The tragic rail accident that shook Greece in February 2023, killing 57 people, continues to wreak havoc in the country with protests and riots in the Greek streets. A new report, compiled by HARSIA, the Hellenic Aviation and Railway Safety Investigation Agency, pinpoints the causes of the accident, placing crititcal importance on the action of the station master and the train drivers. At the same time, it points out that the underlying factors of the accident lie in the chronic pathologies of the country’s railway network.
The report published by HARSIA identified causal and underlying factors which caused the accident, with the causal ones being the most relevant. These include the inexperience of the station master, lack of effective communication and poor training provided by Greece’s infrastructure manager OSE. On the other hand, the lack of proper infrastructure and staff working under significantly stressful conditions were labelled as “underlying factors”.
Inexperience as the causal factor?
The report identifies a number of causal factors for the accident in the Tempi Valley, most of which revolve around the actions of the station master on shift in Larissa at the time of the collision. The report underlined the station master’s inexperience. For example, the document said that deciphering information needed to control train traffic is often a complex operation “for novice station masters”. This is because it often entails a mix of digital information on a control panel and handwritten notes.
The report also stated that it is not clear whether the station master received proper training by Greece’s infrastructure manager OSE. While the HARSIA reports said that it takes “a period of one to one and a half years before getting confident with the required tasks, the station master that was on duty in Larissa station on the night of the accident had less than one month of experience”, the document pointed out.
Station master’s state of mind
The report also made some assumptions regarding the station master’s state of mind in the minutes before the collision. Around half an hour before the accident, the station master mistakenly set the route for entry of another train (train 2597). To correct this error, the report said that the full attention of the station master was required for at least six minutes. “It can be expected that this incident (with the train 2597) and its aftermath created an emotional weight on the inexperienced station master of Larissa, which has occupied his mind and created an additional element of worries”, the 178-page document speculated.
In addition, the report hypothesised that both the station master and the driver of the freight train involved in the accident may have refrained from speaking up when detecting anomalies to their older colleague driving the intercity passenger convoy. “The long-lasting experience and reported assertiveness of the train driver of IC-62 may have influenced the willingness of both his younger colleague and the station master to speak up when detecting some anomalies,” the HARSIA document highlighted.
Systemic problem labelled as underlying factors
If the human mistakes made by the station master and the passenger train driver were considered as the “causal factors” of the accident, the systemic failures of the Greek railway network were labelled as “underlying factors”. Since the financial crisis that hit Greece at the end 2000s, the rail infrastructure in the country has continued to deteriorate and the workforce in the rail sector has been significantly reduced.
In addition, the report said that “OSE does not provide any preventive maintenance of its main assets for control, command and signalling”. Moreover, the document speculated that OSE’s approach does not guarantee workers to reach a valid level of competence in safety-related tasks. Finally, the Greek infrastructure manager does not consider human and organisational factors, leading to excessive workloads “beyond what is humanly acceptable in a sustainable way”, the report claimed.
“Unlike for example, the condition of track elements, for which temporary speed restrictions are imposed, no criteria nor arrangement exist within OSE to adapt the maximum allowed line speed to the condition of the signalling system”, the HARSIA report claimed. In other words, there is no system in place to slow trains down if there are issues with the signalling system.
Cause of fire and explosion still unknown
It seems that the “technical equipment of the rolling stock” did not contribute to the explosion and the subsequent fire. Additionally, the report stated that it is not possible to determine what caused the fire, but “simulations indicate the possible presence of a hitherto unknown fuel”.
The role of controlling authorities
The report also addresses controlling authorities, including the European Union Agency for Railways (ERA) and the Greek Railway Regulatory Authority (RAS). ERA awarded Hellenic Train, the company operating the passenger train involved in the accident, the single safety certification despite some “non-blocking” concerns. “This included an issue related to the strategy for monitoring performance. With this issue still not being resolved, 18 months after certification, any sense of urgency seems to be lost”, the document stressed.
The issues with RAS mentioned in the report include “lack of adequate supervision” which do not allow the identification of non-compliances. These problems were already identified by audits performed by ERA in 2019 and 2022. “The joint follow-up corrective actions by ERA and the European Commission did not lead to any quick improvements in the supervision practices of RAS”, the HARSIA report added.
