The Taiwan Transportation Safety Board (TTSB) released the final report of the Taiwan Railway Administration’s (TRA, now restructured as Taiwan Railway Corporation, Ltd.) Train No. 3121 collision with a foreign object between Chiayi Station and Shuishang Station on May 9, 2023.

At around 05:11 on May 9, 2023, the TRA’s southbound local train No. 3121 (occurrence train) collided with a small rail trolley near chainage marker board K299+756 on the mainline between Chiayi Station and Shuishang Station. The small rail trolley had been left on the track next to the scissor gate of the fourth construction area after a contractor of the Central Region Engineering Branch Office of the Railway Bureau had completed the construction work. The collision caused the main obstacle deflector of the train to break, damaged the equipment under the first and second carriages, and scattered the frame structure and two sets of wheels of the small rail trolley beside the tracks near Shuishang Station. There were no fatalities or injuries in this occurrence.

In accordance with the Transportation Occurrences Investigation Act, R.O.C., and the definition of major transportation occurrences specified therein, TTSB was the independent agency in charge of investigating the railway accident. The agencies (institutions) invited to participate in the investigation include Ministry of Transportation and Communications, Railway Bureau, TRA, CECI Engineering Consultants, Inc., Taiwan, Chan Chun Construction Co., Ltd., and Chun Chi Construction Co., Ltd.

The investigation report was published after review and approval by the 63rd Board Committee Meeting on May 20, 2024.

On the basis of comprehensive factual information and analyses, TTSB proposed the following 11 findings and 8 recommendations:

Findings
Findings Related to Probable Causes

1. On the day of the occurrence, the contractor was executing the C603 contract of the Central Region Engineering Branch Office of the Railway Bureau. After completing the foundation capping and mold removal of the power poles in the fourth construction area between Chiayi Station and Shuishang Station, the on-site engineer, the person in charge of the working site, and the construction supervisor failed to conduct a post-construction inspection. They left the construction site without confirming that all equipment had been removed, resulting in a small rail trolley being left on the track of the temporary east line at K299+756, near the scissor gate of the construction area. When TRA resumed operations, the occurrence train traveling southbound, collided with the small rail trolley left behind. The collision caused the main obstacle deflector of the train to break and damaged the equipment under the train carriages.

Findings Related to Risk

1. After the construction personnel finished their work and left, the contractor's quality control engineer did not inspect the fourth construction area. Meanwhile, the CECI supervisor used videos and photos provided by the contractor from another working site, assuming that the construction area had already been inspected. Therefore, the supervisor did not carry out an on-site inspection and failed to discover that the tracks in the construction area had not been cleared.
2. The contractor's daily pre-job briefing and hazard notifications failed to ensure the construction personnel's execution of post-construction inspection. The management mechanism for the replacement of the on-site person in charge is not perfect and failed to enable the temporarily-assigned person in charge to fully understand their duties and the importance of inspection, and to motivate the on-site personnel to carry out active inspection activities. This led to negligence on the part of the construction personnel, who failed to inspect the construction area after completing their work.
3. The contractor's safety training proved ineffective. The contractor's procedures for post-construction inspections did not meet the Railway Bureau's standards. Inspection staff were not made aware that foreign objects from the construction area could enter the tracks, and the construction personnel were therefore not adequately reminded and required to ensure that the tracks were clear. As a result, the contractor's safety inspection proved ineffective after the construction work was completed.
4. The Central Region Engineering Branch Office delegated the post-construction safety inspection to a supervisory unit and failed to verify that the on-site inspection matched the completed inspection form. The inspection form was completed by an employee of the Central Region Engineering Branch Office without ensuring that the supervisory unit conducted the inspection appropriately.
5. The contractor did not establish a mechanism to track the materials and equipment brought in and out of the construction area by staff, such as making an inventory of the items brought in and their amount before the construction and assigning staff to conduct an inventory count after the construction, to enable the security and construction personnel to effectively manage the number of items brought in and out of the construction area and provide a reference basis for checking the track clearances upon completion of the work.
6. TRA's on-the-job training for railway operating personnel proved ineffective and the annual driving simulator training was not conducted. As a result, TRA was not able to assess whether train drivers could operate trains correctly. In this case, this resulted in the train driver not stopping the train immediately and reporting to the authorities, but continuing to drive the train without adequate safety concepts.

Other Findings

1. The contractor failed to comply with occupational safety and health regulations and did not install auxiliary lighting at the entrances and exits of the construction area to improve the visibility of the working environment at night.
2. The Technical Standards and Regulations for Commuter Electric Multiple Units of the Ministry of Transportation and Communications and international norms have adopted the actual maximum operating speed of trains as the condition for calculating the structural strength of obstacle deflectors and specified the V-shaped design to improve the structural strength. The design conditions for the performance requirements of obstacle deflectors specified by TRA should be evaluated and referenced to mitigate the risk of obstacle deflectors breaking and rolling into bogies after colliding with foreign objects.
3. The construction personnel at the occurrence site have completed safety and health education for new employees and on-track safety and health education and training. The qualifications of all the construction personnel meet the requirements of the Railway Bureau. Their rest and activity were normal in the 72 hours prior to the occurrence. There is no evidence of medical, drug, or alcohol-related factors that may have affected the personnel's performance.
4. The power and braking systems of the occurrence train were checked and found to be in normal condition before departure. No fault codes were generated while the occurrence train traveled between Chiayi Station and Nanjing Station. The train driver operated the train in accordance with the speed limit of the route.

Safety Recommendations

To Railway Bureau, Ministry of Transportation and Communications

1. Regarding on-track construction safety management, fully implement and strengthen mechanisms for on-site management of construction area and post-construction safety inspection between the owner, supervisory unit, and contractor to ensure track clearances after construction work. Specific improvements shall include, at a minimum:
   (1) Strengthen safety education and training;
   (2) Supervise construction supervisory units and contractors to strengthen post-construction safety inspections and fully implement regulations on the work duties of safety inspectors;
   (3) Establish a management mechanism for the replacement of on-site responsible persons;
   (4) Establish a verification mechanism for personnel and equipment entering and leaving the construction area and incorporate it as an item to be confirmed in the application to release the track possession for operation after construction work is complete.

To Taiwan Railway Corporation, Ltd.

1. Strengthen the education and training of railway operating personnel, carry out driving simulator training, and include possible abnormal operations, such as the presence of foreign objects on tracks, in the training to ensure that train drivers can handle and notify the authorities about such situations properly and in accordance with the relevant rules and regulations.
2. Refer to the Technical Standards and Regulations for Commuter Electric Multiple Units of the Ministry of Transportation and Communications and international norms to improve the capabilities of the obstacle deflectors of electric multiple units to resist impacts of collisions and sweep away foreign objects on the tracks.

To CECI Engineering Consultants, Inc., Taiwan

1. Supervise that on-site responsible persons and quality control personnel of contractors fully implement post-construction inspections, respectively.
2. Fully implement the supervisory duties associated with post-construction safety inspections.

To Chan Chun Construction Co., Ltd.

1. Carry out on-site post-construction inspections of construction areas, establish on-site responsible person replacement management mechanism, and set up verification for personnel and equipment to avoid the risk of leaving equipment and materials on the tracks.
2. Implement complete post-construction inspections by quality control personnel.
3. Review and improve lighting at the entrances and exits of construction sites to enhance the visibility of the working at night.

The final report in Chinese is available for download at the website https://www.ttsb.gov.tw

Vivi Yang, Director
Secretariat Office
Tel: +886-2-7727-6217
E-mail: viviy2314@ttsb.gov.tw

Yen-Hang Lin, Deputy Investigator
Railway Occurrence Investigation Division
Tel: +886-2-7727-6256
E-mail: henrylin@ttsb.gov.tw