Derailment at Brétigny-sur-Orge, 12 July 2013
This paper is based on a translation – obtained by RSSB – of BE-ATT’s final report on the derailment
at Brétigny-sur-Orge, which occurred on 12 July 2013. For the full report, click here: LINK
Warning:
Note that BEA-TT’s investigators say that – during the investigation – they relied mainly on ‘such
information as had been made publicly available from the reports of legal experts and the metallurgy
investigation’ (p.20).
In producing its report, BEA-TT was therefore unable to make full in-depth use of the legal and
metallurgical investigations.
Moreover, these two investigations are currently subject to further investigations on the orders of
the judges in charge of the legal enquiry. The issues of the time frames of the crack in the point and
of the severing of the bolts are specifically central to these further analyses.
At this stage, and for as long as the judicial enquiry is in progress, the scenario which led to the
accident cannot be definitely established.
Contents: (Click to
navigate)
What happened?
Causes
Recommendations
The GB situation
Some of the key issues raised and/or suggested by this accident:
Switch and crossing maintenance – including recording procedures
Ageing infrastructure
Organisation of infrastructure depots, including poor supervision, lack of managerial experience, lack
of managerial understanding
Inadequate safety audits
Poor Safety Management System
Inadequate management check function
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
What happened?
At 17.11 (local time) on 12 July 2013, inter-city service 3657 – heading towards Limoges on Track 1 of
the Paris–Orleans line – derailed on pointwork at the northern end of Brétigny-sur-Orge station.
The first two derailed vehicles remained on Track 1, overturning to their right. The third derailed and
turned to block Tracks 1 and 3, having swept along Platform 3 for about 100 metres. The last carriage
came to rest on Track 3 without turning over.
Seven people – three on-board and four on Platform 3 – were killed. Thirty-two were also injured, 11
of them seriously. Some 200 other people, who were either on the train or in the station, suffered
severe shock or material loss.
The derailment occurred about 150 metres ahead of Platform 3 on double slip 6/7/8/9.1
Causes
BE-ATT determined that the derailment
was caused by the obstruction of the
flangeway by the internal fishplate of the
joint connecting the slip to a set of points
(see photograph).
The fishplate pivoted around the body of
the fourth bolt (the head of which had
sheared off) during the passing of the
train.
The three other bolts had also loosened
from their fastenings, a detachment that
began by the fracture of the third bolt’s head, which happened between one and eight months
before the accident. The latter was aggravated by a star-shaped crack, which had developed since
2008.
While double slip 6/7/8/9 was, like its neighbours, known for the recurrent difficulties from which it
suffered, three maintenance process failures worsened the situation:

1
The non-detection during the inspection of the line carried out on 4 July 2013, and indeed
during previous inspections, of the fracture of the third bolt. This is a probable result of the
More precisely, on the crossing of the right-hand rail of the switch’s slip diamond.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
reduced attention given to anomalies affecting the fastenings, compared with other switch
defects which were considered more critical;

The lack of attention which ought to have been given to the checks to which the double slip
was subject in November 2011. This meant that the cracking that had developed was not
reported, though it was probably well advanced; and

A February 2008 recording error re the cracking, the start of which had been detected during
checking that year. (Namely, the crack appears to have been assigned erroneously to one of
the other abutments of the frog.)
Even if no direct and formal connection could be established with the cause of these failures, it
appears that several managerial, organisational and human factors issues aggravated by the specific
features of the ÎIe-de-France region probably contributed to it, namely:

The general ageing of the railway system which involves a big increase in track maintenance
operations carried out in an emergency to deal with the operating needs can lead to certain
tasks considered to be secondary being deferred, and which changes the perception that the
staff have of the normal state of the installations;

An organisation of the infrastructure depot, which can lead to the direct supervision of gangs
being entrusted to young managers who do not have sufficient experience and objectivity,
notwithstanding their commitment and their availability;

Inspection and audit processes which did not enable the drift in quality of certain track
maintenance operations to be clearly detected within the infrastructure depot which covers
the area of Brétigny-sur-Orge.
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Recommendations
Without waiting for the completion of its investigations – and on the basis of information already –
BEA-TT issued an interim report in January 2014, containing three initial recommendations dealing
respectively with the management of bolted assemblies, the reinforcement of the instructions
regarding maintenance of fastenings of switches, and with the adaptability of the maintenance
schedules for these pieces of equipment:

SNCF Infrastructure should improve the level of management of bolted assemblies of switches
throughout the system by attending to certain factors, in particular:
o
The technical specifications and the quality of the components;
o
The locking devices on the bolts;
o
The observance of the instructions for tightening the fastenings and, more generally,
the observance of the specifications and the state of the art rules during the fitting
and maintenance operations on these assemblies.

SNCF Infrastructure should clarify and strengthen the rules regarding the measures to be taken
when anomalies affecting the fastenings of switches are detected. In this context, the
maximum time after any work done or any inspection in which all the fastenings must be
present and tight should be specified, along with a similar time limit for the clips of the second
level.

SNCF Infrastructure should identify the switches or the groups of switches which have
particular features that require increased maintenance or earlier anticipated renewal
compared with normal guidelines. It should also put in place in the general maintenance
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
organisation, or in that of the depots, arrangements that will ensure that these features are
taken into account in a reliable and auditable manner.
In its final report, BEA-TT issued three further recommendations, dealing with the management of
the maintenance of the national railway network. They relate to the deployment of the
modernisation of this network, to the management of the supervision in the depots responsible for
the maintenance, and to the carrying out of safety audits:

SNCF Infrastructure should regularly check – by external audits, and on the basis of explicit
objectives – that the increase in the average age of the various components of the national rail
network is in accordance with the decisions taken, and that the funds available for
maintenance are consistent with the needs, bearing in mind the state of the installations and
the performance expected.

SNCF Infrastructure should improve the policy of the appointment of managers in the depots
in charge of the maintenance of railway infrastructure:

o
By avoiding concentrations of young managers in operational units and by taking
account of this objective in the appointment of management teams in these units;
o
By taking care to appoint at the head of the track sectors teams where the
immediate manager, the supporting technician and the operational technician have
abilities, competences and seniorities which are usefully complementary;
o
By reducing their turnover, in particular in the depots located in the Île de France
region.
SNCF Infrastructure should systematically include in the safety audits of its maintenance
checks on the actual state of a sample of equipment that has recently been the subject of
monitoring or maintenance, in order to evaluate the relevance of the maintenance rules and
the way they were introduced. The very special attention that needs to be devoted to the
carrying out of track inspections and checks on B family switches needs to be emphasised to
management.
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The GB situation
In Britain, fishplates are reportedly used at around 20 sites on 100mph lines to secure track to
switches and crossovers. They are effective if well maintained and allow the rail to expand and
contract under prevalent temperature conditions.
Fishplate breaks increased by 30% between 2008 and 2011. Though the trend reversed in 2012-13,
Network Rail took a proactive step and reviewed bolted crossing risk, briefing its inspection teams to
highlight the issues that came out of the Paris accident.
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Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk