Analysis of Safety and Risk Management: German Train Accident Report

This report provides an in-depth analysis of the 2016 Bad Aibling train accident in Germany, focusing on the failures in safety and risk management systems that led to the fatal collision. The report details the accident's background, including the train protection systems in place, and identifies human error – specifically, a distracted train controller – as the primary cause. It explores the concept of safety breaches, highlighting lapses in attention and violations of safety protocols. Furthermore, the report examines the recommendations made by the German Rail Accident Investigation agency, including policy changes such as the implementation of the European Train Control System, infrastructure upgrades, and the adoption of an integrated management system to address human factors. The report concludes by emphasizing the importance of adhering to European standards, policy frameworks and national regulations in the prevention of future railway accidents.

Running head: SAFETY AND RISK MANAGEMENT SYSTEMS 1
Train Accident in Germany
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Train Accident in Germany
Hazards and risks can occur both at the private sphere and at the workplace. The
definition assigned to a hazard is the condition that has the potential to cause injury, illness and
death. It also extends to disrupting operations at work and damaging of goods. Risk can be
defined as the probability that a hazard may occur and result in injury. Workplaces pose dangers
of safety and risk due to the processes of production. Risk and safety management inculcates the
sets of procedures that formulate and implement mitigation measures with regards to hazards.
The management of risk is dependent on individual state policies and legislation on risk and
safety management. The risk and safety policies on train accidents in Germany are governed by
the EU laws together with federal legislation.
Background on Train Risk and Safety Management in Germany
The German legislation on health and occupational safety works under the umbrella guidelines
that are set out in the Euro wide framework. The European Union guidelines define the structures
and rules on occupational risks and its prevention. It also sets regulations on promoting safer
working environments. The agency mandated to ensure safety standards in the train sector is the
European Agency for Railways (ERA). Its core mandate is set out in regulation 2016/796
(Biennial Report, 2016, p.1). This agency works with stakeholders in the train sector and national
train safety bodies of its member states. National Safety Authorities within the EU collect data
gathered from this Euro agency for action at the state level.
The Federal Railway Authority in Germany is the agency tasked with supervising railway
operations, licensing and safety (BMVI, 2017). It operates in compliance with European Union
laws and provides oversight on safety at the state level. This agency supervises safety operations
at the federal level while regional railways are supervised by the federal states. It operates under

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the parent Ministry of Transport and Digital infrastructure. The risk and safety measures in the
train sector in Germany are enshrined in the General Railways Act which spells out the statutory
obligations to be adhered to. An operational safety management system is a pre-requisite as part
of the obligations required to operate. It also has a railway inspectorate that performs random
inspections on the railway infrastructure.
The Federal Railway Authority regulates regional agreements on cross acceptance
between the member states within the EU (EBA, 2017). This includes agreements between
Germany and Italy, France and several other European nations. The rights of passengers are also
regulated and safety information guidelines set out. It sets out the rights of the passenger and
ensures these rights are safeguarded. Safety rules on stepping distances and gaps are set out in its
national safety rules on trains. The National Investigations Body is the investigation branch and
carries out investigations after train accidents have occurred within the Federal boundaries. It
then initiates the appropriate preventive and corrective measures for the future.
Train Accident- Bad Aibling 2016
In the month of February 2016, two trains in the Bad Aibling region of Germany were
involved in a fatal collision which resulted in the deaths of more than ten persons (Railway
Gazette, 2016). In addition, more than 85 people were also injured with varying degrees of
severity. The accident occurred on the Mangfall Valley Railway which is single-track and
involved two Meridian branded trains operated by Bayerische Oberlandbahn. The two trains had
passenger numbers in excess of 150 persons. Both trains and the railway line were fitted with a
train protection system (PZB) which is a safety measure designed to prevent train locomotive
drivers from passing signals at danger by mistake. This safety feature is meant to reinforce
signaling system at the sides of the railway track.

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According to the investigation reports, the cause of the accident was caused by the train
controller who confessed that he had been playing a computer game and was distracted (Zuvela,
2016). While playing on his mobile phone, he transmitted the wrong signaling information to the
two trains. When he realized his error, he tried to engage in emergency protocols by sending
corrective codes to the two trains. He keyed in the wrong codes and this did not rectify the initial
error he had made. The trains collided as they approached a bend which could have contributed
to both drivers no seeing each other before the crash. Both trains had a driver and their instructor
and were travelling at a relatively high speed when the accident occurred. The automatic braking
system that is meant to stop trains that are not scheduled at that time failed to work during the
accident.
Safety Breach
The breach on safety that translated the risk into an accident has been narrowed down to
lapse of attention and breach of safety protocols. The lapse of attention was the primary
offsetting cause that was compounded by the breach of safety rules. Lapses can be defined as
omissions and missed actions that are caused by lack of proper attention to the task at hand. Most
causes of lapse in attention are caused by boredom due to the repetitive nature of a task or job
(Hopkins, 2014). Another cause could be attributed to fatigue which has been identified as an
Occupational Health Safety hazard. It can result in reduced awareness in situations and impaired
procedural memory and the reduced ability to recall information stored in the brain (Dawson,
2012).It can also lead to a state of reduced self-monitoring and greater divergence from the ideal
desired state when working.
The breach of safety protocols is in relation to not following the laid out procedures that
should be followed in directing traffic over single track rails. The system used over the stretch

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where the accident occurred was the “token block” which allows for one train at a time to use the
railway line (Sharples, 2016). The traffic controller did not check for the schedules of trains for
that particular time and gave the go ahead for both trains to use the single track. His instructions
disabled the Automatic Train Protection system temporarily. The onboard systems of both trains
together with railway track system were disabled. This made it impossible for the system to work
automatically and also cut off the input of the train drivers.
Recommendations, Change of Policy and Implementation. The German Rail Accident
Investigation agency carried out investigation into the accident and made several
recommendations. The investigation showed that the documentation used by the company
managing the tracks was outdated and incorrect in some areas. It did not also contain instructions
for radio use in emergencies. The owner of the railway line at Bad Aibling is Deutsche Bahn
which runs its operations through its subsidiary DB Netze. DB Netze is responsible for ensuring
safety and controlling traffic. The company uses Automatic Train Protection (ATP) system
which has some shortcomings on safety protocols. Bleiker (2016), states that the report
recommended the implementation of the European Train Control System instead of the current
system being used.
The company as part of its policy change embarked on working with German Institute for
Open Communications systems (FOKUS) in order to certify open-source software using the
European standard across its infrastructure (Bleiker, 2016). The software is intended to reduce
human errors along high speed railway tracks and to enhance safety of train passengers and crew.
Human failure and technical mistakes are the most common cause of train accidents like the one
witnessed at Bad Aibling (AP, 2016). The software is meant to be standard across the entire
infrastructure operated by Deutsche Bahn. This standardization should result in lower costs of

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operating uniform safety standard protocols. In addition, Deutsche Bahn adopted an integrated
Management System that factors in safety in its Safety Management System.
The implementation involved the installation of a safety management system using global
certification at its Schenker Logistics office (DB, 2017). This safety management system is
comprehensive and includes measures and protocols that deal with occupational health and
safety, management during emergency and fire safety. This is implemented using administrative
actions in order to reduce hazards along its infrastructure (Safe Work Australia, 2017). This
holistic approach looks intoinputs that affect productivity as human factors. This is intended to
reduce human errors as in the case of the Bad Aibling accident. Actions to be taken in emergency
and crisis situations are also included as part of the safety management framework. These risk
and safety measures are continuously updated to fit the current best industry practices.
The railway line operator has also undertaken a long-term infrastructure upgrade
including its trains. The operator has embarked on an upgrade of stretches of its infrastructure
which it operates. This involves modernizing the technology which controls the signal systems
on danger and command protocols (SKF, 2017).This upgrade also involves building new lines
which use new technology on control technology. The operator has undertaken a program to
replace its existing fleet of trains with the new ICE-4 which has more security features. This
includes smart sensor technology in its wheels which uses redundancy protocols. The sensors are
integrated in the bearing unit and works with the existing safety signal systems.
Hazards and risks are a common occurrence at work and require measures in mitigation
which incorporates risk and safety features. The risk and safety management within Germany
train operations is based on European standards and made operational at the Federal and regional
level. The policy framework postulated is transposed into national laws and regulations. The

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train accident at Bad Aibling was the result of breaches in safety and risk management. The
investigation that followed identified gaps in the risk assessment and asset management process.
Recommendations made were implemented as a policy shift and infrastructure upgrade. This is
to aid in eliminating potential risks in the future.

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References
AP. (2016). Cause of deadly German Train crash still a Mystery. CBS News. Retrieved from
https://www.cbsnews.com/news/germany-train-crash-bad-aibling-human-error-or-
systems-failure/
Biennial Report. (2016). Railway Safety Performance in the European Union. European Union
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https://erail.era.europa.eu/documents/SPR.pdf
Bleiker, C. (2016). After Bad Aibling: railway safety in Europe. DW. Retrieved from
http://www.dw.com/en/after-bad-aibling-railway-safety-in-europe/a-19037919
BMVI. (2017). Railway Operating Safety. Retrieved from
http://www.bmvi.de/EN/Topics/Mobility/Rail/Railway-Operating-Safety/railway-
operating-safety.html
Dawson, D. (2012). Fatigue Risk Management: A safety Management systems approach.
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DB. (2017). Enhancing Safety Standards. Retrieved from
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quality/enhancing-safety-standards.html
EBA. (2017). Federal Railway Authority. Retrieved from
https://www.eba.bund.de/EN/home_node.html
Hopkins, A. (2014). Safety culture and Risk. Wolters Kluwer.
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http://www.railwaygazette.com/analysis/single-news/view/the-price-of-safety.html

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Safe Work Australia. (2017). Identify, assess and control Hazards. Retrieved from
https://www.safeworkaustralia.gov.au/risk
Sharples, S. (2016). Germany Train crash-ways in which rail Safety systems can fail. Phys.
Retrieved from https://phys.org/news/2016-02-germany-crashways-rail-safety.html
SKF. (2017). Deutsche Bahn’s new trains run more efficiently and longer with advanced
technologies. Retrieved from http://www.skf.com/il/news-and-media/news-search/2017-
06-13-deutsche-bahns-new-trains-run-more-efficiently-and-longer-with-advanced-
technologies-from-skf.html
Zuvela, M. (2016). Prosecutor identifies Human Error as cause of Bad Aibling Train Disaster.
DW. Retrieved from http://www.dw.com/en/prosecutor-identifies-human-error-as-cause-
of-bad-aibling-train-disaster/a-19051663