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

Serious accident – extraordinary event at the pedestrian crossing “Buzin”, September 30, 2024

Serious accident – extraordinary event at the pedestrian crossing “Buzin”, September 30, 2024

Serious accident – extraordinary event at the pedestrian crossing “Buzin”, September 30, 2024

Summary:

On 30th September 2024 at 08:41 AM, on the line M502-1 at km 416+242, between stations Zagreb Klara and Velika Gorica, passenger train number 5104 struck a cyclist who was fatally injured at the scene of accident. Train number 5104 was operating on the route Sisak Caprag – Zagreb Main Station. The cyclist approached from the urban side, passing through the staggered protective barrier without dismounting from the bicycle or verifying whether a train was approaching. While crossing the staggered protective barrier, he wore a hood that significantly restricted his field of vision, preventing him from seeing the approaching train coming from the direction of stop Buzin.

Causal factors of the serious accident are:

  • Careless crossing of the railway by the cyclist; failure to confirm whether it was safe to cross,
  • The cyclist wore a hood that considerably limited his field of view, causing him to fail to notice the train approaching from the direction of stop Buzin,
  • Due to reduced attention and concentration, and significantly restricted visibility, the cyclist was not aware of the dangerous situation posed by the approaching train number 5104.

Contributing factors:

  • Noise from surrounding road traffic, reducing the ability of pedestrian crossing users to hear the train horn,
  • Routine habit — frequent crossing of the pedestrian level crossing (PLC) by the cyclist during periods when no trains run, possibly leading to a false sense of security,
  • Use of the PLC at a different time than on previous days, leading to an erroneous assumption that no train would be passing at that time,
  • Being late for training resulted in haste, which caused imprudent crossing of the PLC.

Systemic factors:

  • The driver of train 5104 activated the train horn once, at 735 metres and 29 seconds before reaching the pedestrian level crossing and activating the emergency brake,
  • The level crossing warning sign was installed at a shorter distance (334 metres) than prescribed (500 metres),
  • Lack of awareness of pedestrian crossing users regarding the dangers of crossing the track.

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 railway system, issues the following safety recommendations to the Agency for Railway Safety:

✓ AIN/06-SR-06/2025

The Infrastructure Manager, HŽ Infrastruktura d.o.o., should improve safety at Buzin Pedestrian Level Crossing (PLC) by additionally securing the crossing with both visual and audible signalling within 24 months. Until the aforementioned conditions are fulfilled, the infrastructure manager, HŽ Infrastruktura d.o.o., shall install a Level Crossing Warning Board at the prescribed distance in accordance with Article 67 67. of the Rulebook on Signals, Signal Signs, and Signal Markings in Railway Traffic (“Official Gazette” no. 94/2015) within 30 days.


✓ AIN/06-SR-07/2025

The infrastructure manager, HŽ Infrastruktura Ltd., should improve safety at the Buzin level crossing by installing a “Caution, Railway-Road Crossing” signal board in the direction from station Zagreb-Klara towards stop Buzin, as prescribed by the Rulebook on Signals, Signal Signs, and Signal Markings in Railway Traffic, (“Official Gazette” no. 94/2015). Additionally, the trackside clearance zone, particularly the area around the signal boards, should be regularly maintained to ensure that train drivers can spot and unequivocally interpret their meaning in good time. The deadline for implementing this recommendation is 30 days.


✓ AIN/06-SR-08/2025

The infrastructure manager, HŽ Infrastruktura Ltd., should, through regular educational programmes, raise awareness among preschool children and pupils of all ages about the dangers of using pedestrian level crossings. This should be done by conducting more frequent campaigns during the school year, such as “The Train is Always Faster,” International Level Crossing Awareness Day (ILCAD), and appropriately using posters, brochures, leaflets, and similar materials.


✓ AIN/06-SR-09/2025

The infrastructure manager, HŽ Infrastruktura ltd, should prescribe written warning signs at all pedestrian level crossings (PLC) and subsequently install them. These signs must alert users for increase caution when crossing the track due to the approach of trains, regardless of the type of crossing protection. Signs should also advise cyclists to dismount before crossing the track to raise awareness of the dangers at PLC. The written warning signs must be prescribed within 24 months and installed within 24 months from the date of prescription.


✓ AIN/06-SR-10/2025

Railway undertakings should emphasise to train drivers during regular training the importance of complying with Article 67 of the Rulebook on Signals, Signal Signs, and Signal Markings in Railway Traffic, (“Official Gazette” no. 94/2015).

Investigation details:

Investigation ID 341-09/24-01/04
Start of investigation 06.11.2024.
End of investigation 27.10.2025.
Type
Status

Documents:

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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 railway system, issues the following safety recommendations:

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