Soweto train crash injured hundreds

[John Ashworth]

BBC 20 May 2011 Last updated at 12:13 GMT

Soweto, South Africa, train crash injured hundreds

More than 850 people have been injured in a train crash during Thursday's evening rush hour in the South African township of Soweto in Johannesburg, the train operator Metrorail has said.

A commuter train hit a stationary one from behind, the force of which threw some passengers through windows.

Three of the casualties were in a critical condition, officials said.

Correspondents say most of the injured were treated at the scene, in one of the biggest rail incidents for years.

According to the authorities, 25 of the injured are still in hospital.

South Africa's Railway Safety Regulator (RSR) said it was investigating the cause of the crash, which occurred at 1750 local time (1550 GMT).

'Chaos'

Local television news pictures showed casualties being treated at the scene by medics - some of them tended to by torchlight.
Continue reading the main story

Metrorail, which is responsible for running the trains and is heading the salvage operation, told the BBC that 857 people had been injured in the accident.

Medical rescue official Jeff Wicks told the Sapa news agency there had been "chaos" at the scene.

"We had people who were sprayed 200m around the trains... on arrival, paramedics found passengers from both trains lying on the track," he said.

According to Pretoria News, people lay groaning in the dark, with some waiting more than an hour before being transported to hospital.

Synock Matobako, a spokesman for the emergency services, said they had had to request more ambulances because of the number of casualties.

"This is the biggest incident in recent years, even though no-one has died. People sustained serious multiple injuries."
Fire rumour

Evason Mogomotsi told the BBC he was dozing on the train and woke up when it crashed.

"After the crash, people started screaming and many were trying to get out of the train," he said.

"There was also a rumour that the other train had caught on fire so people were trying to escape.

"Some people were even trying to stand on the people who had fallen in order to get out of the train."

Another passenger, Gladwell Ntusi, said some people jumped out of the windows.

"It was horrible, I saw people with broken legs, others had cracked their temples. It was not a nice scene," he told reporters.

The Metrorail train had been travelling between Mzimhlophe and Phomolong in Soweto.

More than two million passengers travel daily on South Africa's commuter trains.

[allanroy]

The driver of the train that crashed into a stationary train in Soweto last week was dismissed on Tuesday for doing 85km an hour in a 30 km zone, the Passenger Rail Agency of South Africa (Prasa) said on Wednesday.

“He was travelling at 85km an hour in a 30 zone and was doing 33km an hour on impact...he passed through two red signals,” said Lucky Montana, Prasa Group CEO.

CEO for the rail division, Mosenngwa Mofi, said in response to the Soweto accident and another accident in Tshwane a few weeks ago that an extraordinary meeting was held on Saturday to review safety measures.

Some of the decisions taken at the meeting include the introduction of a compulsory stop at all T-signals.

“(These were) previously treated as cautionary signals where drivers could proceed with caution after a three-minute wait.

“The new rule will now compel drivers to stop and give authorisation before proceeding.”

A further decision was made to implement the no fault commuter cover for all valid ticket holders during a train accident.

Prasa said it had also set aside R20 million to assist the victims of the two accidents which will be over and above the payment of hospital bills.

Eight hundred and fifty seven people were injured when two trains collided in Meadowlands a week ago.

[Steve Appleton]

From Business Day, 26 May 2011. http://www.businessday.co.za/Articles/C ... ?id=143858

Rail system under pressure to improve
Following two rail accidents in as many months Metrorail has instituted a zero-tolerance approach to application of driver safety protocols
NICKY SMITH
Published: 2011/05/26 07:00:38 AM

SA’s 40-year-old commuter rail system is coming under increasing pressure from commuters, shareholders and regulators to raise its safety performance and standards. This is after two commuter rail accidents in as many months, in which more than a 1000 people were injured.

Metrorail has instituted a zero-tolerance approach to drivers who do not submit to its safety protocols. It has made disobeying speed limits or signals a fireable offence and ordered train drivers not to rely on their own judgment when they are cautioned to proceed with care.

SA had an old signalling infrastructure, Passenger Rail Agency of SA (Prasa) CEO Lucky Montana said yesterday, but it was "human error" that had caused the two accidents.

In both instances the train drivers ignored signals. In last Thursday’s accident the driver, who was disciplined last month for exceeding route speed limits and put on probation for 12 months, ignored two signals to stop and travelled at 85km/h in a 30km/h zone. The accident injured 857 people and will cost Prasa more than R55m.

Prasa has created a R20m fund to assist victims of the accident if they have a valid train ticket . The cost of repairs to the trains damaged in the collision will run to as much as R35m, Prasa Rail CEO Mosenngwa Mofi said yesterday. Prasa has also undertaken to cover all the medical bills for those who sustained injuries. Yesterday, 18 people were still in hospital because of the accident.

In April, a train travelling from Mabopane to Pretoria slammed into a stationary train, killing the driver and injuring about 200 people. That month, Prasa started a 90-day programme to improve its overall performance, which encompassed safety, driver behaviour, train availability and ensuring the availability of spares at train depots.

Following the latest accident, Prasa has undertaken to strengthen its human factor management. Metrorail had increased the frequency of random testing of its drivers for things such as sobriety and other "fitness for duty" measures, Mr Montana said. Compulsory medical check-ups would take place twice a year, not once.

Tomorrow, the Rail Safety Regulator will unveil a new safety guide called the Human Factor Management Standard, which it has developed with the South African Bureau of Standards.

The Human Factor Management Standard will set minimum requirements for railway operators and their employees, the regulator said. The standard "promotes healthy lifestyles among railway workers and focuses on the management of human factors, including the perceptual, physical and mental capabilities of people", the regulator said. This included things such as "worker fatigue, substance abuse and medical surveillance".

The "recklessness and indiscipline" of some of Metrorail’s drivers was "extremely concerning" and it would not be tolerated, Mr Montana said. The driver who caused last week’s accident was fired on Tuesday. Nineteen other drivers who face disciplinary action by Metrorail for similar infringements face a similar fate.

"We can’t have a situation where accidents occur and nothing drastic happens," Mr Montana said.

[Steve Appleton]

From Business Day, 25 May 2011. http://www.businessday.co.za/Articles/C ... ?id=143811

Metrorail overhaul safety measures following Soweto crash
Commuter rails system admits one driver was ignored signals to stop and was speeding
NICKY SMITH
Published: 2011/05/25 03:42:08 PM

Metrorail, the commuter rail system that transports 2.4m people a day, has overhauled its safety protocols after two trains crashed into each other last week Thursday injuring 857 people because the driver of one train was reckless and ignored signals to stop.

This is the second accident in as many months that was because of human error, Metrorail parent company Passenger Rail Agency of South Africa (Prasa) CEO Lucky Montana told journalists in Johannesburg today. "We are seriously concerned about these accidents," Mr Montana said. "The safety of our passengers is non-negotiable."

Metrorail has set aside a fund of R20m to pay to people injured in the crash, Mr Montana said. It will be a once-off payment directly to passengers harmed in the accident who are in possession of a valid ticket, he said. Amounts to individuals would range between R7500 and R10000.

The accident last week was caused when a train driver ignored two safety signals that require train drivers to stop the train for a compulsory three-minute stop before proceeding with caution. The black box on the train also revealed that the driver had been speeding, Mosenngwa Mofi, the chief operating officer of Metrorail said. The train travelled at 85km/h on a route that requires a maximum speed of 30km/h, he said. On impact the train was travelling at 33km/h, Ms Tembela Kulu, the provincial manager of Prasa rail in Gauteng, said. "He was able to apply the brakes," she said.

Between the two trains about 2400 passengers were on board when the accident occurred.

Metrorail has now made exceeding speed limits on its routes a fireable offense. It is also bringing disciplinary action against 19 other train drivers who have ignored safety protocols, Mr Montana said.

"These 19 drivers will have to show good cause why they should not be fired," Mr Montana said. Six other drivers are being required to undergo refresher courses on driver training after they have received letters of warning. Metrorail has 1108 train drivers, Mr Mosenngwa said.

As part of the changes introduced drivers will now need to get permission from a train control officer before being able to proceed after encountering "a signal at danger," Mr Mosenngwa said. Before this change drivers waited for a minimum of three minutes before proceeding, using their own discretion.

[Steve Appleton]

SA’s 40-year-old commuter rail system is coming under increasing pressure

It's only that old? I think Business Day got a date reference wrong here. Perhaps this is in reference either to the age of the signalling system in use or to the age of the trains. Both are frankly totally irrelevant to the cause of the crash in this case and are probably irrelevant to the cause of most of the recent crashes as well. Old infrastructure can be just as safe as new, provided it is operated within its limitations and is maintained properly.

[John Ashworth]

The age and state of repair (including theft and vandalism) of the signalling system may be a factor, in that signals out of order are now the norm and introduce an enhanced human factor. If everything is working OK, drivers stop at red signals and most signals are interlocked to prevent the signal controllers from making errors (obviously in all countries drivers do still occasionally fail to stop, leading to accidents such as Ladbroke Grove in UK a few years back). In the current environment both driver and signaller have to take extra steps which are open to further human error. It might also be argued that a more modern signalling system would include some form of automatic train protection, where trains are automatically brought to a halt if they fail to stop at certain key signals. In principle that's not necessarily "modern" as the GWR was using it a long, long time ago, but it's now very common on modern networks.

[Steve Appleton]

A bit of signalling 101 is in order here because at first sight to the uninitiated this statement looks like a conflict.

As part of the changes introduced drivers will now need to get permission from a train control officer before being able to proceed after encountering "a signal at danger," Mr Mosenngwa said. Before this change drivers waited for a minimum of three minutes before proceeding, using their own discretion.

Although they look the same, two types of colour-light "stop" signals exist on SA railways.

The first and most numerous are those that are "controlled" by a centralised traffic control centre (CTC) and are used to enforce the operating principle of absolute working. These signals are interlocked to the state and occupancy of the route (including points and turnouts) and the track sections around and ahead of them. Through local relay "interlocking" these signals cannot be cleared (set to a "proceed" aspect - usually yellow or green) if an unsafe condition is commanded. This ensures that only one train can occupy a section of track or follow a given route at any one time. This is known as "absolute working" and is the standard method of working in all colour-light areas. As they are passed, these signals change to red to show "danger" and will not revert to a proceed aspect until they are operated by a train controller; and then only if the route and all the track circuits covering that route are proven clear and all tracks or routes that might conflict with (or cross) that route are also clear and "protected"; that is, that their respective stop signals are all set to danger.

Drivers who encounter such a stop signal at red (showing "danger") must stop before the signal and may not (not ever) pass it until it has either changed to a proceed aspect or the driver has been given an "authority" to pass that signal at danger, no matter how long either of those takes.

The second type of stop signal is an "automatic" signal which is operated essentially by the occupancy of the section of track immediately ahead of the signal, up to the next signal. If the section ahead is occupied, the signal will be at danger. When that section clears, the signal will revert to a proceed aspect automatically - no train controller is involved. These signals are only used on unidirectional tracks and where there are no turnouts or other conflicting routes. They are mainly used to increase track occupancy by creating two or more shorter automatically-controlled "blocks" between the major stop signals, allowing trains to run closer together. These types of signals are also commonly used on many other commuter rail systems, e.g. London Underground and New York Subway for the same purpose.

In SA, these signals are marked with a white "T" on the post and are often called T-signals. In contrast to the "absolute" rule mentioned above, these signals allow limited "permissive" working wherein under defined circumstances more than one train is permitted to occupy a section of track that is controlled by such a signal. This is because the driver is allowed, after waiting at a red danger signal for at least three minutes, and after attempting to contact a train controller, to proceed "on sight". He must travel at such a speed that he can stop his train short of any obstruction (including another train) ahead. This allows a busy commuter network to continue to operate even if the track circuit or T-signal it controls has failed. It allows a train to leave a platform into the section ahead which then permits a following train to pull in and load at that platform. Often, as a train passes such a T-signal, the section ahead is cleared and a long "delay" at the signal was thereby avoided. In effect, capacity in a strained system is increased at peak times.

If everyone follows the rules then this is theoretically safe. Indeed, permissive (or timed) working is still practiced on many railways worldwide. Nonetheless, this does break the currently established local principle of "absolute" working methods and is probably past its "sell by" date, as these accidents (assuming the cause was indeed passing T-signals at danger) show. In my view, introducing rules to treat these signals as absolute stop signals in the same way as any other signal at danger cannot be a bad thing.

[Steve Appleton]

It might also be argued that a more modern signalling system would include some form of automatic train protection, where trains are automatically brought to a halt if they fail to stop at certain key signals.

I agree with John. Some form of warning or protection is key element missing from SA railways when compared with most other systems in first-world countries. I guess this is because of the usual cost/risk benefit analysis. In a lightly loaded, slow-speed, disciplined system, the rarity and cost of accidents is probably considerably less than the cost of implementation. In a self-regulating system, such as we have had in SA until very recently, the bean counters will use that as the prime reason not to install such a system. The cost of human life is generally ignored in such calculations, especially when the life belongs to a relatively low-wage-earning (and in the past, politically insignificant) person.

I hope and suspect that will change and that the regulator (the RSR) will start to push for such a safety implementation, at least in the urban commuter areas. For the heritage steam operators let's hope that any system chosen is not too expensive or difficult to install or that an exemption will be granted.

[Aidan McCarthy]

Hi,

There seems to be systemic mis-understanding of what the instruction Proceed on Sight means and how to execute the instruction. Several of the recent accidents seem to have been caused by drivers continuing at normal line speed when they should be proceeding on sight. To me this always seemed a bit of a vague instruction as it is up to the driver to decide on the safe speed for his train, perhaps in the old days when drivers were highly experienced and had extensive road knowledge this may not have been an issue.

[John Ashworth]

Two relevant articles from Railways Africa:

UNIONS WANT BETTER PROTECTION FOR DRIVERS

on May 31, 2011 in Mishaps Africa, South Africa

On 23 March, following the Soweto collision in which 857 commuters were injured. the United Transport and Allied Trade Union (Utatu) urged the Passenger Rail Agency of South Africa (Prasa) to acquire modern technology that would assist drivers in cases of human error. Preliminary investigations suggest that the second train was travelling too fast and could not stop in time to prevent the accident.

The Railway Safety regulator (RSR) has indicated concern about what it described as the “unacceptably high” rate of train collisions and derailments in the country. Its 2009/2010 annual report states: “The poor condition of railway infrastructure and rolling stock has led to constant failures in railway operations, leading to the constant introduction of inherently less safe manual procedures. A notable number of accidents that the RSR has investigated (mainly in the commuter rail environment) over the years occurred when manual procedures were put in place, often resulting to non-adherence to operating procedures.”

The report linked the poor state of infrastructure and rolling
stock to the “inadequate technical skills to meet the demands of running safe and reliable railway services. The RSR’s audits and investigations have revealed challenges related to operators not having adequate technical capacity to effectively maintain and operate a rail system. Moreover, the RSR investigations have raised serious concerns around the inability of safety critical personnel (for example, train drivers) to deal with abnormal conditions particularly linked with system failures.”

The unions have urged Prasa not to be too quick in blaming personnel, including drivers, saying they were “only human”.
The SA Transport and Allied Workers Union (Satawu) reiterated a call for Prasa to maintain “safer trains, better signalling and safety systems, and better safeguards against worker fatigue”.

“No driver will deliberately commit a mistake; they’re also human beings. Our government has acquired modern technology for the Gautrain, which is for the rich; surely they can do the same for Metrorail, which caters for the poor?” said Utatu leader Chris de Vos.

“Why wait. when poor people’s lives continue to be at risk? Let’s rather do it sooner, get modern technology, or face more of these nasty accidents,” he said.

RETIREES TO RETRAIN NEWER METRORAIL DRIVERS

on May 31, 2011 in South Africa

Selected people are to be brought back from retirement on a short-term basis to mentor newer drivers, Metrorail CEO Mosenngwa Mofi told a media briefing in the aftermath of the 19 May Soweto collision. Other action contemplated, he said, involved strengthening the human factor management programme. This monitors driver-related issues such as fatigue, fitness for duty, sobriety and re-enforcement of medical surveillance and compulsory fitness for duty tests.

“All drivers who have violated safety rules such as, among others, speeding in the past three to six months will be withdrawn from service and undergo refresher training courses,” Mofi said. Automatic signals at danger, where previously drivers were allowed to proceed with caution after a three-minute wait, will henceforth be compulsory stops.

http://www.railwaysafrica.com/blog/2011 ... dium=email and http://www.railwaysafrica.com/blog/2011 ... dium=email

[Steve Appleton]

Found this statement (ex Creamer Media) by the RSR which was apparently published on 28/09/2012 and which indicates a very poor standard of driver training and a serious lack of adherence to the rules :

The Railway Safety Regulator today briefed members of the media on the outcomes of a Board of Inquiry investigation into the Mzimhlophe incident.

On Thursday 19 May 2011 a train from Johannesburg to Naledi collided against the rear end of a stationary train. The collision happened between Mzimhlophe and Phomolong stations, both trains belonged to Prasa-Metrorail. This resulted in 857 commuters being injured, who were later discharged from hospital. No fatalities were registered, however both trains were damaged.
The RSR then instituted a Board of Inquiry (BOI) to thoroughly investigate the incident and establish the root causes of the incident. The investigation commenced on 19 May and was concluded on 31 March 2012. The BOI findings reveal that:
Driver Behaviour- The driver of the train that collided with a stationery one is prone to substandard acts. He exceeded the speed limit and passed 2 danger point signals.
His risk profile indicates a prevalence of speeding incidents twice in 2009 and once in 2011. He was appointed in August 2003 and has had 7 disciplinary actions of which 6 were in the last 22 months, 3 of which were for speeding.


Compliance to Procedures- The driver of the stationery train did not report the failure of the train to the Train Control Officer (TCO) but opted to phoning another driver and technical control. The act of not reporting directly to the TCO when normal train operations are interrupted is a substandard act. Should the correct procedure have been followed, the TCO may have had the opportunity to inform the driver of the on-following train of the circumstances which may have averted the incident, thus preventing 857 commuters from getting injured and damage to rolling stock that costs millions of rands to repair.

The RSR has thus given the operator (Metrorail) a comprehensive BOI Report together with recommendations on how to improve their risk profile.