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A temporary railway that was opened for one and a half months was built into an S-shape for various reasons. In January, the speed limit of trains passing through this section was changed several times. A few days before the incident, the Jinan Railway Bureau issued a speed limit, which was quickly cancelled. The temporary railway with great potential danger, child's play-like dispatching management, and layers of negligence and dereliction of duty eventually led to one of the most serious disasters in China railway history.

At 4: 48 a.m. on April 28th, the train T 195 from Beijing to Qingdao, with the speed of 13 1 km/h, and the cars 9 to 17 suddenly derailed in Wangcun section of Ji Jiao Railway, Shandong Province, and invaded another parallel track, resulting in 5034 collisions with the normal opposite train.

It has been proved that the incident line is an "S"-shaped temporary line, and speeding is considered as the direct cause of the accident. However, people in the industry question why there is such a low-level error as "speeding" on the express train that has basically realized automatic control.

What's the mystery behind all kinds of incomprehensible phenomena? Do they have anything to do with the accident?

I missed three opportunities.

Xinhua News Agency reported that Wang Jun, director of the State Administration of Work Safety, said that according to the preliminary information, the train was seriously speeding, and the actual speed reached 1 and 3 1 km on the section with a speed limit of 80km. The "4 28" Ji Jiao railway traffic accident is a typical liability accident.

Wang Jun said that this fully exposed some serious problems such as inadequate understanding of safety production, inadequate leadership, inadequate responsibility, inadequate investigation and management of hidden dangers, and inadequate supervision and management; It reflects that the grass-roots safety awareness is weak and there are serious loopholes in on-site management.

The question is, why does the train run at the speed of 13 1 km/h when the speed limit should be 80 km/h? It is usually easy to understand that it is caused by the negligence of the train driver. However, the investigation proves that the reasons behind it are extremely complicated. Among many responsibility links, the driver factor may be the least important one.

According to Xinhua News Agency, the accident investigation team announced that Jinan Railway Bureau exposed two outstanding problems in the incident: one was to replace the speed limit dispatch order with documents, and the other was to miss the temporary speed limit order. The director and party secretary of the bureau were dismissed on the spot.

Different from the above conclusions, on April 29, the Ministry of Railways issued an internal bulletin, which explained the facts in detail and pointed out the relevant responsible parties. As can be seen from the report, there are at least three chances to avoid disaster. However, the dereliction of duty of the relevant personnel made the opportunity miss again and again.

The accident happened on April 28th, which was the first day when the train diagram of Ji Jiao Railway was adjusted due to construction. According to Xinhua News Agency, on April 23rd, Jinan Bureau issued the documentNo.10/issued by Jinan Municipal People's Government on April 23rd, 2006. 154 "notice on the implementation of Ji Jiao line construction adjustment train diagram" is planned to be implemented at 0: 00 on April 28th four days later. This document requires a speed limit of 80 km/h in the accident area.

However, on April 29th, Xinhua News Agency's "Xinhua Viewpoint" reported that such an important document of Jinan Bureau was only published on its website, and the foreign bureau and relevant units delivered it by ordinary mail, with Beijing Locomotive Depot as the cc unit. Geng Zhixiu, the new director of Jinan Railway Bureau, admitted on the 29th that "the management of construction documents and dispatching orders of Jinan Railway Bureau is chaotic, and it is extremely serious to replace temporary speed limit orders with documents."

It is understood that in railway operation, the only thing that plays a decisive role in speed is dispatch and command. In other words, even if the file doesn't. 154 is not answered. As long as Jinan Railway Bureau issues a speed limit dispatch order in time, the tragedy can still be avoided.

Under normal circumstances, Jinan Railway Bureau issues speed limit dispatching orders. After receiving T 195, the Beijing Locomotive Depot will merge the relevant speed limit data into the IC card, and then insert it into the "black box" (train operation monitoring and recording device) on the train. In this way, the train will automatically control the speed. If the driver fails to execute the speed limit order due to negligence and other reasons, the train will automatically brake to slow down or stop.

However, Xinhua News Agency reported that on April 26th, three days after the release of Document No.9. 154, Jinan Bureau issued the dispatch order No.4158, requesting to cancel some speed limits, including the speed limit order of the eastern convenience line from Wangcun to Zhoucun (where the accident occurred).

"The file transfer and dispatching command transfer are chaotic, which has laid a great hidden danger for the accident. The danger is getting closer and closer, but the mistakes are still going on ... "Xinhua News Agency's" Xinhua Viewpoint "report lamented.

It is still unknown why Jinan Bureau reneged on its word and cancelled the speed limit in the form of dispatching order after issuing the speed limit order. However, according to an expert from the Railway Research Institute of the Ministry of Railways, the reason may be that many places on the Ji Jiao Line are under construction, and it is also to ensure the normal operation of the train.

"The total running time is relatively fixed. The speed limit in some places must mean speeding up in other places. " The expert said.

It is reported that when T 195 went to Wangcun accident section, the time was 4: 38. According to the adjusted operation diagram, it should arrive at Zibo Station below Wangcun at 4: 19. In other words, in order to ensure that the train arrives in Qingdao at roughly normal time, it is only a question of where to speed up.

At midnight on April 28th, the opportunity came again at 1. The 2245 train passing through Wangcun found that the temporary speed limit sign (80) on site was inconsistent with the data of operation monitoring (no speed limit), and immediately reported it to Jinan Bureau. At 4: 02, the latter issued Dispatching Order No.4444: the speed limit was 80km/h between k293+780 and k290+784.

Conventionally, this dispatching command is to notify the train station, and then the personnel on duty will notify the driver through wireless intercom. The conversation between the two people will be recorded in the "black box" of the train.

But fatally, according to Xinhua News Agency, the order with serial number 4444 was leaked by the station attendant. However, the personnel on duty at Wangcun Station did not confirm the latest temporary speed limit order with the driver T 195, nor did they seriously implement the joint control of vehicles. The driver of T 195 train did not receive this rescue order at last.

At this time, there is only one last line of defense: relying on the naked eye observation of T 195 drivers, find the 80 km/h speed limit sign, and then speed limit the train. But it turns out that the last straw is so fragile. At 4: 30 in the morning, when the driver was most tired, he obviously didn't notice the speed limit sign that flashed by.

According to Xinhua Viewpoint, "the locomotive crew didn't look carefully and lost the last chance to prevent accidents".

In this way, many opportunities were mysteriously missed. Finally, the late T 195 train, like a runaway wild horse, galloped at the speed of 13 1 km/h and quickly overturned.

After the accident, the speed limit sign on the temporary line was changed from "80" to "45", which is quite puzzling.

Introduction of related reasons

Overtime is prone to potential safety hazards.

In an interview with Southern Weekend reporter, Wang Shuiqing mentioned the problem of drivers working overtime: "In recent years, the railway has developed rapidly, but it does not recruit people. It also wants to have a single driver. Some conditions are immature and impossible. The domestic traffic volume has increased, and there are fewer people, so we have to work overtime. "

A normal month for train drivers in China is 65,438+067.4 working hours. Wang Shuiqing said that it usually takes more than 200 working hours, and some will reach more than 300 working hours. Take Jiang as an example, he has to work for two months a month, and overtime will be charged for the part that exceeds 167.4. 167.4 working hours 1.800 yuan. Although "money is needed", Wang Shuiqing still thinks that 167.4 is their real working hours, and the working hours of two or three hundred are not earned by normal people.

Overtime will bring the same "red-eye flight" problem as civil aviation.

On March 24th, a driver of Jinan Bureau was in a daze. Suddenly, he woke up, saw the green light in the next lane, and got off in a daze. Fortunately, there is a time difference. If it's late, you may hit a bus followed. On April 13, the same thing happened in Nanning Bureau. Fortunately, only turnouts and roads are blocked.

These two incidents were classified as general level D and general level C, which were not accidents. If the accident level is reached, the driver will leave his post forever and can only do other jobs or change careers.

Train drivers are usually trained by specialized railway driver schools. Wang Shuiqing graduated from Liuzhou Railway Driver School, studied for two years (now one more year) and practiced for one year. After graduation, I will practice again in the unit. After the internship, I will take the exam. After passing the exam, I will go to work, from the student to the co-driver, and then I will run 90,000 safe kilometers. Only after passing the exam can I become a driver.

Train drivers have a variety of collocation methods: 2+0, two drivers take turns driving, one sleeps in the back and the other drives in the front; 2+ 1, there are always two people in front of the car, two drivers, one co-driver and one sleeping in the back; 1+ 1, that is, a driver and a driver, two people are at the same time, usually running short distances.

The driver's job is monotonous. If everything is a person, it is easy to get tired. "A person sitting there, just wait for a while. Like them (referring to the accident train in Shandong), since they engaged in double-shift single drivers (that is, 2+0), we have experienced that such accidents will happen sooner or later. " Wang Shuiqing said.

Railways run day and night, so do train drivers. The driver's experience is that four to six in the morning is usually the most sleepy time.

Jiang believes that "this accident is due to the driver's working hours greatly exceeding the prescribed time, which leads to the driver's excessive fatigue."

Crystal, spokesperson of the State Administration of Work Safety, told Southern Weekend that at present, the the State Council accident investigation team under the leadership of the State Administration of Work Safety has been established, with several teams, among which the technical team is responsible for investigating the cause of the accident. The technical team is mainly composed of people from the Ministry of Railways: "At the beginning of the investigation, it is a liability accident to rule out accidents first and man-made and natural disasters. The detailed specific reasons will be announced after the investigation. " Watching the news, it's quite true. A lot of dead people, quite spectacular!