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Analysis of the Tempi train accident using socio-technical methods

Kaimakas Vasileios

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Summary

This thesis addresses the analysis of the Tempi railway accident (February 28, 2023), a tragedy that shocked Greek society not only due to the scale of human loss but also due to the shortcomings in safety management within the railway transportation system. The aim of the study is to examine more deeply the root causes that led to the incident by applying two modern socio-technical methodologies: the ACCIMAP method and the STAMP method. Rather than adopting a narrow causal approach that places responsibility solely on first-level human errors (e.g., the stationmaster), the study attempts to analyze the systemic failures arising from the dynamic and multi-level nature of modern railway systems. The ACCIMAP methodology, introduced by Rasmussen and Svedung, enables the mapping of failures across multiple levels — from political leadership and regulatory authorities to organizational structures, working conditions, and human performance. Its application to the Tempi accident revealed the absence of necessary safety policies, lack of investment in ECTS and remote control systems, fragmentation of responsibilities (OSE, ERGOSE, Hellenic Train, RAS), the inability of the oversight mechanisms to enforce controls, and the failure of the training and certification systems. The STAMP (System-Theoretic Accident Model and Processes) approach views the accident through the lens of control theory and feedback mechanisms. It highlights the failure of the control system to maintain the railway system within safe operational boundaries. Specifically, it revealed critical deficiencies in bottom-up feedback (e.g., failure to evaluate warning signs), as well as flawed control actions (such as those made by the stationmaster), which could not be recognized in time due to weak monitoring mechanisms. The STAMP model also revealed communication breakdowns between system components and a lack of shared understanding regarding actual conditions on the railway network. The fifth chapter of the thesis, which serves as a summary and synthesis of the findings, demonstrates that the accident was the result of broader "systemic chaos." The delay in the implementation of ECTS, the absence of a comprehensive Safety Management System, insufficient retraining of personnel, the disorganization of institutional roles, and the complete lack of a prevention and transparency culture created the conditions under which such an accident could not have been prevented. In response to these findings, the thesis formulates specific recommendations: (1) immediate installation and operation of ECTS throughout the railway network, (2) establishment of an independent national railway safety authority, (3) creation of a national database for incident and near-miss reporting, (4) unification of responsibility structures and a clear separation between infrastructure manager and service provider, and (5) establishment of ongoing training based on realistic risk scenarios. Additionally, a significant cultural shift is essential — safety must be approached as a continuous learning process, not as a bureaucratic obligation. This thesis makes a substantial contribution to the systematic study of railway accidents in Greece, proposing a framework that combines theory and practice with the aim of preventing future tragedies through structural reforms and institutional strengthening of safety.

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