|Ministry of Railways||A1: seek quick success and benefits; A2: week management and incomplete rule standards;|
A3: unclear job responsibilities and functions; A4: inadequate inspection and supervision for Shanghai Railway Bureau.
|Department of Technologies, Foundation Department, Science and Technology Division CRSC||B1: lack of careful supervision on the bidding of the equipment in Hening-Hewu Yongwen line train control center; B2: poor management of the operation on new products; B3: not enough examination of the LKD2-T1; B4: without clear regulations on the technical review; B5: no valid or regular technical prereview on the equipment LKD2-T1 for train control center; B6: illegal approval from the Science and Technology Division approved to use the LKD2-T1; B7: inadequate inspection and supervision of the quality management by CRSC; B8: little supervision or inspection from CRSC who fully transmit the project to the local design institute; B9: cursory decision on the bidding for the Hening-Hewu line control equipment; B10: unware of the illegal change of version of the train control center equipment in Hefei station.|
|Shanghai Railway Bureau and the signaling design institute||C1: not enough safety education and training; C2: not sufficient inspection and supervision;|
C3: not sensitive safety awareness; not efficient measures to avoid or alleviate the accident; C4: not appropriate accident handling; C5: unwise decision on update of the LKD2-T1; C6: lack of the technical review on the development of the equipment for train control center; C7: lack of responsibility on scientific research management and inefficient control and supervision of the local companies on the product quality.
|Vehicle depot, electricity depot, engineering system and train control institute||D1: poor travel management and emergency handling; D2: not efficient supervision on the safety production management and train service work; lack of supervision to Wenzhou south station; D3: poor supervision on the dispatching institute and the vehicle depot system; D4: insufficient education and training for the staff; D5: lack of job responsibilities of the electricity emergency management; D6: cursory design of the equipment LKD2-T1; D7: poor equipment research and development management in the train control center; D8: the redesign of the equipment LKD2-T1 by the train control institute.|
|The attendants’ behaviors and process||E1: failure of following further situation of red band by the dispatcher in Shanghai Railway Bureau; E2: careless monitoring on the situation of D3115; E3: no reminder of the emergency to D301; E4: no in time contact with the D301 driver; E5: no record of the circuit failure of the 5829AG; E6: no record of the replacement of some equipments of the track circuit besides 5829AG; E7: illegal behaviors; E8: the mistake to inform D3115 to switch to the visual driving mode if the signal was red; E9: D3115 stopped by the ATP; E10: D3115 failed to drive in visual mode 3 times; E11: D3115 failed to report to the dispatcher; E12: D3115 switched to the visual driving mode but still in the 5829AG; E13: D301 left Yongjia station; E14: D301 rear-ended D3115; E15: illegal to open the protection net for work.|
|Equipment and environment||F1: the damage of 4 sender boxes; F2: the damage of 2 receiver boxes; F3: the damage of 1 attenuator; F4: the fuse of F2 in LKD2-T1; F5: the design flaw in PIO of LKD2-T1; F6: the activation of ATP on the D3115; F7: thunder strike; F8: failure of the ATP on D301 which did not take any action; F9: the reduction of CAN total resistance; F10: unavailable communication between 5829AG and the train control center; F11: wrong displays on the terminal; F12: abnormal track circuit signal; F13: a red band; F14: wrong signal which maintained green for the faulted track section; F15: the sending of the unoccupied signal to D301.|