The accident took place on the evening of July 23 2011 when a high-speed train rear-ended another near the eastern Chinese city of Wenzhou. "The disastrous crash was caused by serious design flaws in the train control system, inadequate safety procedure implemented by the authority and poor emergency response to system failure," says the report.
The type LKD2-T1 train control system used at Wenzhou South control centre was developed by Signal & Communication's Beijing National Railway Research & Design Institute, itself a subsidiary of China Railway Signal & Communication Corporation (CRSC).
The report says the Railway Research & Design Institute did not organise a formal research and development team for the LKD2-T1 model, and failed to carry out a comprehensive assessment and conduct testing when the system was produced.
It suggests, CRSC, as the principal contractor for integrating the signalling and telecommunications on the Ningbo - Wenzhou high-speed line, did not fulfil its duty in overseeing the development of the technology.
Meanwhile, the report says the Ministry of Railways (MOR) did not play its role in the bidding, inspection and implementation of the LKD2-T1 model, allowing it to be installed at Wenzhou South before sufficient testing had been completed.
Local railway staff are criticised for their poor emergency response to the system failure (see entry for 19.54 below). Railway workers at both Shanghai and Wenzhou did not notify the driver of Train D301 that Train D3115 was ahead of it in a timely manner.
Throughout the report, however, criticism is consistently directed at Chinese equipment makers and Chinese railway officials and workers. Foreign railway suppliers, which provide components for China's complex high-speed railway systems and equipment, are not mentioned.
The report was heard by an executive meeting of the State Council, or China's cabinet, chaired by Premier Wen Jiabao on December 28. Afterwards, the State Council announced that 54 Chinese officials were being held accountable and several have now been removed from their posts while the rest are being disciplined.
Recognising safety was compromised in the accelerated push to expand the high-speed rail network, the State Council promised improved safety and better oversight of the development of technology within China's high-speed railway industry. "Safety will be placed first in the future development of China's high-speed railway industry," it said in a statement.
The State Council wants China to make proper plans for the scale of high-speed rail investment and the time needed to build high-speed lines. The State Council stressed the importance of quality control in the high-speed railway system and equipment, and said China should establish the recall system for faulty high-speed railway products. China will also set higher standards for selecting technicians working in the high-speed railway sector, and improve the skills of professionals in this area.
The State Council revealed that during the nationwide safety check following the accident, the problematic LKD2-T1 system was discovered on two more high-speed passenger lines. All the LKD2-T1 models have now been rectified and upgraded.
High-speed railway construction virtually came to a halt in China after the July crash. The sector has been hit hard as the government tightened liquidity and the fatal Wenzhou accident eroded investors' confidence affecting the ministry's ability to borrow money or sell bonds.
Total railway infrastructure investment shrank to only Yuan 469bn ($US 74.4bn) in 2011, a 33% drop from the more than Yuan 700bn invested in 2010, according to MOR data. Railway spending is expected to slow down further this year, as the country only plans to invest Yuan 400bn in railway infrastructure construction, says MOR.
However, the State Council meeting says high-speed railway development is "the right direction" as it helps to improve public transport and boosts economic growth. As long as China strengthens the quality of its railway management, improves safety, and puts more effort into technical innovation, the Chinese high-speed rail sector will advance in a scientific, safe and sustainable manner, the meeting concluded.
Countdown to disaster
Chronicle of events on the evening of July 23 2011
19.30 (approx): a lightning strike causes a problem in the LKD2-T1 type train control system installed at Wenzhou South. A fuse in data collection unit blows out, cutting off the electronic channel for messages to pass between trains and the control centre. As there are no trains on the section monitored by Wenzhou South prior to the blowout, signals remain at green. Frequent lightning strikes also cause a fault in the track circuit of the 750m block section 5829AG between Yongjia and Wenzhou South. Due to the problem, a train will stop when it arrives at this section. A red zone warning flashed on the screen at Wenzhou South control centre indicating the problem in the 5829AG section.
19.39: Mr Zang Kai, on duty at Wenzhou South, spots the red zone warning, informs the main dispatch centre in Shanghai and reports the problem to technicians at Wenzhou South.
19.45: Technicians start to repair the fault, but are unable to resolve it prior to the accident.
19.51: Train D3115, bound for Wenzhou South, arrives at Yongjia, 15.56km north of Wenzhou South.
19.54: The Shanghai dispatch centre, already informed about the red zone warning from Wenzhou station, notices that the red zone warning has not appeared on its screen, indicating a system failure. Shanghai warns Yongjia and Wenzhou South not to rely on the automatic mode of train dispatching and orders them to dispatch trains manually.
20.09: Shanghai informs the driver of D3115 waiting at Yongjia about the problem with the 5829AG block section. Shanghai says the automatic train protection (ATP) system on D3115 will stop the train when it arrives at the 5829AG section. The driver can switch to driving according to visible lineside signals at a maximum speed of 20km/h and restart the train. When the train leaves section 5829AG, the ATP should start to receive normal signals again and the train should automatically switch back to standard operating mode. Shanghai asks D3115 to prepare to leave Yongjia and head for block section 5829AG. 20.12: Train D301 arrives at Yongjia.
20.14: Train D3115 departs Yongjia.
20.21: Train D3115 arrives at section 5829AG and the automatic brake system functions. The driver attempts to change the driving mode as instructed to restart the train, but he fails. He tries three times, but each attempt fails.
20.22 - 20.27: The driver of Train D3115 tries six times to contact Shanghai dispatch centre, but all attempts fail. Wenzhou control centre tries three times to call the driver, but is unable to reach him. Chinese Railways uses GSM-R for communication between drivers and dispatchers.
20.24: Shanghai dispatch centre instructs train D301 to depart Yongjia and head for Wenzhou South. The driver of D301, who has received the order from Shanghai and has seen a green signal indicating there is no train on the line ahead, starts the train and departs Yongjia. The signal should be showing a red aspect as D3115 is in the 5829AG block section, but it is green because the lightning strike has damaged the data collecting unit in the LKD2-T1 system installed at Wenzhou control centre.
20.27: Wenzhou control centre reaches the driver of train D3115 and learns that the train is stationary.
20.29.26: The driver of train D3115 successfully changes the driving mode and restarts the train, proceeding at less than 20km/h.
20.29.32: Wenzhou control centre calls the driver of D301 which is now very close to section 5829AG, and says: "Be careful D301! D3115 is ahead of you! Be careful!" The line goes dead. Train D301 is already in section 5829AG. The driver applies the brakes.
20.30.05: Train D301 travelling at 99km/h rear-ends D3115 which is moving at 16km/h, killing 40 and injuring 172.