Preliminary findings in Puyuma derailment investigation announced

  • Date: 2018-11-26
  • Source: Department of Information Services, Executive Yuan

The Executive Yuan’s administrative task force investigating the October 21 Puyuma Express derailment announced its preliminary findings Monday afternoon, saying an alignment of problems and anomalies contributed to the deadly accident.

Speaking at a news conference, the task force summarized its findings as follows:
1. Puyuma Express No. 6432 was speeding at 141 kilometers per hour (kph) when it entered the curve at Xinma Station, sending the train cars off the rails. The curve has a speed limit of 75 kph and a radius of 306 meters.
2. Prior to the derailment, the train’s air compressors had been malfunctioning, causing the power to cut out at times with the train stopping intermittently. The operational decisions and responses taken by the parties involved did not eliminate the abnormality, however. The conductor continued communicating with the dispatcher to resolve the problem and failed to reduce train speed as required before entering the Xinma Station curve.
3. The train’s automatic train protection (ATP) system had been turned off manually, and since Puyuma ATP systems were not connected to a remote monitoring system, no protective measures were triggered or safety alerts sent.

Citing the “Swiss cheese model” commonly used to investigate causes of major transportation accidents, the task force said the derailment resulted from a series of coincidental factors and anomalies relating to human error, operating procedures, mechanical equipment and organizational management. If the problems or abnormalities were resolved at the time they were discovered, the tragedy would have been averted.

The findings of the investigation so far should be sufficient to determine the causes of the accident, the task force said. To ensure the investigative report is supported by scientific evidence and expert analysis, an academic or professional institution will be commissioned to conduct critical curve speed simulations and derailment collision analyses. The task force had already instructed the Taiwan Railways Administration during the course of the investigation to implement necessary improvement measures, and will continue studying the circumstances and causes of the derailment to identify potential issues and propose comprehensive reforms before releasing the final version of the investigative report.