GREECE: Rail and air accident investigation body EODASAAM exposes serious systemic failures in the Greek railway sector and makes 17 recommendations for improvement in its report into the head-on collision between passenger and freight trains near Tempi which killed 57 people on February 28 2023.
The 178-page report published on February 27 says that the immediate cause of the collision at Evangelismos on the Athens – Thessaloniki main line was that a station master did not use an automated method to set the route for passenger train IC-62 to leave Larissa station. This would have positioned all turnouts correctly. Instead, he ordered manual operation, and forgot to place a turnout in the correct position.
The report says these actions ‘need to be understood in the difficult operational context he was confronted with’, including a series of technical failures, a control panel that ‘can certainly lead to confusion’ and poor communication practices including an open radio channel which did not allow for direct uninterrupted safety-related communications. The rail industry’s competence management was also poor.
The Greek economic crises after 2009 resulted in poorly maintained and increasingly degraded infrastructure, as well as a shortage of staff which the network had not recovered from by the beginning of 2023. The report says infrastructure manager OSE did not carry out preventive maintenance of control, command and signalling assets, instead intervening only when they failed.
The equipment, working environment and overall organisational arrangements were ‘stretching the limits of the operational staff beyond what is humanly acceptable in a sustainable way’.
The lack of an independent national accident investigation body has impeded the Greek railway sector from learning from incidents, and internal investigations focused on errors made by individual frontline staff. Relevant issues had been identified by the EU Agency for Railways, but did not lead to the necessary improvement quickly enough.
EODASAAM was not operational at the time, and its investigation was launched more than a year after the accident by which time information had been lost.
The report notes that there was widespread criticism of the state’s handling of the investigation, raising concerns about the justice system’s impartiality and integrity. The accident led to some of the largest protests in Greek history, and ‘continues to stir public emotions’ with ‘massive demonstrations’ on January 26 this year and protests and strike planned for the second anniversary on February 28.
The report does not look at a signalling renewal contract, funding of investment projects or national and EU control of investment projects, as there were deemed less relevant to the short and medium term improvement of the railway system.
Recommendations
During the investigation, an urgent safety recommendation was made to address the risks associated with safety-related communications.
EODASAAM has now made 17 more recommendations. Several of these go beyond the remit and powers of individual organisations, and implementation will require the support of the Greek government to ensure the railway sector has the human, financial and organisational means to develop and maintain a safe railway system.
The report says OSE needs to better understand the risks related to the operational reality of the current railway system, and to improve the way it is controlling these risks, optimising asset performance and reliability throughout the life-cycle.
It needs to regularly assess the competence of staff performing safety related tasks, and develop a system for performance monitoring to become aware of any deterioration.
OSE needs to be able to learn lessons from incidents, implement structural improvements and maximise the availability of data which could assist incident analysis and support continuous monitoring.
Hellenic Train is recommended to strengthen its competence management systems and develop a system for monitoring the performance of train drivers.
National safety authority RAS should develop a system for the mandatory reporting of safety related occurrences. ‘Even more urgent’ is the need to strengthen its capacity for supervision of the safety performance.
The European Union Agency for Railways is recommended to take measures to support the quicker implementation of safety action plans.
The European Commission is recommended to implement a framework to enforce member states to satisfy EU requirements on safety policy, the functioning of National Safety Authorities and National Investigating Bodies and the system of national rules.
The Ministry for Climate Crisis & Civil Protection is recommended to work with the emergency services to develop detailed instructions for an Emergency Response and Crisis Management Plan with clear instructions for the co-ordination of emergency situations at the operational and at the strategic management level.
The cause of a large fireball at the accident site remains uncertain, but EODASAAM says it has ‘explicitly chosen’ not to postpone publication of its report, because ’the Greek railway system needs to know and accept the results of this accident investigation as soon as possible, in order to be able to start the necessary improvement process’.
