MAIB: Metro Accident Investigation Buro

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iamhankhamTS
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Re: MAIB: Metro Accident Investigation Buro

Post by iamhankhamTS »

perfecttrains1000 wrote: 15 Sep 2019, 15:02
Michiel wrote: 15 Sep 2019, 12:05 I think this accident requires no further explanation.
:lol: Who is going to pay for this Delaying Nightmare :roll:
TfL! :lol: :lol: :lol:
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perfecttrains1000
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Re: MAIB: Metro Accident Investigation Buro

Post by perfecttrains1000 »

iamhankhamTS wrote: 15 Sep 2019, 15:40
perfecttrains1000 wrote: 15 Sep 2019, 15:02 :lol: Who is going to pay for this Delaying Nightmare :roll:
TfL! :lol: :lol: :lol:
:lol: :lol: :lol: thats true
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perfecttrains1000
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Re: MAIB: Metro Accident Investigation Buro

Post by perfecttrains1000 »

Incoming Report

Train 2112TA was Doing its normal service to Araplein when sitting at Varenweg for 10 minutes at a Red when suddenly another train appears in front, the driver slams his horn to get the other driver's (1221AT) Attention. Luckily the driver heard and stopped in-time for no injuries to happen.
Annotation 2019-09-15 193700.jpg
Annotation 2019-09-15 193700.jpg (228.39 KiB) Viewed 4033 times
Annotation 2019-09-15 193643.jpg
Annotation 2019-09-15 193643.jpg (224.25 KiB) Viewed 4033 times
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iamhankhamTS
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Re: MAIB: Metro Accident Investigation Buro

Post by iamhankhamTS »

perfecttrains1000 wrote: 15 Sep 2019, 18:42 Incoming Report

Train 2112TA was Doing its normal service to Araplein when sitting at Varenweg for 10 minutes at a Red when suddenly another train appears in front, the driver slams his horn to get the other driver's (1221AT) Attention. Luckily the driver heard and stopped in-time for no injuries to happen.

Annotation 2019-09-15 193700.jpg

Annotation 2019-09-15 193643.jpg
I will be writing a report soon
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perfecttrains1000
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Re: MAIB: Metro Accident Investigation Buro

Post by perfecttrains1000 »

iamhankhamTS wrote: 15 Sep 2019, 19:26
perfecttrains1000 wrote: 15 Sep 2019, 18:42 Incoming Report

Train 2112TA was Doing its normal service to Araplein when sitting at Varenweg for 10 minutes at a Red when suddenly another train appears in front, the driver slams his horn to get the other driver's (1221AT) Attention. Luckily the driver heard and stopped in-time for no injuries to happen.

Annotation 2019-09-15 193700.jpg

Annotation 2019-09-15 193643.jpg
I will be writing a report soon
ok
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Sgt_DeBones
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Re: MAIB: Metro Accident Investigation Buro

Post by Sgt_DeBones »

perfecttrains1000 wrote: 15 Sep 2019, 18:42 Incoming Report

Train 2112TA was Doing its normal service to Araplein when sitting at Varenweg for 10 minutes at a Red when suddenly another train appears in front, the driver slams his horn to get the other driver's (1221AT) Attention. Luckily the driver heard and stopped in-time for no injuries to happen.
I can tell you for a fact that it's clearly a driver error as they may have turned off their ATP, which is against regulations of operating any metropolitan rail vehicle. Relieve that driver (122) from his duties at once!
WW3 is at our doorstep. Gear up just in case. PROTECT THE METROS!
HexxOP
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Re: MAIB: Metro Accident Investigation Buro

Post by HexxOP »

Hey, just some ideas to push a bit your concept :
(And a little disclaimer, I talk from all reports I ever had in my hands, obviously the content and the way of writing it vary depending on the country, the report's origin (company intern work / national institution / justice ...), the target (is the document is supposed to be published publicly or not, is the writer supposed to make recommendations or not, ...), etc ...)

As you talk of 'MAIB', I'll go for national institution / public report.

First, on a report like this we use to just describe the main facts on the first summary, making interpretations along the document.
If I take your first example :
(By the way, I dont get how a ####MP get to Burcht, but anyway)
At 13:45 on 15th September, a MVG Type A on empty service 5413MP rear-ended an 81-717 on passenger service 2454TA at Burcht.
The ATB was isolated on 5413.
Here you can add the year, the approximate speed at the moment of the contact, if there is any injured passenger and/or personnel, and a lot of details that may help to determine factors that went to the accident, was the train late etc ...
You can also add the actions after the accident, like, how went the evacuation (time to get all passengers out, emergency services response time, ...), line exploitation (like M4 limited to Noorderpoort - Airport section, M5 extended to Centraal Station, Burcht skipped on M6 until ##h##), infrastructure damages and time before normal service resume (## meters of tracks to change, 2 trains out of order, normal service resuming next day at service beginning), etc ...

After this introduction, the facts as told by main actors, even if it in contradiction with technical things we'll discover afterward (obviously, the driver, maybe a passenger on the platform at the moment of the accident if it is relevant), you also can put here results of drug and alcohol tests on the driver (on technical reports the objectives is not to give a direct responsible but to point out what lead to the accident, so if a driver committed a fault, the thing you need to search for is the origin of the fault.
(again if I take the same example, here a driver took a wrong train, so the aspects that must be investigated are : is the driver manually isolated automatic ATB brake ? If yes, how did he thought of it, how it is presented during formations ...), if no, who isolated it without prohibiting the train to depart, and why ? Those are the aspects that are looked for in a report, the objective is to make it unable to happen again, so very often, it goes on formation stuff, management errors etc ... very often, reports are more intellectual things than pure technical aspects of a junction or a brake default. (I let away the fact that using a train on ATB without it showing any other speed than 10 Absolut is really strange but that's more a scenario thing)).

Then, adding and if relevant comparing it to the the facts told just before.
As you know, today on (almost) every train, there is a lot of things that are recorded, speed, signals as detected by train, driving command, positions of doors, electric supply, photographs positions, 3rd rails shoes positions, brake pressure etc ...
If you're motivated enough, you can even reproduce graphics like these.
Interpretation of those : when does the drivers applied emergency brake, were he asleep etc ...

You can add as many technical document as needed to point out things that led to the incident, and as said just before, sometimes we see more management and rules documents than technical things.

The summary again, but with all discoveries that led to the accident, the driver misunderstood this command, or the driver were asleep, and this technical thing were off because of etc ...

Eventually, all recommendation that can avoid this type of accident, like :
1) To Rijndam Electrical Transport company - Remind and explicit to all drivers disposition n°##-#### of driving manual : "ATB must be on blablabla ..."
2) To Rijndam Electrical Transport company - Insure that all trains unable to roll out of the depot in security are flagged and unassigned to any shift.
3) To Transport Ministry - Study the possibility to add a two step authorization to override ATB automatic brake similar to the one existing on some automatic train to be driven manually.

And the last thing which is the most important from my point of view, sanctions and judgments on personal responsibilities are not supposed to be in a report like this, if the incident is 'classic', passing a red signal etc ..., it is held by the company, if this is heavier, it is the justice work to pronounce sanctions (a whole world of difference in the way of processing facts, with defense, explanations from multiple parties etc .), technical reports are oriented to give keys to avoid a similar incident in the future, not giving sanctions.


Anyway, feel free to just not taking care of this whole message if I went too far in the realism ;)
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brozma
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Re: MAIB: Metro Accident Investigation Buro

Post by brozma »

I've got another incident today! Not an accident though, but it could be an accident, if I didn't react in time.
Today (16th of September 2019) at 14:15 (2:15 PM) in Rijndam, I was on duty with my TROLLey (My Toronto CLRV private tram) on line T1 between Garenmarkt and Centraal station. When I was returning from Garenmarkt loop to the platform on track heading to the Centraal station I noticed single citadis tram approaching from Steenstraat heading there from Denia on line T3. At first I didn't pay attention to it, because I thought, it would stop on red light near intersection and let me through (The CVL route for me was already set). But the tram didn't stop, passed the red light and went through the intersection. I immediatelly hit emergency brake, rang the bell like crazy and luckilly I managed to stop, before I hit the citadis tram. The tram went onto the platform on the track heading to the centraal station. The tram stopped, opened door and hazard lights went off. The driver was proabably confused, why did he/she went here and not on dead end track and tried to find it out.
I went to check on the citadis' driver and recognized him as Citadis (user). I asked him if he's blind or something, because he passed a red light and almost hit me. He was confused and didn't look very well, after few seconds he shook his head and asked me what happened. I repeated myself and asked him, if he's okay. He told me, that he didn't slept well last night and he had to suffered from microsleep. I asked him if he didn't tampered with ATB, because ATB is meant for these cases. He told me, he enabled ATB bypass so he could go faster than 35 km/h on the section between Steenstraat and Garenmarkt, because he got delayed for some reason and wanted to catch up the delay. I ordered him to stay where he was, wait and try to stay awake and went back to my tram report incident to Rijndam CVL HQ.

This time I was equiped with my phone when I went to check Citadis and I managed to record our conversation.
Here the transcription of it. Although it was difficult to decipher Citadis' speech, because he was tired and spoke with french accent.
Note. Formatting of text means this:
Text is bold: If written in capitals, person was screaming or talking loudly. If the text isn't written in capitals, the person was talking in serious tone.
Text is underlined: The person was whispering or talking quietly.
Also all expletives are censored for them being inappropriate in here.

Me: *Runs into Citadis' cabin* DUDE ARE YOU[expletive censored]BLIND?! DIDN'T YOU SEE THAT RED LIGHT ON YOUR TRACK?! YOU ALMOST HIT ME IF I DIDN'T STOP!!
Citadis: *Slurred incomprehensible speech. Proabably in french. Notices me and shakes head* Oh hi Brozma. What happened?
Me: You passed the red light and went in my way. Are you okay? You didn't look good.
Citadis: Listen. I've slept badly last night and last thing I remeber is that I went from Steenstraat and stoped here on incorrect platform. I opened the door and tried to went out to find out, what's wrong and I passed out.
Me: You proabably suffered from microsleep. Why are you driving the tram like this? You could cause an accident!
Citadis: I can't get a day off. I have so many absent hours, that I have to catch them up, or I'll be in trouble.
Me: You're in huge [expletive censored] now. Anyway did you do something to ATB? ATB is meant for this thing.
Citadis: Yes I enabled ATB bypass.
Me: WHAT?! Why did you do that?!
Citadis: I've got delayed and I wanted to catch up the delay by going faster than 35 km/h in section between Steenstraat and Garenmarkt.
Me: Is he kidding me?! Well, that was the stupidest way to catch up the delay, you know?
Citadis: I had no choice I had to do it.
Me: Doesn't matter now. Look stay here with this tram. Drop panto down and don't fall asleep. I have to report this one to CVL.
Citadis: No. Please don't!
Me: I'm sorry. I have to do it.
Citadis: *grunts in frustration and says french expletive*
Me: Watch your profanity! Even when I can't speak french, I know this one!

End of the transcription.

Some details about my duty:
The tram I used, was a private Toronto CLRV tram with bort number 4122, owned by me. More info about my tram can be found here.
My CVL code for this duty was 2261HC and I was heading to the Centraal station.

Here are some pictures I made
The positions of trams during Garenmarkt incident.
The positions of trams during Garenmarkt incident.
Garenmarkt near miss 1.jpg (350.33 KiB) Viewed 3908 times
The citadis tram, which went in my way-
The citadis tram, which went in my way-
Garenmarkt near miss 2.jpg (372.36 KiB) Viewed 3908 times
@iamhankhamTS: It's up to you to find out what went wrong and post report here plz.
If you want to make a very fast ride, just disable ATB/ZUB, put trottle to 1.00 and enjoy.
In my Avatar is a Logo of a Prague metro.
Sorry for my bad English. I am Czech and i am learning English
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iamhankhamTS
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Re: MAIB: Metro Accident Investigation Buro

Post by iamhankhamTS »

perfecttrains1000 wrote: 15 Sep 2019, 18:42 Incoming Report

Train 2112TA
Metro Accident Investigation Bureau
Report 2: 1221AT Near Miss


At 14:12, service 2112TA reported an oncoming train into the path of his train at Vistmarkt. The horn of service 2112TA was operated in an attempt to get the attention of the driver on train 1221AT. His actions were successful. Train 1221AT had been running 4L out of Araplien and 5L out of Springstraat due to problems with the crossing. Further more, the driver went past the signal at the junction beyond Sprinstraat Opstel at green. This aspect should not have been shown but due to errors with the ZUB loops, the signal showed the wrong aspect. The driver had taken note and had his train slowed down as he knew 2112TA was expect.

The drivers have been praised in their swift actions and for preventing collision. They await their medallion of heroism from Michiel at the next Simvliet Convention which should occur at the opening of Lightrail. Meanwhile, the citybound track between Araplien Junction and Springstraat via the citybound platform will be closed and trains will use the Araplien bound platform. A reduced service, therefore, will have to operate with half of the services terminating at Stadionweg.
Type: Near Miss
Cause: Signalling Fault
Resolution: Temporary Line Closure and investigation into worker’s log.
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perfecttrains1000
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Re: MAIB: Metro Accident Investigation Buro

Post by perfecttrains1000 »

Nice, also you can use my pictures in any of my Incidents i do
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