Air, Maritime and Railway Traffic Accidents Investigation Agency

Air, Maritime and Railway Traffic Accidents Investigation Agency

Air, Maritime and Railway Traffic Accidents Investigation Agency

Air, Maritime and Railway Traffic Accidents Investigation Agency

Incident – Trains collision near miss, trains number 61015 and 5104 at station Lekenik on the line M502-2, on March 19, 2025

Incident – Trains collision near miss, trains number 61015 and 5104 at station Lekenik on the line M502-2, on March 19, 2025

Incident – Trains collision near miss, trains number 61015 and 5104 at station Lekenik on the line M502-2, on March 19, 2025

Summary:

On 19 March 2025 at 08:21 am, was trains collision near miss between freight train 61015 and passenger train 5104 on line M502-2 between Velika Gorica, Sisak and Novska, at Lekenik station (km 390+450). Freight train 61015 (HŽ Cargo) passed Turopolje station at 08:11 am. The train was routed to enter Lekenik station, where it was scheduled to stop for a crossing with passenger train 5104 which was approaching from the opposite direction Greda station. The train was supposed to stop in front of the exit signal C-3, which showed “STOP”. The driver applied the brakes, but the train’s speed did not decrease enough for the train to stop in front of the exit signal C-3. As he passed the train operator, who was standing on the platform, he shouted to him that he could not stop the train. The train operator then contacted the Control Dispatching Unit (CDU) and requested the power to be switched off on the open line section between Lekenik station and Greda station. Freight train 61015 stopped at km 389+780, and passenger train 5104 at km 388+450. The trains stopped head-to-head at a distance of 1330 m.

There were no injuries in the incident, and there was no material damage to rolling stock or railway infrastructure.

Causal factor of the incident:

  • deviation from standard operating procedures when handling the automatic air brake system; specifically, the prescribed brake test (coupling “Type C” brake test) was omitted prior to moving off, and the effectiveness of the automatic brakes was not verified after departure.

 

Contributing factor:

  • none identified.

 

Systemic factors:

  • during the train hand-over at Velika Gorica station, a lack of alignment with prescribed protocols resulted in the omission of the exchange and dual-signing of the Train Hand-over Report SE-4,
  • no second competent executive staff member (in addition to the driver) was provided to conduct the brake test in the prescribed manner,
  • the hazard “incorrect performance or omission of the prescribed brake test” were not recognised in the railway undertaking’s risk register

The Air, Maritime and Railway Traffic Accidents Investigation Agency, based on the conducted investigation of this incident, in order to increase the safety of the railway system, addresses the following safety recommendations to the Agency for Railway Safety:

✓ AIN/06-SR-5/2026

The railway undertaking HŽ CARGO should, during teaching and training train drivers, devote greater attention to the adequate use of automatic air brakes, i.e. braking procedures, securing trains against self-starting, performing braking tests, and the importance of keeping prescribed records, exchanging and co-signing them with train operators when handing over trains.


✓ AIN/06-SR-6/2026

When performing a braking test, the railway undertaking HŽ CARGO should ensure that, in addition to the train driver, another professionally trained executive worker to ensure that braking tests are performed in the appropriate/prescribed manner.


✓ AIN/06-SR-7/2026

The railway undertaking HŽ CARGO should assess the risks created by the hazard “incorrect performance or omission of the prescribed brake test” and take effective measures to control the hazards.

✓ AIN/06-SR-8/2026

The infrastructure manager HŽ Infrastruktura d.o.o. should, during the training of train operators, emphasize the importance of keeping prescribed records, and their exchange and co-signing with train drivers during handing over trains.

Investigation details:

Investigation ID 341-09/25-03/117
Start of investigation 04.04.2025.
End of investigation 08.05.2026.
Type
Status

Documents:

i

Safety recommendations:

The Air, Maritime and Railway Traffic Accidents Investigation Agency, based on the conducted investigation of this accident, in order to increase the safety of the system, issues the following safety recommendations and/or safety lessons:

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