The Suijia Line freight train collided with the operator and killed 6 officials to release the investigation and handling of the accident

On July 31, the State Railway Administration issued an announcement on the investigation and handling of the major railway traffic accident of the collision between the 42109 freight train and the operator of the "6·4" Suijia Line, and the following is the full text:

At 1:54 on June 4, 2024, the 42109 freight train ran to Tangyuan Station of Suijia Line 330 kilometers and 599 meters in Jiamusi City, Heilongjiang Province, and collided with personnel who were finishing the line, causing 6 deaths and constituting a major railway traffic accident.

After the accident, the leading comrades of the State Council attached great importance to it, and Vice Premier He Lifeng and Vice Premier Zhang Guoqing respectively issued instructions, demanding that the accident be seriously investigated, seriously held accountable, conscientiously learn the lessons of the accident, strengthen safety education and prevention work, and prevent the occurrence of similar accidents. Li Xiaopeng, Minister of Transport, Fei Dongbin, Director of the State Railway Administration, Xu Qin, Secretary of the Heilongjiang Provincial Party Committee, and Liang Huiling, Governor of Heilongjiang Province, respectively gave instructions, and the Ministry of Emergency Management and the State Railway Administration sent personnel to the scene to guide emergency rescue and accident investigation and handling.

In accordance with relevant laws and regulations, the Shenyang Railway Supervision and Administration Bureau organized the establishment of an accident investigation team, which found out the process, causes, emergency response, casualties, direct economic losses and the situation of relevant units, determined the nature and responsibility of the accident, and put forward suggestions for accident rectification and preventive measures.

The relevant situation is hereby announced as follows:

First, the basic situation of the accident

1. Overview of the accident

At 1:25 on June 4, 2024, Wen Moumou, the foreman of the first workshop of mechanized cleaning and screening of Harbin Public Works Machinery Section, and Xue, the squad leader, organized 3 safety guards (labor personnel) and 14 operators (labor personnel) to arrive at the shoulder of the 700-meter closed network in the 330-kilometer Suijia upward line in Tangyuan Station to wait for construction work; At 1:45, after receiving the notice of the construction blockade order, the operation location was mistakenly identified, and 19 members of the operation team crossed the upward line and carried out line sorting operations on the unblocked downward line.

At 1:54:28, the 42109 freight train from the south fork to Jiamusi Station passed through the I. road of Tangyuan Station at a speed of 75 km/h. At 1:54:31, the train collided with people operating at a distance of 330 kilometers and 599 meters during braking, killing six people.

2. The situation of the relevant units

Harbin Public Works Machinery Depot is subordinate to China Railway Harbin Bureau Group Co., Ltd. and is the main unit of construction; China Railway 23rd Bureau Group No. 2 Engineering Co., Ltd. signed a railway business line construction contract with Harbin Public Works Machinery Depot for the overhaul of the track bed with the operation project, and is the contractor of the project construction and cooperation operation; Jiamusi Public Works Depot is subordinate to China Railway Harbin Bureau Group Co., Ltd., which is the railway line equipment management unit of the construction premises.

3. How the accident occurred

On June 4, 2024, the first mechanized cleaning and screening workshop of Harbin Public Works Machinery Depot carried out line finishing construction in the range of 363 meters of 353 kilometers to 311 kilometers and 518 meters of Suijia in accordance with the construction plan. At 1:10, a group of 19 people gathered in front of the camping bus that stayed at Yubara Station 4, picked up and carried tools to the construction site, and arrived at the shoulder of the 330-kilometer 700-meter road of the upward line at 1:25 to wait for the construction to begin.

At 1:45, after receiving the construction blockade order, the screening team crossed the uplink line without confirming the line of checking, and mistakenly operated on the unblocked downlink line.

After the operation began, the foreman Wen Moumou used chalk to mark the number "1-7" on the sleeper from 330 kilometers 700 meters to 330 kilometers and 589 meters, and assigned the track bed finishing work to 14 workers one by one according to 2 people/groups.

At 1:54, after the 42109 train passed through Yubara Station I. Road, the driver found that there were people on the line in front of him, and took emergency braking 77 meters away from the first impact point, and the train collided with 6 workers during the braking process.

In the process of handling 42109 receiving and sending operations at the station, the station liaison officer and the safety protection officer of the adjacent operation group successively reported and conveyed the train operation to the safety guard Wang Moumou for a total of 4 times, and Wang Moumou responded.

4. Collision process analysis

(1) Analysis of the reasons for misidentifying the line of the line

First, the foreman, squad leader and safety guards did not perform their post safety duties, did not contact and confirm with the station liaison officer in accordance with the regulations when crossing the upward line, and blindly organized the on-road operation without identifying and confirming the line line; The other operators are all laborers and the age structure is too old, the awareness of safety precautions is weak, the ability to take the initiative is insufficient, and they blindly obey the command of the foreman.

Second, the operation team responsible for the line finishing is normally to participate in the operation after entering the blockade line by rail car, and this time it is changed to walk to the operation site, and the operation team that has an accident is the first time to go to the site for operation, and is not familiar with the line equipment; The Harbin Public Works Machinery Section did not thoroughly explain the location and path of the operation site, and did not arrange personnel familiar with the on-site situation to follow and monitor; The Jiamusi Public Works Section also did not arrange personnel to supervise the construction of the operation here.

The third is the cleaning and screening operation group in the past normal to follow the way of large-scale road maintenance machinery to carry out line finishing operations, there are obvious references, the original construction of large-scale road maintenance machinery "line breaking bottom screening" project was completed ahead of schedule than the original plan, after the workshop temporarily changed the construction plan, the operation team changed to a separate line finishing operation to the accident area, lost the reference.

(2) Analysis of the reasons for not discovering the incoming traffic in time

First, the personnel participating in the operation misidentified the line of the construction line and thought that the line spacing met the conditions for not stopping the operation, although they obtained the approach information of the downward train through joint control many times and heard the locomotive horn, they all thought that it was an adjacent line and did not need to go down to avoid the train.

The second is that the safety guards violated Article 2.5.6 of the "General Speed Railway Public Works Safety Rules" (Tiegongdian [2023] No. 54), "The on-site guards shall determine the station and movement path according to the terrain conditions of the operation site, the characteristics of train operation, the layout of operators and equipment, etc., and do a good job of self-protection." and "on-site guards should focus on lookout protection,......; When there are no working vehicles in the vertical sunroof and single-line sunroof, the guards should strengthen the provisions of the lookout ,......", carry out safety protection in the working crowd, and do not seriously adhere to the lookout and guess the situation of the incoming vehicles.

The third is that before the 42109 train passes through the right-turn curve after the XI. signal at Yubara Station to the No. 10 fork, the direction of the locomotive lights is biased to the outside of the downward line, and it is difficult to identify the incoming train line through the locomotive lights in advance.

Fourth, the on-site operators wear headlamps for on-site lighting, and the line of sight and sight distance are disturbed by the headlamp light, and are not sensitive to the locomotive lighting light.

Second, the emergency situation

After the accident, the attendant of Tangyuan Station received a report from the driver of the 42109 freight train about hitting and stopping, and immediately notified the relevant units of the situation to rush to the scene to carry out emergency rescue and dial the 120 emergency number. After on-site disposal, at 3:31, the downward line between Tangyuan Station and Wangjiang Station of the Suijia Line was resumed, and the 42109 train started.

After receiving the accident report, China Railway Harbin Bureau Group Co., Ltd. submitted the accident information in a timely manner. The Harbin Railway Public Security Bureau, the Heilongjiang Provincial Emergency Management Department, and the relevant persons in charge of the Jiamusi City and Tangyuan County Party Committee and County Government led the relevant personnel to the accident site to carry out emergency response and aftermath treatment.

3. Casualties

As a result of the accident, six people were killed and no one was injured.

4. Determination of the cause and nature of the accident and responsibility

(1) The cause of the accident

1. Direct causes

(1) Misidentification of the location of construction work. Harbin Public Works Machinery Section Mechanized Screening Workshop Foreman Wen Moumou, squad leader Xue, safety guards Wang Moumou, Li Moumou, Zhang Moumou violated the "Safety Production Law", "Railway Business Line Construction Safety Management Measures", "General Speed Railway Public Works Safety Rules" and other laws and regulations and railway safety production rules and regulations, did not implement post safety responsibilities, did not contact and confirm with the station liaison officer when crossing the upward line, and organized and led the operators to go on the road in violation of regulations without identifying the line and confirming the location of the operation.

(2) Misjudging the line of the train line. Wen Moumou, the foreman of the first workshop of the mechanized cleaning and screening of the Harbin Public Works Machinery Section, and Xue Moumou, the squad leader, violated the regulations, failed to urge the safety guards to look out carefully, and failed to correct the improper position of the safety guards in time; Safety guards Wang Moumou, Li Moumou, and Zhang Moumou violated the provisions of the "General Speed Railway Public Works Safety Rules", blindly believed that the operation team was on the blocked line, did not insist on careful lookout, and did not seriously confirm the train operation of the line.

(3) Lack of construction operation management. China Railway 23rd Bureau Group No. 2 Engineering Co., Ltd. did not appoint safety management personnel to organize construction operations in accordance with the contract, failed to convey the content, scope and precautions of construction operations to each employee, and failed to organize labor personnel to divide labor before the operation.

2. Manage the reason

(1) The responsibility of the person in charge of construction is not implemented. Liu Moumou, deputy director of the first workshop of mechanized cleaning and screening, the person in charge of the construction, violated Article 57 of the "Work Safety Law", failed to implement the safety production responsibilities that were fully responsible for the construction work, and failed to conscientiously perform the duties of organization and command at the construction site.

(2) The construction organization of Harbin Public Works Machinery Section is chaotic. After changing the construction day plan and operation content on the day of the incident, the safety risks were not studied, the control measures were not formulated, the operation was carried out in the unfamiliar section of the line equipment, the key content such as the location of the upper and lower roads and the position of the cross line was missing in the construction operation plan, and the safety technical disclosure meeting and the layout meeting before the construction site were not carefully organized.

(3) China Railway 23rd Bureau Group No. 2 Engineering Co., Ltd. did not perform its duties. Failure to conscientiously implement relevant legal provisions and contract agreements, violating Article 117 of the Administrative Measures for the Construction of Railway Business Lines of China Railway Group (Tie Tiao [2021] No. 160), illegal subcontracting, and failure to implement the safety production education, training and management responsibilities of labor personnel.

(4) The responsibility for the supervision of the construction of the business line of the Jiamusi Public Works Section has not been implemented. No personnel familiar with the business were appointed to supervise and inspect all aspects of the construction involving driving safety, and no personnel were arranged to supervise the construction of the operation team where the accident occurred.

(2) Determination of the nature of the accident and responsibility

According to Article 11 of the Regulations on Emergency Rescue, Investigation and Handling of Railway Traffic Accidents and Articles 10 and 68 of the Rules for the Investigation and Handling of Railway Traffic Accidents, the accident was a major accident involving the responsibility of railway traffic.

In accordance with the provisions of Articles 54, 68 and 71 of the Rules for the Investigation and Handling of Railway Traffic Accidents, it was determined that the Harbin Public Works Machinery Depot of China Railway Harbin Bureau Group Co., Ltd. was primarily responsible for the accident, and China Railway 23rd Bureau Group No. 2 Engineering Co., Ltd. was secondarily responsible for the accident; Investigate the management responsibility of the Jiamusi Public Works Section of China Railway Harbin Bureau Group Co., Ltd.

5. Suggestions on the handling of the persons responsible for the accident

(1) Persons pursuing criminal responsibility (4 persons):

Liu Moumou, deputy director of the first workshop of mechanized screening in charge of construction, Xue Moumou, the squad leader of the first group of cleaning and screening, and Li Moumou and Zhang Moumou, safety guards, have been arrested by the public security organs in accordance with the law.

In view of the fact that the foreman Wen Moumou and the safety guard Wang Moumou were killed in the accident, they were exempt from responsibility.

(2) Personnel given administrative sanctions (21 people)

1. Deputy Secretary of the Party Committee, Director and General Manager of China Railway Harbin Bureau Group Co., Ltd.

2. Member of the Party Committee and Deputy General Manager (in charge of industrial and electricity supply) of China Railway Harbin Bureau Group Co., Ltd.

3. China Railway Harbin Bureau Group Co., Ltd. Harbin Public Works Machinery Section Chief Administrative dismissal.

4. Administrative dismissal of the Secretary of the Party Committee of the Harbin Public Works Machinery Section of China Railway Harbin Bureau Group Co., Ltd.

5. China Railway Harbin Bureau Group Co., Ltd. Harbin Public Works Machinery Depot in charge of production deputy section director administrative dismissal.

6. China Railway Harbin Bureau Group Co., Ltd. Harbin Public Works Machinery Depot in charge of safety deputy section chief dismissed, administrative demerit punishment.

7. The director of the Public Works Department of China Railway Harbin Bureau Group Co., Ltd. was dismissed from office and punished with a major administrative demerit.

8. The deputy director of the Public Works Department of China Railway Harbin Bureau Group Co., Ltd. was dismissed from his post and punished with a major administrative demerit.

9. China Railway Harbin Bureau Group Co., Ltd. Harbin Public Works Machinery Depot Mechanized Screening Workshop Director Administrative dismissal.

10. China Railway Harbin Bureau Group Co., Ltd. Harbin Public Works Machinery Section Mechanized Cleaning and Screening Workshop Branch Secretary Administrative Dismissal.

11. China Railway Harbin Bureau Group Co., Ltd. Harbin Public Works Machinery Section Mechanized Screening Workshop Supervisor Cleaning Deputy Director Administrative Dismissal.

12. China Railway Harbin Bureau Group Co., Ltd. Harbin Public Works Machinery Section Technical Section Chief Administrative dismissal.

13. China Railway Harbin Bureau Group Co., Ltd. Harbin Public Works Machinery Section Safety Section Chief Administrative Dismissal.

14. China Railway Harbin Bureau Group Co., Ltd. Harbin Public Works Machinery Section Technical Section Engineer Administrative Demerit Punishment.

15. China Railway Harbin Bureau Group Co., Ltd. Harbin Public Works Machinery Depot Safety Section Engineer Administrative Demerit Punishment.

16. The chief of the construction section of the Ministry of Public Works of China Railway Harbin Bureau Group Co., Ltd. was administratively dismissed.

17. China Railway Harbin Bureau Group Co., Ltd. Public Works Department of the Department of Public Works Safety Crossing Section Deputy Chief (Section Chief Vacancy) Administrative Dismissal Sanction.

18. China Railway Harbin Bureau Group Co., Ltd. Jiamusi Public Works Section General Speed Maintenance Deputy Section Chief Administrative Warning Punishment.

19. China Railway Harbin Bureau Group Co., Ltd. Construction Department in charge of the deputy director of engineering management administrative warning.

20. The deputy general manager of China Railway 23rd Bureau Group Second Engineering Co., Ltd. was given an administrative warning.

21. China Railway 23rd Bureau Group Second Engineering Co., Ltd. assistant general manager and project manager administrative demerit sanction.

(3) Administrative punishment of the unit responsible for the accident and relevant personnel

The Shenyang Railway Supervision and Administration Bureau shall impose administrative penalties on relevant units and personnel responsible for the accident in accordance with relevant laws and regulations such as the Work Safety Law of the People's Republic of China, the Administrative Punishment Law of the People's Republic of China, and the Railway Safety Management Regulations.

6. Suggestions for accident prevention and rectification measures

1. Establish the concept of safe development and implement the statutory responsibilities of safe production. In-depth study and implementation of the spirit of General Secretary Xi Jinping's important instructions on production safety, further improve the political position, firmly establish the concept of safe development, and strengthen bottom-line thinking and red-line awareness; Deeply learn the lessons of the accident, investigate and reflect on the in-depth management reasons of the accident exposure, and formulate and implement targeted preventive measures; Strengthen education and training on production safety, supervise and guide employees to continuously improve their awareness of self-protection and their ability to avoid danger and escape. Relevant units and departments should pay close attention to the implementation of safety responsibilities and measures with a sense of responsibility of "always rest assured", and resolutely prevent and curb the occurrence of major and extraordinarily serious accidents.

2. Strengthen the investigation and rectification of the construction safety of the business line. Scientifically analyze and judge the weak links in the construction management of railway business lines, further optimize the construction organization and management, organize and carry out special rectification of construction safety of business lines in a timely manner, and benchmark the whole process from the aspects of construction organization and leadership, construction plan review, construction plan preparation and approval, safety agreement signing, personnel training, etc., and be responsible for and review step by step, and organize construction in strict accordance with the plan. At the same time, it is necessary to strengthen the performance of cadres at all levels, strengthen the on-site monitoring and control of cadres, and increase the supervision and assessment of the implementation of operational standards; Conscientiously implement the construction supervision and inspection responsibilities of the equipment management unit, and formulate effective measures to supervise and inspect the whole process of construction; Establish and improve the operation safety card control system, improve the self-control ability of the operation team and the safety prevention level of all employees.

3. Further improve on-site safety prevention capabilities. By adding line signs, taking sealing methods to confirm the operation area, strengthening the physical isolation measures of the operation area, and building a multi-party joint control prevention and control system, the comprehensive prevention system is built and improved, and the shortcomings of on-site safety management are improved, and the safety prevention ability is improved. By further promoting the effective operation of the dual prevention mechanism, focusing on key problems and key links, strengthening the research, judgment and control of construction safety risks, investigating and rectifying the hidden dangers of construction accidents, and effectively promoting the improvement of the level of intrinsic safety.

4. Standardize the management of outsourced personnel. Improve and improve the labor and employment management system, strictly check job qualifications, and strengthen the process supervision and dynamic supervision of labor and employment; Strengthen the management of construction business outsourcing, further clarify the division of responsibilities of relevant units, improve the "restricted business outsourcing list", improve the process supervision and inspection procedures and standards, and conscientiously implement the safety production responsibilities of all parties.