Die Unfallkommission forderte 2024 die Stärkung der Protokolle gegen mögliche menschliche Fehler nach einem Ereignis ähnlich dem von Urda

Spain’s railway accident investigation body warned in 2024 that relying solely on human verification creates a potential risk of collision when automated safety systems fail. The Commission for Railway Accident Investigation, known as CIAF, issued this caution following an incident at Cuenca station. The report highlighted that visual checks by traffic controllers constitute a barrier that is prone to failure because it depends entirely on the human element. This finding draws attention to the need for technical mitigation measures. The warning emerged against the backdrop of the high-speed train crash in Urda, Toledo province, which killed at least 69 people. That disaster involved the German LZB signaling system, whereas the Cuenca incident occurred on a line operating the more modern European Rail Traffic Management System, or ERTMS. The specific incident under review took place on June 25, 2024, involving AVE train number 05903. The train was running with ERTMS Level 1 safety protocols. It improperly passed a signal that ordered it to stop at Cuenca-Fernando Zobel station. The initial error lay with the driver, who misinterpreted the appearance of the light signal. Subsequently, the responsible party for circulation committed a second error by authorizing the train to resume movement. Although the TRIP function, a safety mode within ERTMS, automatically braked the train, neither the driver nor the controller initially identified that the signal had been overpassed. Minutes later, a centralized traffic control regulator suspected the violation and requested that the circulation officer order the driver to stop. After reviewing camera footage, authorities instructed the train to reverse back to track five at the station. The CIAF report emphasized that the only effective barrier preventing a potential collision in this instance was the visual confirmation by the circulation officer that the section of track was clear before allowing the train to move again. The document stated that this safeguard is susceptible to failure due to its total reliance on human judgment. Consequently, the commission recommended implementing technical measures to mitigate these risks. The findings illustrate a vulnerability similar to that detected in the Urda tragedy, where safety depended on human authorization when automation or signaling failed. Without automatic technical restrictions, such failures can escalate into collisions. The investigation also addressed the multi-causality inherent in railway incidents. Factors cited included the driver’s erroneous interpretation of signals, previous experiences, and divided attention caused by training personnel entering the cab. Other systemic factors mentioned include shift changes at the control center and similarities between signals with different indications that vary depending on the ERTMS level. The expectation of receiving a run order by the driver was also noted. The CIAF had previously documented a recurrence of similar signal overpasses. Based on these observations, the commission recommended reinforcing signal ergonomics, strengthening protocols following a TRIP activation, and accelerating the implementation of ERTMS Level 2. These recommendations aim to reduce dependence on individual vigilance during critical operational moments. The report serves as a detailed analysis of how procedural gaps interact with technological limitations to create hazardous conditions on Spanish rail lines. Authorities continue to assess the necessary upgrades to ensure passenger safety across the network.