Taipei, A series of mechanical malfunctions on a Puyuma express train and the poor troubleshooting capability of both the train driver and the Taiwan Railways Administration (TRA) dispatch control room are to blame for a deadly crash last month, a Cabinet investigation task force said Monday.
In addition, the TRA's failure to establish and implement standard operation procedures (SOP) also indirectly contributed to the tragedy, said Allen Hu (???), head of the Bureau of High Speed Rail, who is executive secretary and spokesman for the task force.
Citing the "Swiss cheese model," which is often used to determine the cause of an accident, Hu said the crash was the result of an accumulation of human errors, ranging from train delivery checks to follow-up maintenance work and operational issues.
Under the model, an accident takes place only when multiple layers of risks -- like holes on slices of cheese -- are not blocked but align. At that point hazards go unchecked and lead to failure.
"If any of the problems had been solved at the time they were discovered, the tragedy would not have happened," Hu said in releasing the investigation report from the task force, which was set up the day after the deadly derailment to conduct an independent investigation.
While the immediate cause of the accident was speeding, as train No. 6432 from New Taipei to Taitung derailed in Yilan while traveling at nearly double the permissible speed limit as it entered a curve, there were already problems before that, he added.
For instance, two of the four air compressors on the ill-fated train were already not working before the train left Shulin terminal, and TRA had no SOP as to whether a train should operate under such circumstances, Hu said.
The malfunction of the air compressors led to power problems on the train, which caused the driver to shut off a system that keeps travel speed under a safe limit, as he tried to increase the speed.
What was even worse was that after the driver, Yu Cheng-chung (???), turned off the automatic train protection (ATP) system, he was too distracted dealing with the power problems to report what he had done in a timely manner, Hu said.
Yu mentioned his decision to dispatchers just minutes before the crash occurred, and when informed there was little urgency in the response of the dispatcher.
The TRA was also negligent in responding to problems, added Yang Cheng-chun (???), deputy head of the bureau and another member of the task force.
A TRA internal bulletin had received two alerts about the train's power problems 20 minutes before the crash near Xinma Station, which requested an immediate check-up of the train at Yilan Station.
"The train should have been stopped for an examination but it was not, which shows very poor risk response capability," Yang said.
The task force also blasted the TRA for its poor handling of train operation set-up when it first received the Puyuma trains from the Japanese manufacturer Nippon Sharyo six years ago.
A remote control system that could alert the central control room if the ATP was shut off was never installed, Hu said, adding that the task force has asked the TRA to review its contract with the Japanese company to determine which side is at fault and should pay compensation.
The Puyuma train derailment on Oct. 21 left 18 people dead and 200 injured and was the deadliest train accident in Taiwan in 37 years.
Source: Focus Taiwan News Channel