BA-2009-443-5-01 Based on the current regulations, the acquired familiarity with routes and tracks never expires, regardless of the date of exam or substantial changes in the track layout and infrastructure. The IC believes that an engine-driver might get into trouble due to unexpected, substantial changes in the track layout. It can lead to dangerous situations especially when the engine-driver meets these changes in extraordinary circumstances (e.g. signal box error). An engine-driver who has not been working on a given route for a prolonged period, unavoidably loses routine, and this loss of familiarity may also have a similar outcome.
The IC, in accordance with the EU directive, believes that the current regulations concerning the validity of track layout familiarity of engine-drivers should be reviewed. Therefore the IC recommends the NTA to review – in co-operation with MÁV Zrt - the current regulations on the route knowledge of the engine drivers and make recommendations to their change accordingly. In particular, the IC suggests that a booklet which contains the major changes in the infrastructure (including the setting up of main signals) should be issued no later than the Modifications to Timetables, and that the engine-drivers shall be familiar with the information in the booklet as a precondition to work.

BA-2009-443-5-02 The IC recommends the NTA to fully review the regulations on route knowledge including positions in which to work is subject to route knowledge, with special regard to Directive 2007/59/EC of the European Parliament and of the Council as well as Directive 18/2010. (III.12.) of the Ministry of Transport, Telecommunication and Energy in case of engine-drivers.

BA-2009-443-5-03 In the course of the investigation, the IC established that there is no designated place at Nagylapos crossover where the locomotive crew would be able to do the couplings prescribed in Appendix 2 of Regulation E.1. The recent changes in the crossovers - in their construction and traffic controlling role - may create dangerous situations while these changes are not fully included in the current regulations. Therefore the IC recommends the NTA to review – in co-operation with MÁV Zrt - the current regulations on disabling the Unified Vigilance Warning and Train Control Device (EÉVB) in certain situations in order to clarify where exactly the EÉVB may be disabled (at places such as Nagylapos crossover).

BA-2009-443-5-04 In the course of the investigation, the IC established that according to the current regulations, the movements inspector of Nagylapos crossover - who works on his own at the crossover - should have left the office having written the so called ‘written order’ and should have gone to entry signal ‘B’ 2200 metres away to hand out the written order to the train crew. Afterwards he should have gone back to the office to send line clear or subsidiary signal onto entry signal ‘B’. The IC believes that the current regulation is unrealistic and poses further risks of more serious accidents. Therefore the IC recommends the NTA to review – in co-operation with MÁV Zrt - the rules of writing and handing out written orders with regard to Nagylapos crossover and similar places, in order to find a reasonable and feasible solution while ensuring safe railway transport.

BA-2009-443-5-05 In the recent years during the renovation of the railway network, new crossovers have been set up with different functions and structures. In parallel, the definition of ‘crossover’ changed significantly when the Traffic Regulations were amended. Based on the circumstances of the occurrence, the available documents and the statements heard at the Closing Discussion, the IC concluded that these changes and the relevant rules are not obvious. Thus, the IC believes that the rules should be reviewed in order to ensure their uniform, clear interpretation as well as to enhance railway safety. Therefore the IC recommends the NTA to review the definition of crossover and the rules and procedures related to railway traffic at crossovers, with special emphasis on the different functions and modern structure of crossovers.
The IC also wishes to draw the attention of parties concerned in railway transport to the importance and thoroughness of monitoring and controlling work procedures during which special attention should be paid on complying with the relevant regulations and orders, stopping wrong practices as well as on maintaining a good level of theoretical and practical professional knowledge.