Event

 In the evening of July 30, 2009, a bus having two decks returned from a daytrip to Barcelona in Spain and rode northwestward on highway C‐32 [1, 2]. There were 65 passengers on board, of which 64 having the Dutch nationality and 1 having the German nationality. The passengers were tourists. The driver took the exit Sant Pol de Mar at 23.10 h. The bus could not follow the exit in a bend, rode through terrain, fell over on its left side, and crossed a road leading to the highway. It then broke through a crash barrier. The bus also collided with at least one other car. Six people died in the accident, whereas almost 40 people were injured. The driver was severely injured.

Background of the Accident

 The maximum speed of this bus on a Spanish highway was 100 km h⁻¹. The prescribed maximum velocity for this exit was 40 km h⁻¹. According to the report of the Catalonian police, the driver drove too fast on the exit. It is probable that the driver took the wrong exit as he should have taken the exit Calella, which is 5 km down the track from the exit Sant Pol de Mar. The bend of that exit is less sharp than that of the exit Sant Pol de Mar. The driver overtook several buses shortly before leaving the highway via the exit Sant Pol de Mar.

Putting on a safety belt was obligatory on board this bus. However, many passengers had not put on their safety belt. It is reported that those passengers who had put on their safety belt were practically free from injuries.

Additional Remarks

 The driver drove too fast on the exit. Many passengers had not put on their safety belt. A further aspect is that the bend of the exit was sharp. The prescribed maximum velocity on the exit was 40 km h⁻¹. The prescribed maximum velocity on such an exit in, for instance, The Netherlands is 50 km h⁻¹. The design of exits should take safety aspects into account. Cars leaving the highway still have high speeds and it takes time to reduce the speed. Sharp bends in exits have to be avoided in particular when icy roads have to be taken into account.

Event

 A German bus was hit by a fast train on a level crossing without crossing barriers at Siófok in Hungary at approximately 09.00 hours on May 8, 2003 [3, 4]. The speed of the train was approximately 100 km h⁻¹, and the speed of the bus was very low. The level crossing was equipped with functioning flashing red lights. The train split the bus into two parts. One of the two parts was entrained by the train that came to a standstill about 150 m from the level crossing. The other part was not entrained but took fire and burnt itself out. The locomotive and the first car of the train derailed. A total of 36 German tourists were on board the bus. Thirty‐three bus passengers and the bus driver died in the accident, whereas 3 bus passengers were injured. The train driver was injured, whereas the train passengers were unharmed.

Background of the Accident

 The bus driver possibly tried to stay in touch with buses riding in front of him. He overtook a minibus waiting before the level crossing. Waiting times can be rather long in Hungary. Because of this maneuver, he could only cross the level crossing at a very low speed. He could have noticed both the approaching train and the flashing light.

Two general remarks are made. It is only allowed to cross a level crossing if it is certain that the other side can be reached. It is not allowed to cross a level crossing when flashing lights are present.

Additional Remarks

 The accident is due to human failure. It would probably not have happened if the level crossing would have been designed with crossing barriers.

Event Number 1

 A truck and trailer had loaded 12 metric tonnes of flour from a warehouse at the end of Presterkamp on March 24, 2011 (see Figure 5.1) [5]. The combination then moved backward through Presterkamp and on to the Ochtruper Strasse in the direction of a railroad crossing shortly before 09.20 h. The railroad is a single track one. The driver wanted to enter the Ochtruper Strasse in this way in order to be able to move forward in the opposite direction as a next step. The driver stopped the combination on the railroad crossing. An approaching train hit the trailer subsequently. The train driver and 12 passengers were slightly injured by broken glass. The truck driver had left his cabin and was not injured. The train was damaged severely by the rear shaft of the trailer over a length of approximately 40 m. The truck and the trailer were also severely damaged. They were found again at the same side of the railway track, that is, the side of the warehouse.

Event Number 2

 Event Numbers 1 and 2 happened at the same railroad crossing (see Figure 5.2) [6]. A truck and trailer rode on the Ochtruper Strasse in the direction of the town center on August 5, 2013. Shortly before 11.20 h, the driver stopped the combination when the truck had not yet completely passed the railroad. The driver had wanted to move backward into Presterkamp to deliver the load to the warehouse at the end of Presterkamp. The half‐barriers then closed automatically because a train approached. One half‐barrier came down between the truck and the trailer. Next, the train hit the combination and separated the truck from the trailer. They were found again at different sides of the railway track. The train driver and 14 passengers were slightly injured by broken glass. The truck driver had left his cabin and was also slightly injured. Both the train and the combination were damaged severely.

Additional Remarks

 The drivers of the two truck/trailer combinations stopped on a railroad crossing in order to be able to maneuver their combinations. That is not allowed. A railroad crossing should be passed at a moderate speed if the light signals and acoustic signals are not active.

The railroad crossing and the warehouse are very close to each other. The situation is prone to human mistakes.

Event

 A freight‐train rode on Line Number 53 from Mechelen to Schellebelle in Belgium on May 4, 2013. Schellebelle is the name of both a small community near Wetteren and a junction of the Belgian railway system. There is a switch at Schellebelle junction enabling a train riding on Line 53 from Mechelen to Schellebelle to continue its journey on Line 50 from Brussels to Port of Ghent. Port of Ghent is Gent's sea harbor. It was the intention that the train concerned would continue its trip on Line 50 in the direction of Port of Ghent. The train consisted of 2 engines and 13 wagons. Several wagons contained acrylonitrile, which is a liquid at atmospheric pressure. Its boiling point at atmospheric pressure is 77.3 °C. The compound is inflammable and toxic. The train had a speed over 80 km h⁻¹ when it approached the switch mentioned at Schellebelle shortly before 02.00 h. The train passed a sign instructing the train driver to reduce the speed of the train. However, the train driver did not adjust the speed. When he next saw a sign indicating that the speed should be 40 km h⁻¹, he activated the brakes of the train. Six wagons derailed subsequently in the switch at Schellebelle junction. The contents of three of these damaged wagons took fire. They contained acrylonitrile. The fire‐brigade used water to extinguish the fire. The water used entrained liquid acrylonitrile into the local sewer system. An aspect is that acrylonitrile is soluble in water; a saturated aqueous solution of the compound contains 7.3% by weight of the material at 20 °C. The sewer system of Wetteren became polluted with acrylonitrile. Vapors were resorbed and caused the death of one man aged 64, whereas 49 people experienced serious health problems. Totally, 600 people were evacuated.

Concluding Remarks

 The train driver failed to adapt the train's speed. It is improbable that this accident would have taken place in, for example, The Netherlands, where a train is automatically brought to a halt if the train driver fails to adjust the speed; see Section 3.2.3.

Event

 A fast train carrying passengers was on its way from Madrid to Ferrol in Spain on July 24, 2013. The train consisted of a front power car, eight cars, and a rear power car. Shortly before Santiago di Compostela and at approximately 20.45 h, the train had a speed of 184 km h⁻¹. Signals were given to the driver to reduce the speed to 80 km h⁻¹. The reason for the requested and required reduction of the speed is the fact that there was a bend in the railway ahead. However, the driver did, at that point in time, not adjust the speed. At a later point in time, he activated the brakes and reduced the speed to 153 km h⁻¹. The train had then already entered the bend and derailed. A total of 222 people were on board the train, of which 79 died. More than 120 people were injured, of which 20 seriously. The driver was also injured.

Concluding Remarks

 See the concluding remark of the previous section (Section 5.2.4). It is again the train driver missing the signal to reduce the speed. A human failure! It is known that people tend to make mistakes. Designs should therefore include features to correct the mistakes.

Event

 A train carrying 238 passengers and 5 crew members was on its way from Washington DC to New York City on May 12, 2015 [7]. The train consisted of one locomotive and seven cars. It departed Philadelphia's 30th Street Station at about 09.10 h p.m.. It traveled at a speed of 171 km h⁻¹ when it entered a left curve in the Port Richmond neighborhood of Philadelphia. The train driver then applied the emergency brake and the train derailed and crashed at 09.23 h p.m., while it had a speed of 164 km h⁻¹. The entire train went off the track, with three cars rolling onto their sides. Eight people were killed in the accident and more than 200 people were injured, of which 11 critically.

Additional Remarks

 The driver of the manually controlled train was expected to reduce the speed to maximum 130 km h⁻¹ on approaching the curve. The maximum prescribed speed in the curve was 80 km h⁻¹. However, these speeds were not selected. A projectile may have hit the windshield of the train's locomotive shortly before the derailment so the driver could not see the signals. This aspect is being investigated at present. A system to stop the train automatically or slow it to a safe speed, regardless of driver input, was not in place.

Concluding Remarks

 The train derailed when the emergency brake was activated to reduce the speed in an effort to take the bend. The driver's corrective action was too late.

See further the concluding remarks of Section 5.2.4.

Event

 The Baltic Ace was a roll‐on roll‐off (RoRo) carrier and had a load of 1417 automobiles [8]. It was on its way from Zeebrugge in Belgium to Finland. The ship collided with a container ship, Corvus J, in the North Sea in the evening of December 5, 2012. It was dark at the time of the collision. The Corvus J was on its way from Edinburgh in Scotland to Antwerp in Belgium. The Baltic Ace sunk quickly as a result of the collision. There were 24 men on board, of which 13 were saved and 11 men lost their lives. The Corvus J had suffered minor damage and could continue its journey to Antwerp.

Roll‐on Roll‐off Carriers and Ferries

 The Baltic Ace was 148 m long and 25 m wide. It had eight car decks over the full length of the ship and a capacity of 2000 automobiles. Whereas ships like the Baltic Ace are effective for the transport of automobiles, they suffer from a relatively low stability. The ships can capsize quickly when water enters through a hole in the hull.

An accident resembling the accident of the Baltic Ace occurred in 2002. The RoRo carrier Tricolore collided with the container ship Kariba in The Channel. The Tricolore sank quickly, whereas the Kariba could continue its journey.

In 1987, the RoRo ferry The Herald of Free Enterprise capsized quickly after having left the harbor of Zeebrugge in Belgium. The cause was that water entered the ship through doors that had been left open.

In 1994, the RoRo ferry Estonia capsized quickly in the Baltic Sea. The cause was that, in bad weather, water entered the ship when the doors gave in.

Concluding Remarks

 The stability of most RoRo ships is poor because the main part of these ships is above sea level.

The stability of a ship such as the Baltic Ace could be improved by the installation of bulkheads. Watertight doors in the bulkheads would allow the passage of cars. An additional possibility would be the provision of a double hull.

The present design of RoRo carriers and ferries is a vulnerable design from a safety point of view.

Event

 Members of cabin crews of airplanes state that they suffer from health problems caused by the quality of the cabin air. Their immediate symptoms are headache, vision disorders, and signs of paralysis. Chronic problems of the nervous system are experienced. The problems concern, e.g. the legs, arms, and hands, the memory, and the coordination.

The Alleged Cause of the Health Problems

 Commercial jet airplanes were introduced in 1960s. The airplanes fly at a height of, e.g. 10–12 km. The ambient air pressure is about 0.2 bara at a height of 12 km. The air pressure in the cabin and the cockpit of airplanes is typically maintained at 0.75 bara, the ambient pressure at a height of 2400 m. Air is lost from the airplane because the cabin pressure is higher than the outside pressure. Thus, the air loss has to be made up. This is done as follows. The air needed for the combustion of the fuel in the jet engines is taken from the outside atmosphere and is compressed. Some of this air is passed on to the cabin. Thus, this make‐up air has been in contact with parts of an engine. The motor contains engine oil to which an antiwear additive has been added. The direct contact between the make‐up for the cabin air and the engine oil is prevented by the presence of seals. However, if the oil seals are defective, oil fumes can enter the cabin [9]. Furthermore, the seals are not gastight so that minute amounts of gaseous components resorbed by the engine oil are always entrained by the make‐up for the cabin air. The gaseous components specifically in focus are resorbed by the antiwear additive. Motor engine oil typically contains 1–5% by weight of this material [10]. The chemical name of the additive is tricresyl phosphate (TCP). The additive does not consist of an unambiguously defined chemical compound but is a mixture of isomers of TCP. The antiwear additive is a neurotoxin. The threshold limit value (TLV)–time‐weighted average (TWA) value has been set at 0.1 mg m⁻³. The TWA indication concerns the average exposure on the basis of an 8 hours per day, 40 hours per week working schedule.

Additional Remarks

 The Boeing 787 Dreamliner takes the air for the cabin directly from the atmosphere. Thus, the make‐up air does not come into contact with engine parts.

The Concorde also took the air for the cabin directly from the atmosphere. Again, the make‐up air did not come into contact with parts of engines.

There are indications that there is a relationship between the health problems of members of the cabin crews of airplanes and the presence of TCP in the cabin air. However, the relationship has not yet been unambiguously established.

Concluding Remarks

 In retrospect, it would have been better if the cabin air supply system selected for the Boeing 787 Dreamliner and the Concorde would have been chosen for all commercial jet airplanes in the 1960s. Thus, the occurrence of health problems caused by inhalation of TCP would have been made impossible. In Section 3.2.5, it is recommended that engineering students in the first year acquire knowledge of engineering in general. It is also stipulated that, in general, it has advantages for engineers to also have knowledge of other fields than their own field. The section is on a burning battery in a Boeing 787 Dreamliner in 2013. The aeronautical engineers making the design for the make‐up of the cabin air of jet airplanes could have had a feel for the toxicity of the antiwear additive and the possibility of cabin air contamination.

This case again illustrates that safety, including toxicity items, has to be taken into account in the design stage.

Event

 Kristian Serban died at Hannover in Germany on February 9, 2012 [11]. He had the Rumanian nationality, was 23 years old, and worked in Germany as a building worker. He tried to take clothes out of a container for used clothes and got stuck in the opening of the container. His death was caused by asphyxiation. At the time of his death, the ambient temperature was −13 °C.

Additional Facts

 The container is built to prevent thefts. It is possible to push a lid and then introduce the used clothes through a 20‐cm slot. Usually, the used clothes are brought to the container in plastic bags. However, Kristian Serban pushed the lid and tried to collect used clothes from the container. He then got stuck with his head in the container.

Kristian Serban and his uncle, also of Rumanian nationality, rescued another Rumanian from the same container 1 week earlier.

Concluding Remarks

 Everybody has seen people grabbing in garbage cans to collect items. It should not be possible that those people can manage to get into a container to find themselves trapped in the container. Containers should be designed to allow the passage of clothes into the container. At the same time, they should, normally speaking, not allow the passage of humans. I am sure that it is possible to design such containers and the collection of used clothes can be organized properly.

Event

 A woman fell from a stairs in a restaurant at Zutphen in The Netherlands on April 14, 2014 [12]. She was heavily injured and was taken to a hospital, where she died.

Additional Facts

 The restaurant's wardrobe was close to a stairs leading from the ground floor to the cellar. The woman followed a waiter with the intention to indicate her coat in the wardrobe. On arriving at the wardrobe, she fell down the stairs, probably she focused on her coat and did not pay attention to the stairs.

Concluding Remarks

 The accident would probably not have occurred when the locations of the wardrobe and the stairs would have been separated.

Event

 A car hit a group of people at Raard near Dokkum in The Netherlands shortly after 01.00 h on January 1, 2013 [13, 14]. One man died in a hospital on the same day and 16 people were injured. Four people were seriously injured.

Additional Facts

 A group of approximately 40 people from Raard had come together to celebrate the New Year. A fire had been lighted on the occasion by the side of a public road. Part of the group stood on the public road. Street lighting was not present. It rained at the time of the accident. The driver did not hit the people on purpose. She did not drive too fast. She had neither consumed alcoholic drinks nor was she under the influence of medicines or drugs. Her car appeared to be in working order. It is surmised that the driver did not notice the group because her sight was restricted because of the fire and the rain. The group of people celebrating the New Year did not notice the approaching car either because they paid attention to the fire, were talking with each other, and the wind was blowing.

Coming together to celebrate the New Year at this location was a tradition at Raard.

Concluding Remarks

 A larger distance between a fire and a public road would have been safer. That would call for a different location of the fire. Closing off the public road at the same location would have been an alternative.

Event

 A match between two teams of professional soccer players took place at Eindhoven in The Netherlands on January 18, 2013. One of the players was sent off by the referee because of an incorrect tackle. The player concerned, being on his way to the dressing room, punched a wire glass window in anger and became seriously injured at his arm.

Additional Facts

 The soccer player concerned had not been able to play for 8 months due to injuries. He was disappointed by the referee's decision in the match in which he was able to rejoin the team after his relatively long absence.

Concluding Remarks

 It is known that soccer matches arouse emotions. A player, who was sent off the soccer field, should, on his way to the dressing room, not meet with wire glass windows or wire glass doors. It is known that wire glass windows can cause more harm to humans than wooden doors, iron doors, and stone walls.

Event

 A youth team of a soccer club at Delden in The Netherlands came together at Delden at the end of the season on June 22, 2013 [15]. An inflatable castle was one of the attractions at this party (see Figure 5.3). A gust of wind lifted up the moon bounce and threw it upside down. Several children fell out of it. Three children were injured.

Additional Facts

 The inflatable castle had not been anchored. And 2013 was the third year the club used the moon bounce. Neither incidents nor accidents had happened in the previous years. The inflatable castle was the property of a local school. The club had borrowed it from the school.

Concluding Remark

 It is known that inflatable castles and similar items should be anchored.

Event

 A boy of 8 years old fell into the left part of an M‐shaped water basin at Hengelo (O) in The Netherlands in July 2013 (see Figure 5.4) [16]. The water basin drained off into a drain via a pipe having a diameter of 50 cm and a length of 12 m. The height difference between the basin and the drain was about 1 m. The boy was entrained by the water flow through the pipe and emerged in the drain unharmed.

Additional Facts

 The water basin did not have a fence. A fence consisting of horizontal stainless cords had been present; however, the cords had been stolen. There was no grating between the basin and the drain.

The basin and the drain are part of the local water economy. They are also part of a recreational area.

The boy of 8 years old was accompanied by a boy of similar age. There was no senior supervision. The boys were attracted by the swirl in the basin.

Concluding Remark 

A fence and a grating for the drain would have been appropriate.

Event

 A milking machine was used at a farm at Losser in The Netherlands [17]. Normally, an agent is administered to the teats of the cows to take care of the teats after milking. However, instead of that agent, a cleaning agent for the milking machine was brought into contact with the teats in the evening of December 18, 2009. The cleaning agent was an aqueous solution of sodium hydroxide. The mistake was noticed the next morning. By then, the cleaning agent had caused serious chemical burns of the teats and of the udders and 61 out of a total number of 67 cows had to be slaughtered.

Additional Facts

 Both the agent for the teats and the cleaning agent had been delivered to the farmer in the same blue jerrycans. The jerrycans containing the agent for the teats and the jerrycans containing the cleaning agent were labeled differently. The jerrycans containing the cleaning agent could be connected to the milking machine in the same manner as the jerrycans containing the agent for the teats. The farmer had exchanged the jerrycans containing the agent for the teats for the jerrycans containing the cleaning agent by mistake. Aqueous solutions of sodium hydroxide cause chemical burns.

Concluding Remarks

 Different colors for the jerrycans containing the two agents would have been better. This practice is, for instance, well known in the chemical industry. Furthermore, it should not be possible to connect the jerrycans containing the cleaning agent directly to the line leading to the intermediate storage of the agent for the teats. This practice is also observed in the chemical industry. As a matter of fact, this has been changed in the stock farming.