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Eschede ICE884 Derailment - WORKSAFE BC MODEL - Coggle Diagram
Eschede ICE884 Derailment - WORKSAFE BC MODEL
People
Deutsche Bahn Management
Profit Oriented
Prestige
'German Engineering'
Reputation
State of the art train
all about luxury/comfort
had wheels changed on all trains after personally experiencing unpleasant vibrations
could have found other ways to fix this issue
different form of suspension
change of rail beds to more appropriate ones for high speed trains
chose cheapest option
allowed technology that was not designed for highspeeds nor tested under high speed conditions
ignored warning by The Fraunhofer Institute for Structural Durability and System Reliability (LBF) about usage of those wheels in 1992
ignored warnings by tram company Üstra that they were having metal fatigue issues on same type wheel even on trams low speed of 24km/h in 1997
didn't act on 8 separate train staff complaints about loud noise and vibration coming from particular wheel 2 months before accident
didn't act on 3 separate system warning about damage to particular wheel one week before wheel failure
expected engineers/ maintenance crew to pick up on immanent failures and resolve issue before failure
didn't expect any issues after 7 years of smooth service. service has run 365 days a year, 7 days a week, multiple times a day without incidence
Deutsche Bahn Engineers
use technology unsuited/untested for high-speed trains
under pressure to please management fast and fix vibration issues cheaply
Train driver
had no way of monitoring wheels on each cr
had no warning signal to tell him what is going on behind him
did not feel anything other than a light pull when the rest of the train uncoupled fro his locomotive
had no visual of the train cars behind him
relying on maintenance crew to keep trains in check
Conductor
stuck to company policy not to pull emergency break immediately
followed policy by going to investigate issue personally
in no position to make any other decision
only customer service staff
no technical/mechanical knowledge of the train
First Car Passenger
didn't know what that piece was that came through the floor in his compartment
didn't know it was still dragging on the tracks
didn't know that there was an emergency brake in his compartment
was shocked and stressed ->couldn't find an emergency brake
didn't know where conductor was
trying to keep his wife and son safe
didn't know how urgent it was to get help/stop the train
Deutsche Bahn Maintenance Crew
didn't use ulrasound for wheel inspection
time restriction
technology had given falsereadings in the past
only using torches for visual inspection of wheels
company policy
nothing has ever gone wrong
Workplaces
train locomotive
conductor had no visual of the rest of the train
conductor had no access to date telling him about the conditions of the wheels on each car
very noisy inside train
lots of vibration
conductor could not hear what was going on behind him
conductor could not feel what was happening behind him
rail track
old rail track
not specifically designed for intercity high-speed trains
design for much slower regional rail traffic
two switch points positioned right before a bridge
sensor on track inconsistent
sensors on track don't pick up broken or missing wheels
Train cars
conductor
narrow hall ways and long cars
took one minute to get from car 3 to car 1
Management
Organisational/ Systems Factors
Policies
Train staff not to pull emergency break without proven reason
wheels get replaced when worn down to less than 854mm diameter (expert recommendation is 880mm)
Procedures
train staff to investigate disruptions/disturbances/ issues in person before pulling emergency break
regular maintenance inspection on wheels only conducted by torch not with ultrasound technology to find fatigue cracks
Management Decisions
replacing mono-bloc wheel with rubber damped type wheels for travel comfort
going against expert recommendation to replace worn down to 880mm diameter (new wheel = 920mm diameter) and push it to 854mm limit
Job Design
Workload
maintenance workers overloaded
Task Design
maintenance not using newest technology (ultrasound inspection) despite available
maintenance workers using torches to inspect wheel by wheel visually
lenghty process very easy to iss important clues of metal fatigue
Information Transfer
no communication between conductor and train driver
no information data on state of wheels during trip available
driver has no information about state of train behind him until he comes to a stop