Safety and Risk Management: A Case Study of Bavarian Train Crash

This report discusses the safety breaches that led to the Bavarian train crash, the nature and extent of the issue, response to the questions, recovery operations, and changes implemented after the incident. It also highlights the importance of safety and risk management in preventing accidents and prioritizing the safety of passengers.

Running head: SAFETY AND RISK MANAGEMENT
Safety and risk management
Name of student
Name of University
Author note

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Executive summary
The Bavarian train crash was a result of safety breach, which led to the death and injury
of many people. Investigations were carried out and it showed that the negligence of the
dispatcher was one of the safety breaches where they were not being able to identify the
movements of trains in the same line by the other railway executives, which might have stopped
the incident. The person was found to be playing with games on mobile phones, due to which, he
missed the scope of informing the train drivers that the trains were allowed to move in the same
time simultaneously. Before providing any emergency responses, the trains collided with each
other and resulted in injuries and deaths to many. Necessary support were provided and
implementation of laws, policies and rules regarding safety helped in overcoming the entire
situation slowly and new rules were integrated to maintain safety measures and keep the
passengers safe along with the railway tracks to prevent transportation delay in the future.
Table of Content

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s
Executive summary.........................................................................................................................1
Introduction......................................................................................................................................3
Case of safety breaches....................................................................................................................3
Nature and extent of the issue..........................................................................................................4
Response to the questions................................................................................................................5
Recovery operations.....................................................................................................................5
Changes implemented after the incident..........................................................................................6
Conclusion.......................................................................................................................................7
References........................................................................................................................................8

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Introduction
The topic introduces the importance of safety and risk management and how it can be
beneficial for undertaking remedial measures during or after a train crash incident. The report
will demonstrate a train crash incident, which has been caused due to breach of human safety and
also the various principles of safety management that will be applied to strengthen the train
network. This can not only prevent the occurrence of further accidents involving train, but will
also improve the level of safety and health of passengers (Glendon, Clarke & McKenna, 2016).
The case study that is involved here has been the Bavarian train crash in Germany.
Case of safety breaches
The case involving the train crash is selected because it has occurred due to safety breach,
which is relevant to the topic. The incident revolves around the face to face collision of a freight
train and passenger train in the Southern area of Bavaria’s German state. The safety breach was
caused due to the wrong doings or misconduct by the on-duty traffic controller. The incident
resulted in the death of eleven people and it has been the outcome caused due to tragic mistakes
made by the controller during his duty hours (Khan, Rathnayaka & Ahmed, 2015).
The safety breaches involved during the accident include major mistakes done by the
train dispatcher and there were no technical defects as well. Thus, the dispatcher was blamed and
it was later investigated that he had been the culprit. Firstly, he cleared a single track line in
Bavaria for the two trains to pass simultaneously and secondly, rather than sending the warning
radio message to the train drivers, he got into a stressed situation that time and it had already
caused the accident and resulted in the death of 11 persons. Several people were injured and due

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to the collision face to face, it was quite difficult for the rescue workers to clear the entire site
properly (Moura et al., 2017). The safety breach was caused due to his negligence in performing
his roles and responsibilities properly and also failing to deliver the right information to the train
drivers in spite of letting the two trains move through the single track at a time (Liu et al., 2016).
Nature and extent of the issue
Had it been educated before, the train crash could have been ceased. However, it was
discovered that there were no breakdowns in the train's signaling system or in the engine. After
much examination, it was discovered that the train dispatcher gave wrong information and
messages or rather did not send any messages to the train drivers, regardless of allowing both the
trains pass both of the trains in the single track line (Grote, 2015). The dispatcher was rather
busy with playing games on the mobile phone, which made him get distracted and while trying
to send emergency codes to the train drivers, the wrong combination was entered into the
computer, due to which the train drivers were not aware of the situation and what might have
caused (Hollnagel, 2018).
The trains provide great convenience for people to travel and based on the laws, rules and
regulations set by the Railways, it is always important to maintain proper health and safety
measures to keep the passengers safe and sound while travelling. The safety breach here was
caused due to the negligence of the worker and because the hazards and risks were not identified
at first that might have caused after letting two trains pass through the single track at the same
time (Haimes, 2015).

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Response to the questions
To respond to the questions that arose and ensure that the site is cleared, the transport
minister of Germany visited the site where the accident occurred and even made the workers
investigate about the cause of accident and safety breaches, which resulted in the accident. He
provided sympathy to the families of the victims and even the celebrations in the nearby areas
were cancelled to pay tribute to the horrifying incident as well (Hopkin, 2018).
To respond to the questions, investigations were conducted and rescue operations were
managed with the involvement of over 700 emergency service workers, many police officers,
firefighters and even civil protection workers. The helicopters were used as air ambulances to
transport the injured people from both Germany and Austria. DB Netze Emergency Technical
department worked for the entire case and provided breakdown cranes to facilitate the
transportation of workers and even clean p the area by removing the two damaged trains (Khan
et al., 2016). The Government has taken various initiatives to change the policies and set high
standards of safety while controlling the switches, monitor the track lines and make sure to send
the right information to prevent collision of two trains at the same track.
Recovery operations
A huge number of rescue workers came to the place emergency vehicles and helicopters
came to the site to rescue the people who were in need. The safety systems were checked though
no faults were found at the last maintenance check. The recovery operation as carried out by
dismantling the power lines in the over head on the track and the destroyed train wagons were
smashed after removing any passengers who might have been within the ruins (Hale & Borys,
2013). There were many people injured, because of which, the Blood donation centers posted

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social campaigns on Facebook and other social networking websites to gather enough volunteers
and provide help and support to the victims. The transport minister also stated about the safety
breach caused not only due to the negligence of the dispatcher but also due to the moving of the
train above the speed limit, which was 100 km/hour. The dispatcher was busy playing games on
his mobile phone and thus was not cautious about the incident that could have caused with the
two trains passing in the same line (Meran et al., 2016). As soon as he understood the
consequence, he decided to provide emergency response to the train drivers, but it was too late
until then. The stretch track could have used the PZB90 system to automatically detect the trains
and not depend on the dispatcher to pass the messages. This could have forced the trains to put
brakes once tit pass through the re signal (Leveson, 2015). A technical malfunction might also
have prevented the crash, i.e., head on collision between the two trains.
Changes implemented after the incident
Changes were made in the policies and procedures of transport for ensuring that the crisis
situations could be overcome and speed restrictions were made. The speed restrictions could be
placed by making changes to the implemented policies so that proper information were
transferred to the river once a single track line was opened for passing the two trains at the same
time (Van Gulijk et al., 2015). Though it was the responsibility or duty of the dispatcher or
controller to keep track of the rains, still there should have been other rail officials and engineers
who should have kept an eye on the trains and made sure to inform them about the track through
which both the trains should pass simultaneously. Under the Health and Safety at Work Act, the
senior Rail track officers and executives might even face charges regarding the negligence
showed due to which the dispatcher did not perform his duties properly, which caused the train

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crash and took lives of multiple people (Liu, Saat & Barkan, 2013). Policies and procedures were
implemented with the management of changes to make sure that the workers in duty abide by the
laws, rules and regulations regarding safety of passengers and people within the workplace and
at the same time, facilitate the transportation. The safety standards are set to create new
standardized features and enable Protective Direction to provide the railway department with
constant update on the movement of trains (Restel, 2014).
Conclusion
The report was prepared to discuss about the breaches of safety rules and regulations
related to the cause of a train accident in Germany. The safety and risk management was
important to make sure that the accidents do not occur and the safety of passengers could be
prioritized. The safety breach included the Bavarian train accident that resulted in few deaths and
injury to many people as well. It was due to the negligence of the worker who failed to provide
proper information to the train drivers before allowing the two trains move in the same track
simultaneously. The speed limit was also not maintained, which was also considered as a safety
breach while there was absence of a proper tracking system to check the movement of the trains,
due to which, the railway workers missed the situation, which might have prevented the accident
to occur. Soon after the accident, new safety laws, policies and procedures were managed to
ensure that the accident does not occur again and the transportation facilities could be improved.

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References
Glendon, A. I., Clarke, S., & McKenna, E. (2016). Human safety and risk management. Crc
Press.
Grote, G. (2015). Promoting safety by increasing uncertainty–Implications for risk management.
Safety science, 71, 71-79.
Haimes, Y. Y. (2015). Risk modeling, assessment, and management. John Wiley & Sons.
Hale, A., & Borys, D. (2013). Working to rule or working safely? Part 2: The management of
safety rules and procedures. Safety science, 55, 222-231.
Hollnagel, E. (2018). Safety-I and Safety-II: the past and future of safety management. CRC
Press.
Hopkin, P. (2018). Fundamentals of risk management: understanding, evaluating and
implementing effective risk management. Kogan Page Publishers.
Khan, F., Hashemi, S. J., Paltrinieri, N., Amyotte, P., Cozzani, V., & Reniers, G. (2016).
Dynamic risk management: a contemporary approach to process safety management.
Current opinion in chemical engineering, 14, 9-17.
Khan, F., Rathnayaka, S., & Ahmed, S. (2015). Methods and models in process safety and risk
management: Past, present and future. Process Safety and Environmental Protection, 98,
116-147.
Leveson, N. (2015). A systems approach to risk management through leading safety indicators.
Reliability Engineering & System Safety, 136, 17-34.
Liu, J., Wang, X., Khattak, A. J., Hu, J., Cui, J., & Ma, J. (2016). How big data serves for freight
safety management at highway-rail grade crossings? A spatial approach fused with path
analysis. Neurocomputing, 181, 38-52.

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Liu, X., Saat, M., & Barkan, C. (2013). Safety effectiveness of integrated risk reduction
strategies for rail transport of hazardous materials. Transportation Research Record:
Journal of the Transportation Research Board, (2374), 102-110.
Meran, A. P., Baykasoglu, C., Mugan, A., & Toprak, T. (2016). Development of a design for a
crash energy management system for use in a railway passenger car. Proceedings of the
Institution of Mechanical Engineers, Part F: Journal of Rail and Rapid Transit, 230(1),
206-219.
Moura, R., Beer, M., Patelli, E., Lewis, J., & Knoll, F. (2017). Learning from accidents:
Investigating the genesis of human errors in multi-attribute settings to improve the
organisation of design.
Restel, F. (2014, September). The Markov reliability and safety model of the railway
transportation system. In Safety and Reliability: Methodology and Applications-
Proceedings of the European Safety and Reliability Conference (pp. 303-311).
Van Gulijk, C., Hughes, P., Figueres-Esteban, M., Dacre, M., & Harrison, C. (2015). Big Data
Risk Analysis for Rail Safety?. In Proceedings of ESREL 2015. CRC/Balkema.