Train accident at LPG terminal

DESCRIPTION OF THE EVENT

The following analysis concerns a rail accident that occurred at one of Poland's LPG transshipment terminals. The incident, which occurred on the terminal's rail siding, involved the derailment of a rail tank car used to transport gas. No one from the side of the Terminal Owner/Manager of the siding was involved in the incident. However, on the part of the Railway Operator, a Setter acting as shunting manager was involved. The Rail Operator's task was to pick up 3 LPG vanity cars. The Railway Operator was in charge of the 6-car depot. The wagons were to be joined together and then taken away. The rail shunting manager on the part of the Carrier, upon entering the terminal area, was informed by the crossing guard about the alignment of the depot to which the wagons were to be connected, the rubber wedge protection used and the available infrastructure, as shown in the diagram below.

After receiving instructions from the crossing guard, the shunter began the procedure for setting up the wagon train. During the shunting procedure, the approaching locomotive with the wagon depot stepped between the two outermost wagons of the depot. Subsequently, the approaching depot hit the standing depot secured by rubber wedges, which caused the rubber wedge to impinge and derail the first of the cars.

INCIDENT ANALYSIS

The incident was reported to the State Commission for Investigation of Railway Accidents. The Terminal Owner/Manager of the siding appointed a commission (a legal requirement) to clarify the cause of the rail accident based on the collected material, which made it possible to formulate the following conclusions. The commission concluded that the immediate cause of the incident was that the wagon ran into a rubber wedge, the wheel climbed onto the rubber wedge, partially crushed the foot of the wedge, and moved the wagon off the rail with the wedge. The incident resulted in the derailment of a standing set of railroad tank cars.

The commission found that the primary cause resulting in the derailment of the wagon was the securing of the wagon with wedges without the use of the hand brake. Also not insignificant for the course of the incident was the improperly implemented procedure for the arrival of the wagon depot coordinated by the shunting manager. He did not correctly determine the distance between the depots, as he was standing in a place (between the wagons) from which it is not possible to make a realistic assessment of the distance. In addition, the shunting manager did not verify the method of securing the standing group of wagons (he did not remove the rubber wedge from under the wagon wheel), which is his duty before starting shunting work.
Particular attention should be paid to the entry of the shunting manager between two railcars before joining the trainsets; it posed a direct threat to life and health. Such behavior is incompatible with the current procedures for conducting rail shunting.

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CONCLUSIONS.

The incident described above did not contribute to further dangerous situations, no one was injured or harmed as a result. The Terminal Owner/Manager of the siding and the Railway Operator jointly took measures to clarify the causes of the incident and implement procedures to avoid similar mistakes in the future. We present the following conclusions in order to disseminate good practice, since the safety of the LPG industry is among the priorities of POGP's activities, and the system of experience exchange between participants in this sector is one of the pillars on which we jointly build this safety.
Based on the analysis of the described incident, the following conclusions were developed:

• The railroad operator removed the shunting supervisor from immediate operations and sent him to renewal training;
• Both parties to the incident, i.e. the Terminal Owner/Siding Manager as well as the Railway Operator, discussed the incident at periodic briefings for railroad personnel;
• The rail operator will issue an internal newsletter;
• The rail operator will send a letter to the president of UTK to take a position on the use of rubber wedges;
• The internal procedure of the rail siding of the Terminal Owner/Siding Manager facility has been amended to include rules for the use of rubber wedges;
• Terminal employees were informed of the incident, presenting them with the course of the incident and the findings of the committee investigating the train accident;
• Information about the incident was presented to the industry organization, the Polish LPG Organization, in order to raise awareness and prevent the occurrence of similar incidents in the future.