Background
Stavoren is a town of 960 people (as of 2020) in the north of the Netherlands, located right on the coast of the IJsselmeer (a large lake created by closing off a bay of the North Sea) 64km/40mi north-northeast of Amsterdam and 41km /25.5mi east of Den Helder.
The town is the western terminus of the Leeuwarden–Stavoren rail line, a 50.2km/31mi single-track non-electrified branch line opening in 1885 (back then as a main line). At the time of its opening and well into the 1900s the rail line was not only important in connecting various towns in the area but also to give a faster connection from the northern part of the country to Amsterdam, opening a year before a ferry line over the IJsselmeer. After WW2 the line was almost retired as faster connections ran parallel to it, after several changes the services on the line are today provided by Arriva, a British subsidiary of the DB (German national railway), who took over operations in December 2007. Nowadays the line is exclusively used by regional passenger services, its status as an important connection that even saw international trains is long gone.
The train involved
To prolong the lifespan of rails before they need replacement rail companies occasionally run “railgrinders”, specialized maintenance trains that grind off some of the steel to remove deformation and corrosion. In late July 2010 such maintenance-work was scheduled to take place near Stavoren Station, for which an external company was contracted. The train was manned by an Italian crew based at a hotel in Zwolle (about an hour away by car, 2 by train) including a driver and a Dutch train driver acting as a guide (or “pilot”, to use the terminology from ships) who was certified for the rail line. Responsible for the grinding-work (and the renter of the train) was BAM, a Dutch construction-company contracted for the rail-grinding by ProRail, a Dutch government agency in charge of maintaining and extending the national railway network (excluding trams and metros). The train used for the job was a Speno International RR 48 M-5. The train consists of 9 articulated segments measuring a total of 112.75m/370ft in length at a weight of 398 metric tons. It can load 21 metric tons of equipment and materials and travel at up to 95kph/59mph when not in grinding-mode.
The accident
On the 25th of July 2010 Speno RR 48 M-5 arrived at Zwolle Goederen freight yard at approximately 6pm, towed by another locomotive. At Zwolle the train was handed over to the Italian-Dutch crew who prepped the train for the night’s work and departed Zwolle with the Speno under its own power by 7pm. In the meantime the crew’s superiors had decided to take the train all the way to Stavoren, opposing earlier plans, and run the grinding-trip west to east from there. This meant that the train would not have to wait for the last regular passenger train to clear an eastern section of the line and it could also travel to the starting point at its top speed rather than just 40kph/25mph as it would just run among the other scheduled trains on its trip west. Originally the train had been meant to turn around at Sneek station, a few kilometers ahead of Stavoren, and drive up to Leeuwarden station in grinding-mode. On paper, the changed schedule earned the crew 30 minutes.
At 10:16pm the train departed Leeuwarden station for Stavoren. One of the Italian workers rode with the driver and pilot in the forward cab, which was against the Dutch regulations. Before departure the train crew had learned of the changed schedule, making the Italian workers, who apparently hadn’t quite understood the message and had become anxious, thinking they were now meant to work longer than planned. By 11:18pm the driver made a phone call shortly after departing Hindeloopen station (9km/5.5mi from Stavoren) to his superior, announcing that he was approximately 2km/1.25mi from Stavoren station. At this point the (illegally present) worker in the driver’s cab started to ask the driver about the confusing change of the night’s plans, which led to the driver resorting to notes and timetables to try and figure out if he had gotten it right. The conversation between the men was held in broken German, with the driver later saying he had to turn around more than once to see/ensure he was understood.
During one of those moments with the driver facing away from the windshield the train passed the three so-called “Keperbaak”-signs, fixed distance-boards situated 70m/230ft from one-another with the last one standing 1200m/3940ft from the buffer-stops at Stavoren station. Note that, at this point, the train was still running at full speed. 200m/660ft further on the train passed the well-lit Koeweg road level crossing, here another group of workers were waiting to be picked up for the return trip, their job being the protection of the Asphalt against grinding-damage. Seeing the train barelling towards them at several times the supposed speed they attempted to get the driver’s attention by waving and shouting, without success. They were spotted by a worker in the rear cab, who used the intercom to ask the driver how far they were from Stavoren station. The driver thought he had recognized the level crossing but assumed it at a different location, expecting to see a speed limit sign he had marked in his notes any minute now. Instead, moments after replying as such on the intercom and while still looking for a track kilometer sign for orientation, the driver could see the start of Stavoren’s platform emerging out of the dark.
The pilot started shouting at the driver to brake, who in turn triggered an emergency stop. Obviously there was no way the 420 metric ton behemoth would come to a stop in under 300m/980ft. The three men left the cab and positioned themselves at the back of the leading car with their backs against the rear wall of the cab. A moment later, at approximately 11:30pm, the Speno train crashed through the buffer stop at the end of Stavoren station at around 80kph/50mph, crossed the road beyond it, crashed into a parked empty marine diesel tanker trailer and dragged it along as it proceeded to crash into and then continue on straight through a water sports equipment store located on the other side of the road. Finally, having obliterated the buffer stop, a semi-trailer and about half a building the severely damaged train came to a stop 80m/262ft beyond the end of the tracks. The rear of the train was still on the tracks while the front end was buried in a pile of rubble with the remains of a steel tank folded around the driver’s cab. Two of the men on board suffered minor injuries, thanks to the late hour no one was in or around the store and could have been harmed.
Aftermath
The men managed to leave the train on their own after the accident, soon being met with responders notified by locals after what must’ve been a both deafening and confusing noise. With the accident luckily being fairly light on injuries the site was soon blocked off from the public and handed over to investigators as the first photos of a house cut in two by a train started appearing online. Failing to find a defect on the train investigators quickly focused on the human side of the operation, and with every bit they uncovered things looked increasingly bad. First of all, only the train crew and their immediate superiors knew of the changed schedule, there had been no confirmation/permission from the people in charge, not even a request for such.
Secondly, the pilot wasn’t as educated on the line as everyone thought. He had been provided track diagrams by ProRail which indicated signals, signs and distances, but no curves. The diagrams also showed speed warning and speed reduction signs ahead of Stavoren station which the pilot chose as the braking-point to accurately stop at the station. The problem wasn’t his choice of braking-point, it was that the diagrams were outdated and the chosen signs had been removed years ago. When the pilot took a cab-ride on a regular train he failed to notice the absence of the signs.
Furthermore, the Italian driver had not been specifically taught about signs and signalling on the line and there appeared to be a language barrier with the people on board conversing in German with some difficulty. When the pilot called his superiors about being approximately 2km/1.25mi the Italian driver could’ve picked up on that (or on the station they had just left), but he had merely been told to rely on the Dutch pilot. Why the pilot didn’t make the connection of the remaining distance, the train’s speed and needing to brake is unknown.
The line from Leeuwarden to Stavoren is pretty easy to learn, in fact, consisting of just a few sidings at stations, three left-hand turns and three right-hand turns. There are no big elevation changes or complexities (tunnels, bridges, galleries), just a handful of level crossings which are hard to miss at night. Just by counting turns and sidings you’d get a fairly good idea of your location even without knowing the towns along the route. The pilot seemed to largely keep track of the train’s location, as evident by the phone call, it was only when distraction set in that he messed up, and the unfamiliar driver was left “high and dry” with catastrophic consequences. As such, he arguably can’t be blamed for the ensuing destruction.
Next up the investigators pointed out the lack of any light-signals ahead of or at Stavoren station, with information only being transmitted to the drivers by means of retro-reflective signs (similar to normal road signs) that light up when hit by the passing trains’ headlights. A main role here was held by the Keperbaak signs, three vertical white boards with three, two and one black lines or chevrons on them with the last board showing an additional Z on top. Upon passing these signs drivers are expected to decelerate to 40kph/25mph or less, depending on the rail line, to be able to safely stop for the following signal or stop-sign (pretty exactly what it sounds like). Obviously, this solution is based on the assumption that the train driver knows what exact speed he’s meant to slow down to. The signs originate in the days of steam-power and were meant to either be seen or to reflect different amounts (due to angle and size) of driving noise back into the cab letting a locomotive crew notice them even if they can’t see them due to bad weather or the locomotive’s smoke, as the crews would hear a distinct hiss as they pass each sign. After the end of steam-traction in the Netherlands (January 1958) the boards were simplified and also no longer indicate an upcoming signal but replace the signal altogether, cutting cost and complexity.
The approach to Stavoren station is one of four places where the Keperbaak-signs are still in use this way, and the only usage on a higher speed line with the other three locations being low-speed branch-lines for freight traffic. Due to this rarity the pilot was unfamiliar with them and chose the more common speed warning boards instead. He didn’t know that they had been removed and no-one had bothered to update the diagrams when scanning them for a digital database. In the Netherlands any end-of-track or red signal is preceded by either a pre-signal or a warning sign, not a speed reduction sign, which should’ve pointed the pilot towards his error. Even if there had been speed reduction signs as indicated in the outdated diagrams, there had to have been another sign or signal warning of the end of track. However, due to his unfamiliarity with the rarely used Keperbaak-signs the driver neglected to note their position in his notes for the night, adding another link in the chain-reaction that led to the accident. He knew where he was when he called about being about to arrive, had he noted the signs he would’ve known it was time to slow down, distraction from the third person in the cab or not.
At this point the investigators stumbled over another detail. During modernizations Stavoren station hadn’t received modern signals, but it was tied into the Dutch signaling and train control system ATB. The section from Leeuwarden to the junction between the Harlingen and Stavoren lines (barely a kilometer) is secured by the basic ATBEG-v system, here trains are required to switch to the more advanced ATBNG-system. However, the grinding train was only compatible with the former system, meaning from that junction onward it ran with no external system being able to control and if needed take control of it. Stavoren station was secured with ATBNG, and the train was supposed to be compatible with that system, but it obviously didn’t allowing it to run at excessive speed literally until the end. Someone involved in the process of picking and renting the train for the job had either missed this problem completely or misjudged/misunderstood the difference and proceeded regardless. After this discovery BAM was banned from using Speno-trains on Dutch rails until they could ensure safe operation, but as this resulted in the tracks just not being ground at all the ban was already lifted by August 2010 with the condition of “especially high care” being directed at the safe operation of the still insufficiently equipped trains.
After the accident, whose damage some sources listed at a staggering 20 million Euros/22.6 million USD, the 60 years old pilot was initially charged with negligent endangerment of rail traffic and later just endangerment of rail traffic, a charge that could see him in prison for a year. However, by 2014 it was decided to drop all charges against him as his role had not been significantly bigger in the cause of the accident than that of all the other flaws uncovered by the investigation, thus causing a lack of “significant criminal guilt”. His employer, Spoorflex, meanwhile, went bankrupt just two weeks after the accident as the accident did severe damage to their image and several customers cancelled contracts with the company. The train involved in the accident was actually rebuilt/repaired after the accident, while the structurally unsound remains of the house had to be demolished and made way for a small park and fish-shop. The signs-and-signaling situation at Stavoren remains largely unchanged, and the Speno RR 48 units are also still in operation all over Europe.
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