Well, is this another technogenic thing?
I've warmed up enough to start fulfilling your requests. Near Bastia they asked for Gooseberry – well, here it is.
Actually, I didn't really want to write about this case – it's too well-known and described in great detail in various sources, but oh well. But by the way, it is the most obvious example of the cumulative effect (aka the Swiss cheese theory), so we'll look at it from this point of view. So, let's go count the holes.
Hole 1. Weather. On May 2, 1977, the Minsk region suddenly experienced a heat wave – up to +30°C in the shade. Despite the timely warning from the Geophysical Station of the Belarusian Railways, the road master did not take any measures, which resulted in…
…hole 2. The heated rails short-circuited the insulating joint of the pre-entry signal 7702, causing the red signal to come on. The duty officer at the track post quickly realized that the signal was malfunctioning and sent an electrician to sort out the malfunction, but…
…hole 3. Didn't tell anyone else about it. As a result, no one knew about the traffic light failure except her and the electrician. Meanwhile, the electrician who arrived at the scene discovered the cause of the malfunction and reported it to the duty officer. She sent him reinforcements in the form of a road foreman and a track foreman. The repairs were threatening to drag on, and in order to avoid a disruption to the traffic schedule, the electrician went into gross violation of the instructions, creating…
…hole 4. He manually switched the traffic light to green before each passing train, returning it to red after passing. In this way, more than a dozen trains were allowed to pass in a couple of hours. Which, in turn, led to the formation of…
…holes 5. A tired electrician forgot to switch the traffic light back to red after the #548 Olekhnovichi-Minsk electric train passed. As a result, the pre-entry traffic light on the section occupied by the electric train was still green. Meanwhile, a…
…hole 6. Due to the aforementioned heat, the phase splitter of the electric train standing at the station began to smoke from overheating, which led to a delay in departure and the appearance of…
… holes 7 (By the way, evaluate the safety margin of the system! How many factors had to be brought together to cause an accident!). The duty officer at the track post went out to the platform to see what was happening and did not see how…
…hole 8. As passenger train #280 Grodno-Orsha approaches, having just passed a faulty traffic light on the green light. The board at the duty station honestly displayed its approach, but alas, it tried in vain – the duty station was on the platform. Thanks to…
…hole 9 – a bend in the tracks before the track post, the train was not noticed from the platform in time, just as the train driver was unable to assess the situation on the platform. In addition, the driver was alone in the cabin (at that time they were trying to introduce an innovation and do without assistance). As a result, emergency braking was applied only when the trains were separated by only a hundred meters.
As a result, at 17:10, passenger train #280 Grodno-Orsha crashed into the jam-packed electric train #548 Olekhnovichi-Minsk at a speed of 35 km/h. The impact crushed the last two cars of the electric train, the passenger train suffered a smashed and burning locomotive and the first two cars derailed. I will not get carried away with the description, look at the photos. To extract the injured and dead, the cars had to be cut with an oxyacetylene torch, because they looked like crumpled paper.
The disaster took the lives of 22 passengers of the electric train, 82 were injured. The passengers of the 280th were luckier: no one was seriously injured. The rubble was cleared until the morning of the next day.
The electrician, the road foreman, the passenger train driver and the duty officer were put on trial. The latter received a suspended sentence, the others got real terms (To be honest, I don’t understand the logic of the court; the duty officer and the electrician violated the instructions clearly and intentionally, the train driver was simply in the wrong place at the wrong time. However, the investigation decided that he applied emergency braking too late and, according to their calculations, the train should have had time to brake completely). The Kryzhovka crash is currently considered the largest train disaster in the history of the Belarusian Railways. That’s how things are…
Author: Daniil Lee
