Bad Aibling rail accident

On 9 February 2016, two Meridian-branded passenger trains were involved in a head-on collision at Bad Aibling in southeastern Germany. Of approximately 150 people on board the two trains, 12 people died and 85 others were injured, including 24 seriously.[1][2][3][4][5][6][8]

Bad Aibling rail accident
ET 355, the westbound train, photographed in 2014
Details
Date9 February 2016
06:47 CET (05:47 UTC)[1]
LocationBad Aibling, Bavaria
CountryGermany
LineDB Netze Mangfall Valley Railway
OperatorBayerische Oberlandbahn "Meridian"
Incident typeHead-on collision
CauseSignalman's error
Statistics
Trains2
Passengers±150[1]
Deaths12[2][3][4][5][6][7]
Injured85[1][3][4][5][8]
Damage200 m (650 ft) track[9]

Two months after the accident, investigators announced that it had been caused by the responsible Deutsche Bahn train dispatcher who gave incorrect orders to the two trains while distracted by a game he was playing on his mobile phone.[10] The dispatcher further compounded his error when, realizing it, he tried to send emergency codes to the trains but entered the wrong combination into his computer.

Accident
Location of the disaster
ET 325, the eastbound train, photographed in 2014

The collision occurred at 06:46:56 CET (05:46:56 UTC)[11]:22 on the single-track Mangfall Valley Railway (German: Mangfalltalbahn) on a curve between the stations of Kolbermoor and Bad Aibling-Kurpark close to the Bad Aibling sewage works in Bavaria.[1][12][13] As of 11 February 2016, a total of 11 people had died, including several railway employees. In total 85 people were injured; 24 injured seriously and 61 injured less seriously.[1][2][3][5][6][8][14][15][16][17] A twelfth victim died from his injuries two months after the accident.[18]

The two trains were Stadler FLIRT3 multiple-units, operated under the Meridian brand by the Bayerische Oberlandbahn (BOB), a subsidiary of Transdev Germany.[19][20] The eastbound train was a six-car unit with 333 seats (ET 325), scheduled to run from Munich to Rosenheim, while the westbound train was a three-car unit with 158 seats (ET 355), scheduled to run from Rosenheim to Holzkirchen.[21][22] There were more than 150 passengers on board the two trains,[23] considerably fewer than usual because of Carnival Holidays.[24] The trains were equipped with a total of three train event recorders.[20] The line and both trains were equipped with the Punktförmige Zugbeeinflussung (PZB) train protection system, which was designed to reinforce line-side signalling and prevent drivers from accidentally passing signals at danger.[25]

The eastbound and westbound trains were scheduled to pass each other at Kolbermoor railway station, with the westbound train (M 79506) towards the direction of Munich timetabled to wait for five minutes for the eastbound train from Munich (M 79505) to arrive.[26] The westbound train departed Kolbermoor on schedule but the eastbound train was four minutes behind schedule. One train was travelling at 52 kilometres per hour (32 mph) and the other at 87 kilometres per hour (54 mph).[11]:22[14]

Rescue operation
Bad Aibling rail accident
km
to Holzkirchen
level-crossing
27.8
 Bad Aibling
level-crossing
28.6
 Bad Aibling-Kurpark
level-crossing
sewage works
30.3
 Site of collision
Mangfall
river
│
Stuckenholz
forest
32.4
level-crossing
33.0
 Kolbermoor
to Rosenheim
One of the less-damaged carriages
Emergency engineering train ready for operation in Kolbermoor

The rescue operation involved a total of approximately 700 emergency service workers,[27] including 180 firefighters, 215 Bavarian State Police officers, 50 Federal Police officers, 30 federal civil protection employees of Technisches Hilfswerk, and 200 rescuers from the Bavarian Red Cross, including Water Rescue and Mountain Rescue units.[27] A total of 11 helicopters took part in the rescue efforts. Air ambulances from both Germany and Austria were used to transport the injured to hospitals.[28]

The site of the accident was difficult to reach because it lies between the Stuckenholz forest and the canalised Mangfall river (Mangfallkanal). This made rescue work considerably more difficult because rescue workers had to be transported by boat and casualty extraction supported by air ambulance.[29] Injured people were extracted by boat to the opposite bank of the river.[12]

Recovery operation

On 9 February 2016, two breakdown cranes belonging to the DB Netze Emergency Technical department (DB Netz Notfalltechnik) were dispatched from Fulda and Leipzig to assist in recovery and removal of the two damaged trains.[30] The crane from Fulda is capable of lifting 160 tonnes, and the second crane from Leipzig is capable of lifting 75 tonnes.[31]

Reaction

German Transport Minister Alexander Dobrindt visited the site of the accident. He said it was a "horrifying sight". Bavarian Interior Minister Joachim Herrmann said that it was "difficult to comprehend" how the accident happened.[14] Chancellor Angela Merkel said she was "dismayed and saddened" by the crash.[14] German Foreign Minister Frank-Walter Steinmeier stated: "My deepest sympathy goes to their families."[32] Minister-President of Bavaria Horst Seehofer said "The whole of Bavaria has been shaken".[33]

As a result of the accident, the carnival celebrations on Shrove Tuesday in Rosenheim, Bad Aibling and the surrounding area were cancelled.[34] The traditional political debates on Ash Wednesday in Lower Bavaria were called off.[35]

Investigations
Dispatch office of Bad Aibling railway station, which is also in operation as a signalling centre for the railway stations in Kolbermoor, Heufeld and Bad Aibling-Kurpark

The German Rail Accident Investigation Agency (Eisenbahn-Unfalluntersuchungsstelle des Bundes, EUB) opened investigation number 04/2016 into the accident.[36] The German police opened a separate investigation.[4] Police confirmed that nine of the eleven deaths had been identified as being local men from the districts of Rosenheim and Traunstein aged 24–59.[37] The cause of this accident was unclear.[38] By the evening of 9 February 2016, Federal Transport Minister Alexander Dobrindt reported that two of the trains' three train event recorders had been recovered. The third was still located in one of the wedged train carriages.[39] On 12 February it was announced that the third event recorder had been recovered. Police said that the recorder was damaged, but attempts would be made to extract the data. Data from the other two recorders had thus far provided no indication of human error on the part of the train crew.[40]

In a press conference on 16 February 2016, the local prosecutor (Staatsanwalt) identified "human error" as the cause of the crash. A train dispatcher at the signalling centre in Bad Aibling had given a wrong instruction.[41] German investigators said they found no evidence of mechanical failure or technical defects that would have caused the crash.[42] The dispatcher was also charged with gefährlicher Eingriff in den Bahnverkehr (dangerous interference with railroads),[43] which is punishable with up to ten years' imprisonment.[44]

Zs 1 subsidiary signal

Many German railway main signals are equipped with an additional subsidiary signal called "Zs 1" (shown as three white dots in a triangle shape). This subsidiary signal replaces a written order authorising a train driver to pass the signal while it is showing a stop aspect. The train dispatcher can activate it from the signal box. There are no safety controls in the signal box, other than special operating rules, for the dispatcher to activate a Zs 1 signal. When a Zs 1 subsidiary signal is shown to the train driver, he must press and hold the PZB button "Befehl" ("Order") in the cab while moving the train over an active 2000-Hz emergency stop inductor located at the main signal. A warning tone sounds in the cab to acknowledge to the driver that he is pressing the Written Order button. If in a station the Zs 1 signal is the last signal, after the complete train has passed the stop signal and any following points(at a speed not exceeding 40 km/h (25 mph)), the driver may continue with normal speed.[45] The Zs 1 subsidiary signal is supposed to be used only in circumstances when a route for a train cannot be set. There are sections in the rulebook on how and when it may be activated safely, but according to the local prosecutor, these rules were not adhered to.[46][47]

In April 2016 it was revealed that the dispatcher had been playing a game on his mobile phone at the time. After realising he had made an error, allowing both trains to proceed, he dialled an incorrect number when trying to issue an emergency call. No technical fault existed with either the trains or the signalling system.[48] With these new findings the prosecutors reversed their initial assumption of Augenblicksversagen (lapse of attention) turning it into a charge of Pflichtverletzung (breach of obligations), which carries a heavier penalty – as a result an arrest warrant was issued, and the train dispatcher was held in pre-trial detention from 12 April 2016.[49][50] The prosecutors brought the charges to the court in Traunstein in mid July 2016 with accusations on twelve accounts of fahrlässige Tötung (involuntary manslaughter, i.e. murder by negligence) and 89 accounts of fahrlässige Körperverletzung (involuntary battery, i.e. injury by negligence).[51] The main trial was scheduled for seven days between 10 November and 5 December 2016.[52] On the first day of trial the defendant confessed to the charges brought by the prosecutors, but his lawyer wanted the degree of guilt to be evaluated during the subsequent proceedings - although he showed a degree of compassion for the victims, the defendant refused to answer questions on the intensity of his preoccupation with the mobile game.[53][54][55]

The expert witness from the EUB investigation board had shown in court that the documentation for the interlocking section (Betriebsstellbuch) was outdated, slightly incorrect and did not contain directions for the emergency radio. Nevertheless, the actual interlocking setup was logical and fully functional in a way that an experienced train dispatcher could handle correctly. The defendant, however, had not followed general guidelines for problem handling - if he had double-checked the existing routes (Blockabschnittsprüfung) on the signal box panel, then he should have easily spotted the route set for the train from Kolbermoor that was automatically blocking the exit signal for Bad Aibling. Nor did he radio to the train driver to proceed slowly under the unusual circumstances.[56] The original error had occurred somewhat earlier, however: with one of the trains running late, he chose to move the train crossing from Kolbermoor to Bad Aibling by juggling some of the signals. With a delay of only four minutes, however, this action was not allowed.[56]

The court ruled on 5 December that he was guilty on all of the charges, and he was sentenced to three and a half years in prison.[57][58] The verdict is final as the lawyers of Michael P (40) renounced any appeal a week later.[59] In July 2018 he was released on probation after having served two-thirds of the prison sentence.[60] This had been already expected shortly after the conviction as it is in accordance with German law (§57 StGB).[61]

A preliminary report was published by the German investigation agency on 7 March 2017. The report stated that the infrastructure was fully functional, but that some documentation was slightly outdated (for example, an unused GSM-R radio infill station was listed). The reconstructed timeline showed that an emergency call was first initiated 35 seconds before the crash, but to the wrong emergency call group. The emergency code for track workers had been selected twice (code 569, "Trackside maintenance groups: High-priority call", "Notruf-Strecke", labelled "Not Str MWM-MRO") instead of the general GSM-R emergency number (code 299, "Train groups: Emergency call", "Zugfunknotruf", labelled "ZF-Not MWM-MRO").[11] The final investigation report was published on 29 October 2018.[62]

Timeline
The exit signal at Bad Aibling Kurpark. On the day of the accident three white dots below the red lamp allowed the train to pass it

The reconstructed timeline shows that the westbound train 79506 entered the section to Kolbermoor at 6:37. The first action in the following series of events occurred at 6:38 when the train dispatcher set the signals for the train allowing both entry to Kolbermoor station as well as allowing exit towards Bad Aibling. The westbound train reached the station at 6:40. The train was supposed to wait till 6:45 at the platform for the eastbound train to arrive.

The eastbound train 79505 arrives at Bad Aibling station at 6:42. Since the exit signal at Kolbermoor was set to passing, the signal box did block the single track section to Bad Aibling for this train. Nethertheless the train dispatcher tried to set the exit signal for the eastbound train from Bad Aibling towards Kolbermoor. He resolved the situation by assuming a technical error using the replacement signal "order" at 6:43 for the exit signal at the station and another replacement signal at the following station Bad Aibling Kurpark at 6:45. Now both trains were clear to enter the single-track section in opposite direction.

The eastbound train leaves Bad Aibling station at 6:43:38. The time was taken from the train recorder as the train passes over an active PZB inductor at the signal at danger. The westbound train 79506 at Kolbermoor waits for the regular departure time leaving the station at 06:45:02. The train recorder of the eastbound train 79505 showed a stop at 06:45:14 in Bad Aibling Kurpark quickly continuing on the single-track section. The signal at danger at Bad Aibling Kurpark was recorded at 06:45:46 (see picture).

Shortly later the train dispatcher recognized the situation with both trains showing up on the same track whereas the train drivers can not see each other due to a curve near the Bad Aibling sewage works. At 06:46:20 an emergency signal was radioed by the train dispatcher received by other workers but not the train drivers. Both train recorders show an emergency break at 06:46:55, only a second before the crash. At the emergency break the train travelled at 56 km/h and 92 km/h respectively. The last entries on the train recorders at 06:46:56 show a remaining speed of 52 km/h and 87 km/h. The energy supply for the overhead catenary was automatically shut down at 6:47:02 assumed from a short circuit.

Recommendations

The investigation report issued in 2017 recommended that the menu options on GSM-R terminals should be altered, so that after pressing the emergency button, only a single menu option would be available. This single menu item would combine the track maintaince emergency (code 569) and train emergency (code 299) functions.[11] The existence of two emergency functions comes from the general GSM-R standard to define only an emergency code for trains. In order to allow track workers to continue to warn a train dispatcher (about an obstacle they found) Deutsche Bahn did not try to alter the EU-wide harmonized standard but they asked for a second channel at the national regulator (Eisenbahnbundesamt) which was approved.[63] That way the previous non-digital handheld phones could be replaced by new ones step by step. As a result, track workers and train drivers do have only one emergency channel, it is just the train dispatcher to have two.

The final investigation report issued in 2018 added a few more recommendations. The investigators had asked the Technical University of Braunschweig to assess the psychological environment. The scientific report has been attached to the final report. The researchers noted that the official rule book contains no section how to do an initial analysis in case of operational interruptions (unlike Switzerland which had reorganized the rule book in the 1990s adding a chapter on „Kernprozess Störungen“) whereas the required steps are spread out over different sections relating to the railway functions. The training for train dispatchers should also include hints for correct behaviour in times of mental underload.[62]

See also

References
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  2. Polizei Oberbayern Süd (11 February 2016). "leider 11. Todesopfer zu beklagen - Mann erliegt in Klinik Verletzungen" [Regrettably 11 fatalities - man succumbed to injuries in hospital] (published at 17:23 CET). Twitter (in German). Archived from the original on 8 February 2018. Retrieved 11 February 2016.
  3. Polizei Oberbayern Süd (11 February 2016). "Schreckliches Zugunglück bei Bad Aibling; 11. Todesopfer im Krankenhaus verstorben; alle Toten identifiziert; 20 Schwerverletzte und 62 Leichtverletzte; schwierige Bergungsarbeiten am Unglücksort gehen heute weiter; 3. Blackbox noch nicht geborgen" [Terrible train accident in Bad Aibling; 11th fatality died in hospital; all the dead identified; 20 seriously injured and 62 slightly injured; difficult salvage operations at the accident continuing this day; third black box not yet recovered] (published at 13:17 CET, updated later) (Press release) (in German). Bayerische Polizei. Retrieved 11 February 2016. 10. Todesopfer identifiziert werden: es handelt sich um einen 38 Jahre alten Mann aus dem Landkreis Spree-Neiße (Brandenburg). Im Laufe des heutigen Donnerstag erlag ein 47 Jahre alter Mann, der aus dem Landkreis München stammt, seinen schweren Verletzungen, damit erhöht sich die Zahl der Todesopfer auf 11. Daneben sind jetzt noch 20 Schwerverletzte bekannt und 62 leichtverletzte Menschen.
  4. Polizei Oberbayern Süd (10 February 2017). "#BadAibling - 10 Todesopfer (keine Steigerung mehr zu erwarten), keine Person vermisst, kriminalpolizeiliche Ermittlungen laufen" [10 deaths (with no expected increase), no missing person, Police investigation underway] (published at 08:21 CET). Twitter (in German). Archived from the original on 10 February 2016. Retrieved 10 February 2016.
  5. Polizei Oberbayern Süd (9 February 2016). "Schreckliches Zugunglück bei Bad Aibling; bislang 10 Tote; 1 Mensch noch vermisst; 17 Schwerverletzte und 63 Leichtverletzte; bis zu 700 Helfer im Einsatz; Staatsanwaltschaft und Kripo ermitteln zur Ursache" [Terrible train accident in Bad Aibling; so far 10 dead; 1 person still missing; 17 seriously injured and 63 slightly injured; up to 700 helpers in use; prosecutors and detectives identify the cause] (published 17:05 CET) (Press release) (in German). Bayerische Polizei. Retrieved 9 February 2016. 63 Menschen, so der Stand jetzt, wurden dabei leicht verletzt. 17 Menschen wurden schwerverletzt, 9 Menschen konnten nur mehr tot geborgen werden, eine weitere Person verstarb im Laufe des Tages in einem Krankenhaus.
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  7. "Archived copy". Archived from the original on 16 April 2016. Retrieved 13 April 2016.CS1 maint: archived copy as title (link)
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  9. Polizei Oberbayern Süd (14 February 2016). "Zugunglück bei Bad Aibling; Zahl der Toten und Verletzten unverändert; Bergungsarbeiten der Züge nahezu abgeschlossen; Ermittlungen von Staatsanwaltschaft und Kripo laufen" [Train crash in Bad Aibling; Number of deaths and injuries unchanged; Salvage of trains almost complete; Investigations by public prosecutor and criminal police underway] (Press release) (in German). Retrieved 17 February 2016. Der Gleiskörper wurde in diesem Streckenabschnitt auf einer Länge von knapp 200 Meter stark beschädigt und ist daher nicht befahrbar.
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  13. "Mehrere Tote bei Zugunglück in Oberbayern" [Death toll rises in Upper Bavaria train accident]. Die Welt (in German). 9 February 2016. Retrieved 9 February 2016. zwei Meridian-Züge des Betreibers Transdev gegen 7 Uhr auf der eingleisigen Strecke kollidiert. Das Tempo auf der Strecke beträgt normalerweise rund 120 Stundenkilometer. Ein Zug sei nahe des Klärwerks bei Bad Aibling … Die Bahnstrecke zwischen Holzkirchen und Rosenheim (Mangfalltalbahn) ist auf unbestimmte Zeit gesperrt.
  14. "Germany train crash: Several killed in Bavarian town of Bad Aibling". BBC News Online. 9 February 2016. Archived from the original on 9 February 2016. Retrieved 9 February 2016. …drivers of both trains and two train guards were among those killed, regional broadcaster Bayerischer Rundfunk said, quoting police.
  15. "Germany train crash: Controller error theory dismissed". BBC News Online. Archived from the original on 11 February 2016. Retrieved 10 February 2016.
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  18. "Weiteres Opfer erliegt schweren Verletzungen". Spiegel. Retrieved 12 September 2018.
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  20. Harloff, Thomas; Scharnitzky, Ralf (9 February 2016). "So ist die Strecke technisch gesichert" [How technology protected the railway section]. Süddeutsche Zeitung (in German). Archived from the original on 10 February 2016. Retrieved 9 February 2016. Züge des Typs Stadler Flirt3 … Die beiden verunglückten Züge, deren Name eine Abkürzung für Flinker Leichter Innovativer Regional Triebzug ist, verfügen über insgesamt drei Black Boxes. (English: Stadler FLIRT3 Train ... The trains involved in the accident had, in total, three black boxes. The name is an acronym for Fast Light Innovative Regional Train.)
  21. Harloff, Thomas; Scharnitzky, Ralf (9 February 2016). "So ist die Strecke technisch gesichert" [How the track has been technically secured]. Süddeutsche Zeitung (in German). Archived from the original on 10 February 2016. Retrieved 9 February 2016. Die BOB setzt 28 sechsteilige Züge von jeweils 107 Metern Länge und mit 333 Sitzplätzen ein. Hinzu kommen sieben dreigliedrige, 59 Meter lange und mit 158 Sitzplätzen ausgerüstete Bahnen. (English: The BOB has 28 six-car trains. Each is 107 m long with 333 seats. After these came 7 three-car units, 59 m long with 158 seats.)
  22. "Elektrotriebwagen deutscher Privatbahnen" [EMUs German private railways]. Drehscheibe Online (in German). Archived from the original on 16 February 2016. Retrieved 9 February 2016. 94 80 1427 005-2 D-BOBy, Bayerische Oberlandbahn GmbH, ET 355, Stadler 39407-39409 Bj.2014, Abn: Velten 27.06.2014, 09.02.2016 Frontalzusammenstoß mit 1430 025 bei Bad Aibling … 94 80 1430 025-5 D-BOBy, Bayerische Oberlandbahn GmbH, ET 325, Stadler 39595-39600 (39601) / Bj.2013, Abn: 17.02.2014, 09.02.2016 Frontalzusammenstoß mit 1427 005 bei Bad Aibling
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  30. "Zugunglück: Bahn schickt spezielle Bergezüge aus Fulda und Leipzig" [DB dispatches special trains from Fulda and Leipzig]. Hit Radio FFH (in German). 9 February 2016. Archived from the original on 13 February 2016. Retrieved 10 February 2016. Die Deutsche Bahn hat zwei spezielle Kran-Züge aus Fulda und Leipzig zum Ort des Zugunglücks in Bad Aibling geschickt. Die 160-Tonnen-Maschinen sollen mithelfen, die zerstörten Waggons und Loks zu bergen.
  31. "Fuldaer Rettungszug nach Bahnkatastrophe im Einsatz". Hessischer Rundfunk (in German). 10 February 2016. Archived from the original on 12 February 2016. Retrieved 10 February 2016. in Fulda stationiertes Notfallteam der Deutschen Bahn ist am Mittwoch … Der Spezialkran ist Teil einer Rettungs-und Bergungseinheit der Deutschen Bahn, die in Fulda stationiert ist. … Der Notfallkran besitzt eine Tragkraft von 160 Tonnen. … Ein weiterer Notfallkran aus Leipzig mit einer Tragkraft von 75 Tonnen
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  37. Polizei Oberbayern Süd (11 February 2016). "Schreckliches Zugunglück bei Bad Aibling; 10 Tote geborgen; keine Vermissten mehr; Bergungsarbeiten der Züge haben begonnen; Ermittlungen von Staatsanwaltschaft und Kripo laufen" [Terrible train accident in Bad Aibling; 10 dead recovered; no more missing persons; Salvage of the trains has begun; Investigation by prosecutors and detectives underway] (published at 09:06 CET) (Press release) (in German). Bayerische Polizei. Retrieved 11 February 2016. Bei den 10 Getöteten handelt es sich um 9 Männer im Alter zwischen 24 und 59 Jahren. Alle stammen aus den Landkreisen Rosenheim und Traunstein. … Unter der Leitung der Staatsanwaltschaft Traunstein begannen am Morgen am Unglücksort die Bergungsarbeiten. … Danach kann möglicherweise die noch fehlende, dritte Blackbox gefunden werden.
  38. Bendixen, Oliver; Bohrer-Glas, Dagmar; Binder, Julia (9 February 2016). "Bahnunglück bei Bad Aibling Zahl der Toten steigt auf vier" [Railway disaster at Bad Aibling: Death toll rises to ten]. Bayerischer Rundfunk (in German). Archived from the original on 9 February 2016. Retrieved 9 February 2016. Beim Zusammenstoß zweier Meridian-Regionalzüge bei Bad Aibling im Landkreis Rosenheim sind mindestens vier Menschen ums Leben gekommen. Das gab die Polizei kurz vor 9.30 Uhr bekannt. Rund 150 Fahrgäste sind verletzt worden.
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  52. "Landgericht Traunstein Aktuell - Hinweise zum Zugunglück von Bad Aibling". Archived from the original on 9 October 2016. Retrieved 11 October 2016. Das Landgericht Traunstein hat mit Beschluss vom 22.9.2016 die Anklage der Staatsanwaltschaft Traunstein zur Hauptverhandlung zugelassen und das Hauptverfahren eröffnet. Es wurden folgende Termine zur Hauptverhandlung bestimmt: 10., 14., 21. und 28. November 2016 sowie 1., 2. und 5. Dezember 2016.
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  56. "Das ist ein eindeutiger Verstoß - das darf er nicht". BR24. 21 November 2016. Archived from the original on 22 November 2016.
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