Railway safety
There were 109 railway safety incidents and 16 accidents in 2023. Among the 16 accidents were 4 collisions with a person (in which 2 people died; suicides not included), 4 accidents at a level crossing (in which 2 people died), 3 collisions with an object (one of which was the collision near Voorschoten in April 2023), 4 instances of a passenger falling while boarding or disembarking and 1 instance of fire on a train. To further improve railway safety, we have taken various measures including those listed below.
Accident near Voorschoten
On the night of 3 to 4 April, a horrific train accident took place on the Leiden-Voorschoten line, killing an employee of a contractor. Trackwork was being carried out on this line at several places that night, which involved the use of a crane on trolleys. While replacing a rail, the crane inadvertently ended up on the active track before the requested service interruption was in force. This was followed by a collision with a freight train, in which the crane driver died. A few minutes later, an NS passenger train also collided with the crane, leading to derailment and injuries to the train driver, the main guard and 28 passengers. ProRail, DB Cargo, BAM and NS are jointly investigating the accident. In addition, independent investigations by the Dutch Safety Board, the Public Prosecution Service and the Netherlands Labour Authority are ongoing.
Signals passed at danger (SPAD)
In 2023, a total of 29 SPAD (signal passed at danger) incidents within a Remote-Controlled Area (RCA) were registered. In 5 of these cases, the train reached a ‘danger point’: a point where the SPAD could actually have resulted in a collision, crash or derailment. In none of the incidents did this actually happen. The number of times the danger point was reached has stabilised since 2020. NS aims to reduce the number of SPAD incidents where a danger point is reached to zero.
NS monitors all SPAD incidents in order to learn from them by establishing their causes and identify further measures to prevent them.
Risk management
NS aims to focus its risk management more on predictive indicators by developing clear frameworks and applying them effectively. In doing so, we use IT to control processes, risks and measures. In addition to continuously monitoring existing risks, our work in 2023 included:
Organisation-wide improvement of the approach to risk management. To support the development of the so-called Rail System of the Future, for example, we provide unambiguous management guidelines and methods to achieve safety targets and ensure continuous improvement. In doing so, we help rail traffic grow in a demonstrably safe manner.
Support for new and ongoing projects in establishing and implementing risk management. This covers the whole cycle from drafting plans to getting files approved by external bodies. Obviously, there is a considerable emphasis on major programmes like ERTMS, ATO and the introduction of the ICNG, but we also focus on risk management at major events such as the Dutch Grand Prix in Zandvoort.
Gaining experience with ERTMS
ERTMS is regarded by the EU as the new standard for train safety. Unlike NS’54 and ATB, ERTMS allows active braking curve monitoring of the train. The outdated NS’54 and ATB will be replaced by ERTMS in the coming years. The Hanze Line and the Amsterdam-Utrecht track section will be equipped with a new version of ERTMS, in addition to the existing safety system (ATB). Trial runs on the Amsterdam-Utrecht track section ERTMS started in July 2023. On the Hanze Line, infrastructure conversion work has been plagued by delays. NS is aiming to start trial runs on that line too in 2024. These trial runs will enable train drivers, train dispatchers, mechanics and other staff to gain experience with ERTMS. Trained drivers will then be offered shifts on lines with ERTMS to apply the new rules and procedures.
Human and Organisational Factors
The discipline of Human and Organisational Factors (HOF) is an integral part of the change development process. For instance, we specify HOF requirements, e.g. when developing new rolling stock or training for train drivers, and contribute to risk management from a HOF perspective.
A renewed NS vision for HOF was drawn up in 2023. HOF verifies specifications for new rolling stock on Human Factors aspects, as in the case of DDNG specifications and the VIRM conversion. Examples include specifications for the driver’s desk and sight lines for signal observation. This allows train drivers to carry out their work safely. As a result, HOF allows us to influence processes from an early stage and contribute from a safety perspective to optimal performance. HOF is conducting several studies in connection with the ERTMS programme. In 2023, we completed a study to establish the extent to which train drivers are able to remember specific ERTMS knowledge when they are not actually using the system.
This ‘ERTMS forgetting curve study’ shows how important it is for drivers to gain practical experience as soon as possible after training. The Human Factors perspective has also been integrated into the ERTMS driver training programme. The aim is for drivers to decide and act in full awareness of the situation while driving. Furthermore, HOF is involved in various safety issues, such as reassessment of the views on self-reliance in tunnel evacuation.
Safety culture
NS promotes a proactive safety culture in which colleagues make a collective effort to create a safe working environment. We do so by listening to each other, being open about safety levels and being aware of the risks involved in our work and our working environment. In 2023, our policy to strengthen the safety culture featured the following key focus areas:
Organisation-wide communication on safety, including a Safety Week and workshops on compliance with safety rules and protocols. In addition, the digital safety portal has been improved so that every employee can easily find up-to-date safety information.
Conversations with employees about incidents and their causes. These conversations create awareness among employees and give them insight into NS’s safety performance.
Conversations between management and employees during workplace safety rounds. During these rounds, we consult employees to find out why safety rules are not complied with in certain situations, and then address the obstacles or issues identified.
STM ATB
In 2023, NS and ProRail conducted a feasibility study on the added functionality in STM ATB (Specific Transmission Module – Automatic Train Protection). This solution uses transponders between the rails to gather and transmit train data, and substantially improves rail safety at a relatively low cost. STM ATB has made it impossible to pass a stop signal at high speed. To minimise safety risks, the addition of this functionality is very important for NS, partly because during the roll-out of ERTMS the ATB system will also remain in use for years to come. In consultation with ProRail, we have decided to build STM ATB with added functionality into the trains that will be equipped with ERTMS. NS will then instruct ProRail to install the transponders in the tracks. The condition is that this should not negatively affect trains that do not yet have this added functionality. Other carriers can also opt to make use of this STM ATB with added functionality.