Yesterday afternoon 18 when, director to call that night we write an analysis of Huaihua power supply section of the material, to the security supervisor group led by the Secretary Secretary, arranged into speech for leadership use. I am the car service professionals, only took part in the investigation of the accident, only looking at the direct cause of the accident, do not have the time and conditions to check the management aspects of the situation, only crustily skin of head wrote the following words:

 

Analysis of the "5.26" F power rail car against the signal C accident

 

   Nineteen forty-two on May 26, 2010, anxious willow line X station happened because of Huaihua power supply section rail car drivers did not confirm the departure signal, interrupt lookout, the station attendant to cancel the departure route case, take out of the station signal, squeeze bad No. 1 turnout, and has entered the interval of the railway traffic accident general class C10. Column F power supply section full responsibility.

   One, the cause of the accident

   1 rail car driver didn't confirm the outbound signal is open and departure signal, a serious violation of "technical regulation" 288th third "train at the start the relevant personnel should be: the driver must confirm the occupancy interval driving certificate and the departure signal or departure indicator display correctly, can be specified starting train", speculation drive.

   Vice driver 2 rail cars into the specified Xuegang serious violations of "railcar management rules" in article thirty-sixth, driving without a license.

   3 rail car driver seriously violates the monitoring device usage, train in a degraded state power, andAlarm monitoring device, the use of the wrong "drive" button, resulting in monitoring devices in the home signal shows a red light without control, leading to train against the signal.

   4 rail car driver and assistant driver violates the "rail car attendant a standard", operation not seriously implement the calling system.

   Two, the lesson from the accident

   1 safety management is not in place, the inertia of accidents occur

   One is the safe production education does not reach the designated position, rail car driver of risk factors is not clear.

Vehicle inertia accident related departure operation are: 1,Leakage rate limiting scheduling command or wireless train dispatching telephone to convey speed command;2Listen to the report, error or error to repeat; 3Approach is not ready, start.

   Such as: in April 13, 1998, the original F railway company train dispatcher wrong will be H station attendant to a train operation plan ("ask what time can open?") As D station attendant on the interval after construction report (think station report "works done"), blind to interval opened scheduling command, advance construction blocking the construction plans to open 7 minutes to interval lies in the actual blockade Construction issued a freight train, the honour of being the site trainer can display the stop signal, to avoid car accident caused injuries.

   Station attendant in the following cases, easy to forget to prepare for departure route or error for the departure route: 1,Due to fill in the railway tickets, forget to prepare for departure route;2Due to the blockade, fill in the open interval for walking train dispatching command, forget to prepare for departure route; 3Fill in the opposite direction, because the train dispatching command, forget to prepare for departure route or error for the departure route.

   Such as:

   In March 30, 1991, Ji'nan Branch Bureau of Qingdao Kang Jia Zhuang station to the GaoMi Railway Station downlink line block construction, change the single lane, 2738 trains on the Kang Jia Zhuang station after, with 283 passenger trains in 4 road parking submit dispatching command, and then right before row approach and the circumstances blind departure, which approach is not ready a train accident insurance ("railway traffic accident cases" page thirty-ninth)

   In March 25, 2001, the J station to the blockade on open interval by train, forget about the departure route (replaced by single lane, not row approach), which supplies power to the F section of rail car driver delivery scheduling command and departure.

   Two rail car driver blindly fast, easy to overlook the confirmation of the outbound signal.

   Such as:

   Nine four on April 21, 2001, F Zhi River power supply section of net work area maintenance vehicle (Department of propulsion operation) in station attendant error for the departure route cases, wrong will be adjacent line outbound signal as the line out of the station signal, drive by departure notice the cold Shop Station staff (who was not identified station departure station signal is open, blind inform maintenance car driver to drive, later said he did not start). Nine seven, maintenance of vehicles running to the station signal 20 meters, the driver found 3 outbound signals are red, quickly take emergency measures, but it was too late, squeeze bad No. 13 turnout, car two car derailment. At that time, the driverClosed locomotive signal and monitor. F power supply section of the main responsibility, important responsibility in Huaihua train operation depot.

   10 pm the same day, F power supply section led by car en route from F rushed to the scene of the accident, the driver of the car in order to avoid a opposite direction to turn the three wheeled motorcycle, a touch on the brakes too hard, and fast speed, slippery when wet, losing control of the vehicle, hit the side of the road into the side of the road culvert pole after the ditch, causing the car 2 people wounded, vehicle damage, a direct economic loss of 7 yuan, a road traffic liability accident.

    Three rail car driver and co driver to confirm the departure signal, and calling system does not perform, accustomed to the departure signal. As the station start personnel to control machine.

   Such as: according to the F Office of safety supervision office provides information

In 1996 some month some day, take the train to the closed interval scheduling command signal, F power supply section in the G station, immediately notify the maintenance vehicle, was the presence of F Train Operation Depot long after stop.

   Nine thirty-seven on June 20, 2001, F the railway rail car driver station staff at G did not show the start signal, only to confirm the outbound signal has been opened, to train.

   2 key points of safety production management is not in place. For a long time, rail car driver only outbound signal and the station attendant open signal between after and rail car driver of the vehicle integrated control language driving situation has not the relevant departments and units to get attention, which endanger the safety in production hidden dangers exist for a long time.

   Three, suggestions

   1 rail car units used to deeply absorb the lessons from the accident, infer other things from one fact, find the existing rail car train and shunting of the hidden trouble, to be timely rectification, to prevent similar incidents from happening again.

   One is to respect the scientific management of production safety knowledge, a correct understanding of the cause of the accident

   When the accident occurred, often when in "is entirely due to small error......" The cause of the accident, there is no "serious mistake", all errors are "small". So, can not ignore the hidden people don't follow at least work program weaknesses.

   People's behavior is a regularity. If we take into account the accident occurred around people, we can know the accident also regularly. If the master the principle of regularity or behavior, may reduce the accident, may even destroy the accident.

   Not equipment caused the accident, in spite of the risk factors is the problem. Because the signal equipment fault backward security, equipment is made up of people management (using, management of the locomotive safety device).

   Business leadership, management and supervision of personnel, responsible for the safety of people holding "accident must be eliminated" this belief is the biggest secret eliminate accident. Establish confidence, to win.

   Two is to fully realize the rail car drivers did not confirm the departure signal (not to accept the scheduling command) and very serious consequences may result in automatic car.

   In July 1, 2002 16, Liuzhou Bureau on board the station to station interval tail bud block construction, in the train dispatcher not issued into the closed section command, not to the number of cases, two rail cars (one for the Catenary Inspection Vehicle) into both ends of the station closed interval, to K373+933m positive conflict, cause casualties.

   2 rail car unit to strengthen the safety education to the rail car driver, and pay special attention to adopt the method that the accident case education, strive to improve the rail car driver risk prediction ability. For example:

   (1) the connotation to correctly understand the signal to start with. This "signal" refers to the two signal: driving certificate (outbound signal has been open, Lu ticket or to blockade on open interval with train dispatching command has been received) start signal and the station start staff issued.

   (2) to strictly departure operation and calling system, prevent MIS recognized station signal. And running way also to do the outbound signal the display state of uninterrupted lookout.

   (3) to repeat the phrase strictly distinguish the signal of the station opening HERSHEY'S vehicle integrated control language and used the radio to the start of term, strictly with provisions repeat outbound signal open and departure notice, put an end to the illegal behavior of the machine station signal only by opening HERSHEY'S joint control term start.

   (4) by road or by scheduling command ticket drive to enter the closed section, should strictly control the running speed, to confirm the departure route on the switch opened position, found the switch opened position or driving the wrong way on double track sections, should immediately stop and take safety measures.

   3 rail car units used to strictly control the rail car driver standardization work, should strengthen the analysis of the recording pen by using a recording pen and, discover existing rail car driver homework problems, to the illegal operations to timely treatment.

   4 rail cars use units to strictly control "repair work" management of rail cars, machines, and resolutely put an end to illegal operation behavior, ensure its safety control function.

   5 rail cars use unit pay more attention to the management of radio train dispatching equipment "effective", and create good conditions for safe production.

 

   Postscript:

   About 23, I completed the material to write and submit to the other a deputy director supply professional, finally finishing the work done by him.

   I asked him, will be brought before the analysis of incidents occurred?

   He answered: No.

   I think, if not combined with previous issues to analyze, how can the occurrence of management problems? How to find out the rule of occurrence?

   Back home, found a mobile phone text messages, is a director at twenty seventeen to distribute to: "advice from leading security sensitive, professional departments workshop daily management, site operations at control, regulations and work style of cadres and other aspects."

   Look, my article is most unacceptable.

   However, I still will this analysis I write to the F power supply section leadership, hope he paid attention to my questions.