On October 21, 2018, Taiwan Railways Administration (TRA) eastbound Puyuma Express train, No. 6432 (The accident train) departed at 1450 from the Shulin Train Station (樹林站) in New Taipei City and bounded for the Taitung Train Station (臺東站) in Taitung County. At 1539, the accident train began to experience powering system abnormality, parking brake system automatic activation, and resulted in a train stop. At 1617, the accident train driver isolated the Automatic Train Protection (ATP) without announcing and kept the operation on. At 1649, was recorded train speed 140 km/h in the Train Control and Monitor System (TCMS), all cars of the accident train were derailed at mileage K89+251 with 4 cars overturned before approaching the Sinma Train Station (新馬站) in Yilan County’s Suao Township. There were 370 people on board the train (including the crews), 18 were fatally injured, 17 were serious injured, 274 were injured and 61 were not injured in this accident.

The Legislative Yuan passed the Organization Act of the Taiwan Transportation Safety Board and the Transportation Occurrence Investigation Act on April 2, 2018, however, a subsidiary resolution that calling for the establishment of the Taiwan Transportation Safety Board (TTSB) and ask the TTSB to review the Puyuma investigation report submitted by the Executive Yuan on December 21, 2018. For clarifying the problems and the root causes of the Puyuma occurrence, on August 1, 2019, the TTSB started to operate. On September 6, 2019, the TTSB committee meeting concluded that it was recommended to proceed the necessary reinforcements for the investigation report of the 6432 Accident (published on December 21, 2018 by the Executive Yuan), in accordance with the article 3 and article 6 of the Transportation Occurrence Investigation Act.

Immediately after the establishment of the TTSB, it recruited investigators from the railway divisions, and conducted professional training and active investigations. In accordance with the Act, seven organizations, including the Railway Bureau, Taiwan Railways Administration, Taiwan Railway Union, the Nippon Sharyo, LTD., the Nabtesco Corporation, the Toshiba Electronic Components Taiwan Corporation, and the Bombardier Transportation Taiwan Limited, were invited to organize the investigation team, which was divided into four professional subgroups, namely, operation & engineering, electro-mechanics, data recorders, and organization management.

On October 24, 2019, after acquiring the exhibits from the Taiwan Yilan District Court, the investigation team began to review all the exhibits, analyzed the data recorders, interviewed the personnel, re-examine the wreckage of the accident train and conducted reinforcement survey on rolling stock maintenance, track and signal.

The TTSB also conducted seven tests and researches, including driver fatigue risk index, main air compressor performance degradation, overturning speed and overturning point, simulated train overturning, verification of main reservoir pressure and train performance, speed accuracy, and TCMS human-machine interface, etc. In addition, the investigation team also investigated a number of organizational management issues of the Taiwan Railways Administration.

It took more than six months to complete the draft factual report and a confirmation meeting was held on March 23, 2020. The draft report was reviewed firstly by the Railway Professional Working Group on March 31, and then approved by the Board Meeting later, the TTSB released the factual report on April 21 according to the Transportation Occurrence Investigation Act.

The investigation team plans to complete the draft final report in August 2020 and submit it to the Board for deliberation. The TTSB will release the final report (including factual data, analysis, findings and recommendations) after the Board’s review and approval. It is expected to prevent recurrence of similar occurrences via analyzing the risk control mechanism and organizational safety issues thoroughly.

Sherry Liu, Safety Investigator
Tel: 89127388-6286
Email:sherry@ttsb.gov.tw
Website: https://www.ttsb.gov.tw