Title Train derailment, 22-06-16, Telciu-Cosbuc (Romania) Occurrence type Railway vehicle movement events Train derailment Occurrence Class Accident Date of occurrence 22-06-16 Local time 17:48 Events Railway vehicle movement events - Train derailment Descriptions Language English Translation provider Information providers own translation Description two wagons loaded with logs from the freight train no.42564 derailed in open line between railway stations Telciu and Cosbuc Location name Telciu-Cosbuc Railway System type Railway Country Romania Location type Line Border Country Line type Single track Line number Allowed line speed Km number Latitude 47:24:17 North Longitude 24:23:16 East Location description open line between telciu and cosbuc railway station Additional location in in the north of Roamanian railway network, on the Cluj railway county Location type details Plain track Fixed installations Occurrence details Railway vehicles Movement type Freight train Train number 42564 RU Romania Wagons overturned No National Company for Freight Railway Transport "CFR-Marfa" S.A. Train speed at mom Passengers onboard No Vehicle description Eacs type wagons Other objects involved in the occurrence Other objects ERAIL-REP PUBLIC 2 Monday, March 11, 2019
-5101 Parties involved IM Involved Romania - National Railway Company "CFR" S.A. RU Romania - National Company for Freight Railway Transport "CFR-Marfa" S.A. Passengers Staff Level crossing users Unauthorised persons Others Total Material consequences Material Damage Damage description Fatalities Serious injuries Minor injuries Infrastructure Estimated total mate < 150 000 Rolling stock one oghie from a wagon derailed and one wheelset from s wagon derailed Images Name Description Type Size Last modified Organization Repository 0 Causation Causes Language English Translation provider Information providers own translation Direct Cause description ERAIL-REP PUBLIC 3 Monday, March 11, 2019
-5101 Direct cause: The direct cause of this railway accident is the loss of the horizontal stability of the group rail-sleepers under the action of the dynamic forces sent by the rolling stock during the train running, it leading to the overclimbing of the active shoulder of the rail head, corresponding to the outside rail of the curve, by the flange of the wheel no.5 from the right side of the first axle from the second bogie, in the running direction, of the wagon no.31535301647-2 (the 31st one of the train), followed by the fall of the left wheel of the same axle between the rails. Contributing factors: - high values of the temperature registered in the rails, taking into account that : the derailment happened in an area with mixed cross section, it leading to the keeping of high temperatures registered in the air and in the rails; when the derailment happened, the temperature registered in rails was between 460C-480C (when the derailment happened it was of about 460C); - the non-welded track at the derailment site was not formed in accordance with the instructions, that is the joints were not on square because for the track construction at the derailment site one used rails of different lengths, and the number of joints from the outside rail of the curve was different from the number of joints from the inside rail of the curve (on the outside rail of the curve there were 6 joints and on the inside one there were 4 joints); - the sizes of the expansion joints, whose values in operation were under the values of the joints accepted in operation; - the shape of the broken stone track bed, that did not comply with the geometry of the broken stone track bed for the current line, route in curve, non-welded track fitted on wooden sleepers; - existence at the derailment site of some track sections with insufficient broken stone; Underlying and root causes description Underlying causes: - infringement of the provisions of art.10, point B.2 from Instruction of norms and tolerances for the track construction and maintenance - no.314/1989, concerning the expansion joints, that have to be from size point of view as uniform as possible; - infringement of the provisions from the point 4 from Chapter 4 Norms of manpower and material consumption, of Instruction for the line maintenance - no.300/1982 concerning the ensuring of the norm of manpower for the current manual maintenance. - infringement of the provisions of art.14.2 from Instruction of norms and tolerances for the track construction and maintenance - no.314/1989 concerning the shape of the broken stone track bed and its sizes. Root causes: - non-application of the provisions from the Instruction for the track maintenance no.300/1982, document associated to the operational procedure code PO SMS 0-4.07 Compliance with the technical specifications, standards and requirements relevant for the whole lifetime of the lines in the maintenance process, part of the safety management system of CNCF CFR SA, concerning the sizing of the staff from the sub-units for the line maintenance, in relation to the work quantity; - non-identification of the dangers generated by the insufficient supply with some materials necessary in the maintenance process, in order to make track panel from normal wooden sleepers and rails. Language Romanian Translation provider Original version Direct Cause description ERAIL-REP PUBLIC 4 Monday, March 11, 2019
-5101 Cauza directa: Cauza directa a producerii acestui accident feroviar o constituie pierderea stabilita?ii în plan orizontal al cadrului?ine traverse sub ac?iunea for?elor dinamice transmise de materialul rulant în timpul circula?iei trenului, fapt ce a condus la escaladarea flancului activ al ciupercii?inei, corespunzatoare firului exterior al curbei, de catre buza ro?ii nr.5 de pe partea dreapta a primei osii a celui de-al doilea boghiu, în sensul de mers, al vagonului nr.31535301647-2 (al 31-lea din compunerea trenului), urmata de caderea ro?ii din partea stânga a aceleia?i osii între firele caii. Factori care au contribuit: - valorile mari ale temperaturii înregistrate în?ine,?inând cont de faptul ca: deraierea s-a produs într-o zona în care profilul transversal al caii este mixt, fapt care are ca efect men?inerea temperaturilor ridicate înregistrate în aer?i în?ine; la data producerii deraierii temperatura înregistrata în?ine a fost cuprinsa între 460C-480C (la ora producerii deraierii aceasta era de aproximativ 460C); - alcatuirea neinstruc?ionala a caii cu joante în zona producerii deraierii în sensul ca joantele nu erau la echer datorita faptului ca pentru construc?ia caii în zona producerii deraierii au fost folosite?ine de lungimi diferite, iar numarul joantelor de pe firul exterior al curbei era diferit de numarul joantelor de pe firul interior al curbei (pe firul exterior al curbei erau 6 joante, iar pe firul interior al curbei erau 4 joante); - dimensiunile rosturilor de dilata?ie, ale caror valori în exploatare erau mai mici decât valorile rosturilor admise în exploatare; - forma prismei de piatra sparta, care nu respecta geometria prismei de piatra sparta pentru linie curenta, traseu în curba, cale cu joante montata pe traverse de lemn; - existen?a în zona producerii deraierii a unor por?iuni de linie cu piatra sparta insuficienta; Underlying and root causes description Cauze subiacente: - nerespectarea prevederilor art.10, pct.b.2 din Instruc?ia de norme?i toleran?e pentru construc?ia?i între?inerea caii - nr.314/1989, referitoare la rosturile de dilata?ie, rosturi care trebuie sa fie cât mai uniforme ca marime; - nerespectarea prevederilor pct.4 din Cap. 4 Norme de manopera?i de consum de materiale, al Instruc?iei de între?inere a liniilor ferate - nr.300/1982 referitoare la asigurarea normei de manopera la între?inerea curenta în execu?ie manuala. - nerespectarea prevederilor art.14.2 din Instruc?ia de norme?i toleran?e pentru construc?ia?i între?inerea caii - nr.314/1989 referitoare la forma prismei de piatra sparta?i dimensiunile acesteia. Cauze primare: - neaplicarea prevederilor Instruc?iei de între?inere a caii nr.300/1982, document asociat al procedurii opera?ionale cod PO SMS 0-4.07 Respectarea specifica?iilor tehnice, standardelor?i cerin?elor relevante pe întreg ciclul de via?a a liniilor în procesul de între?inere, parte a sistemului de management al siguran?ei al CNCF CFR SA, referitoare la dimensionarea personalului subunita?ilor de între?inere linii, în raport cu volumul de lucrari; - neidentificarea pericolelor generate de aprovizionarea insuficienta cu unele materiale necesare în procesul de mentenan?a pentru realizarea de panouri din traverse normale de lemn?i?ine Causation classification Railway vehicle movement events - Train derailment 1 - Plain line track ERAIL-REP PUBLIC 5 Monday, March 11, 2019
-5101 1 - Maintenance of infrastructure 1 - Risk assessment ERAIL-REP PUBLIC 6 Monday, March 11, 2019
-5101 Recommendations Causation links Railway vehicle movement events - Train derailment Subsystem - Infrastructure - Plain line track Causal factors - Maintenance - Maintenance of infrastructure Systemic factors - Risk assessment 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 -5101 National investigatio 207 Occurrence creation 23-06-16 15:07:12 Investigator in charge Decision to investigate 23-06-16 Declaration date 23-06-16 Date of IM/RU notific 22-06-16 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 Microsoft PDF File 2171699 6/26/2017 Word - RI 9:24:42 Telciu AM Cosbuc 22 07 2016 CR transmis.p df ERAIL-REP PUBLIC 7 Monday, March 11, 2019