BA2008-0446-5-01.: The IC recommends MÁV Zrt. to revise 4.2.2. of the Appendix of E.1. Regulations for traction vehicle staff and consider narrowing its scope, and initiate its modification accordingly.

The justification of the safety recommendation:

In the view of the IC, the current regulation is too general and prescribes the deactivation of the speed limiting function of the train control device in situations where the circumstances do not require to do so, moreover, in situations where the maintenance of this function would be strongly justified.

1.2 Further safety recommendations

BA2008-0446-5-02: The IC recommends the NTA to review the regulations as to when can block signals be considered inoperative, and how these regulations are implemented. The IC also suggests that the NTA should examine whether the concerned staff are prepared for decision-making and should consider improving the relevant education, compiling guides and checklists, or further specifying the current regulation.

The justification of the safety recommendation:

The regulations on declaring the block signals inoperative only give the possibility of decision-making but there are no exact guidelines, decision-making aspects.

BA2008-0446-5-03: The IC recommends the NTA to revise - with the cooperation of railway undertakings - the questions of speed limit applied in case of subsidiary signals, with special regard to:

–       technical circumstances having changed since its introduction,

–       psychological effects on engine-drivers,

–       active and passive safety risks deriving from the applied speed.

The justification of the safety recommendation:

The permission of higher speed (adequately and reasonably prescribed) may reduce the urge to disregard the speed limit, and this way LCs turning to failure state could also be avoided.

BA2008-0446-5-04: The IC recommends the NTA to obligate the usage of communications equipment (locomotive radio, mobile phone, etc) for the communication between traffic controllers and engine-drivers while the train is running, and regularly examine that the equipment is operating normally and is used.

The justification of the safety recommendation:

The lack of communications equipment which hinder/delay decision-making contributed to the occurrence of this accident.

BA2008-0446-5-05: The IC recommends - via the European Railway Agency (ERA) - manufacturers of vehicles to re-examine certain equipment, installations and furnishings of vehicles manufactured or redesigned by them (e.g. luggage racks, lights, windows, doors, etc.) with regard to risk factors in a possible accident. When designing the vehicles, they should choose solutions which decrease the extent of injuries to persons to the possible minimum in case of such occurrences.

The justification of the safety recommendation:

As it was found in the course of the investigation, the luggage racks are very rigid but are fitted inadequately and thus they can easily fell off in case of accidents causing or making injuries more serious. Other parts/fittings of carriages breaking off in the course of the collision may also pose similar risks.