Collisions and derailment Voorschoten

Maintenance on intensively used rail network must and can be safer

When it comes to track maintenance, the Dutch State Secretary for Infrastructure and Water Management focuses too one-sidedly on track availability for passenger and freight transport. This is the wrong incentive.  Consequently, considerations such as safe working, reducing the dangers of night work and learning from accidents are not given sufficient attention. That is the conclusion of the Dutch Safety Board after extensive analysis of the train accident at Voorschoten station.

In the early hours of 4 April 2023, an excavator crossed an in-service track during scheduled maintenance work and was hit by a freight train and subsequently by a passenger train. In this accident, the excavator operator lost his life and some 30 people were injured, some of whom very seriously. The resulting damage to trains and further surroundings was extensive.  

The Safety Board has not been able to establish the direct cause of the collision. After investigation and analysis, the Safety Board concludes that the fact that maintenance took place while trains continued to run alongside the works and that workers had to cross tracks that were in service to get to their work location, played a role. In addition, the fact that workers were dependent on error-prone verbal communication for their information may have played a role.

Register in order to learn

Chris van Dam, chair of the Safety Board: ‘The Dutch rail network is one of the safest in the world. Nevertheless, things still go wrong or almost wrong on the railways and we must learn from that.  We recommend the industry to put more effort into registering and analysing incidents. This will allow the industry to learn collectively, as well as to innovate when it comes to safety.’

Reduce the risks of night work, also for the self-employed

Track maintenance is often carried out at night, as in the early hours of 4 April 2023.  Night work involves additional safety risks not yet sufficiently recognised by the rail industry. The Safety Board believes that ProRail should pay more attention to this, especially when awarding tenders to contractors, subcontractors and cooperating parties in the rail industry. Special attention should be paid to self-employed workers, who are frequently engaged in night-time work to complete rosters because they are not subject to the Dutch Working Hours Act. The Safety Board's investigation shows that they are being used excessively.

The accident in brief

In the early hours of 4 April 2023 at about 3.25, a freight train collided with a road-rail excavator (KROL). This excavator was being used during work on the track. The collision with the freight train resulted in the excavator ending up on the side track, where it was hit by a passenger train a short time later. The passenger train derailed and landed partially in an adjacent field. The excavator operator did not survive the collision. About 30 people in the trains were injured, 20 of whom were taken to hospital.

Recommendations

RECOMMENDATIONS

The Dutch Safety Board has identified structural deficiencies in the management of risks during works on the track. The Board sees opportunities for the parties involved to take joint measures to eliminate these deficiencies in order to contribute to a safe working environment, the safe travel of rail users and a safe living environment near the tracks.

To this end, the Board is making the following recommendations:
To the State Secretary for Infrastructure and Water Management

1. Ensure that in the commissioning of ProRail as infrastructure manager, values other than availability of the network and track integrity, such as safe working and the safe passing of trains at worksites, are embedded. In addition, remove the barriers for ProRail to develop and implement innovations in the industry with regard to safe working on the railways, on the one hand, and on the other, to create a facility for recording, analysing and sharing information on accidents and near misses (see recommendation 2).

To ProRail

2. Set up a facility where information on rail accidents and near misses is recorded and put to use. Require all rail stakeholders, including railway companies, to submit their incidents. Target in this facility the broad safety domain, i.e. including occupational safety and railway safety. Ensure that all relevant parties jointly learn from accidents and near misses and share lessons with each other.

3. Use the facility to be established (see recommendation 2) to improve safety based on risk analysis. Maintain control over the safety of works and rail traffic in all phases of maintenance work, from strategy and innovation to implementation. In particular use industry professionalism in addition to imposing rules to make situational trade-offs.

4. Promote the safety of railway workers. If you cannot take all tracks into possession, at least ensure the following:

a. a robust (physical) worksite shielding.
b. a work location that is safely accessible. Stop using island possessions and temporary crossing periods to worksites and road-rail access points.
c. a facility so that track workers can see on site whether or not tracks are in possession. To this end, introduce tools complementary to verbal communication.
d. record verbal safety communication to promote learning from accidents or near misses.

5. Reduce the negative health and safety consequences of night work and excessive working without increasing safety risks. Ensure that railAlert and maintenance contractors take measures to reduce the risks of night work. In doing so, ensure
that when working on the track, the working hours of self-employed workers as a minimum comply with the Working Hours Act.