Final report on Puyuma Express derailment released

  • Date: 2018-12-21
  • Source: Department of Information Services, Executive Yuan

At a Friday afternoon press conference, the Executive Yuan’s administrative task force investigating the October 21 Puyuma Express derailment released its final report, which detailed the cause of the deadly accident, the problems and anomalies underlying the tragedy, and recommended improvements to avoid similar accidents in the future.

The task force said an inductive analysis showed that there was no single cause of the accident; rather, the derailment resulted from the convergence of issues involving organizational faults, equipment failures, problematic procedures, human error and environmental influences. These problems were detailed in a preliminary report that the task force announced at a November 26 press conference.

The task force went on to list a series of immediate corrections to underlying problems as well as further improvements addressing broader overall issues. The Taiwan Railways Administration has already been directed to implement the immediate corrections.

As for overall improvements, the report put forward 18 recommendations. These include: reviewing the control room’s dispatch command system and functions; examining all Puyuma air compressor maintenance regulations and troubleshooting procedures; improving the remote monitoring system’s ability to detect and warn of activation or deactivation of a train’s automatic train protection (ATP) system, and creating an automatic speed control mechanism when the ATP is deactivated; reviewing notification, response and decision-making procedures in the event of vehicle anomaly or malfunction; enhancing front-line personnel’s proper understanding of ATP system functions and stability; and strengthening training and education on train inspections, anomaly reporting, troubleshooting and emergency maintenance.

The derailment occurred on October 21, 2018 at 4:49 p.m. when Puyuma Express No. 6432 entered a curve near Xinma Station in Yilan County. The accident killed 18 passengers and injured another 267.