At first it looked like a crazy accident. A contractor was making a sharp turn with his truck on a sandy road. He had been hired to reinforce a steep slope on Taiwan’s east coast – any falling debris could pose a safety concern for trains running below.
At the edge of the ravine, his truck got stuck. He and another worker attempted to free him using a strip of cloth and an excavator. The track broke and the truck rolled down the hill onto the railroad tracks.
About a minute later, the Taroko Express # 408 collided with the truck, killing 49 people and injuring more than 200.
In an instant, the scenic oceanfront mountain became the site of Taiwan’s deadliest rail disaster in seven decades.
This April morning’s tragedy is one of many crises that have rocked democracy on this island of 23.5 million people, which prides itself on being a responsible and well-run society. It undermined confidence in the government at a time when Taiwan was grappling with an outbreak of coronavirus cases and ongoing power outages.
Although the prosecution has accused the contractor, Lee Yi-hsiang, and others of manslaughter, the roots of the disaster run much deeper, revealing systemic flaws in the government agency that manages the rail system, the Taiwan Railway Administration.
A detailed examination of the crash by The New York Times, based on interviews with current and past officials, railroad workers, contractors and safety experts, found the agency was suffering from a culture complacency and weak oversight.
Contractors like Lee were mismanaged, maintenance issues were frequent, and authorities failed to see or ignore safety warnings, creating conditions that contributed to the crash.
A government adviser told authorities in 2017 that the line the crash happened on was an accident waiting to happen. Earlier this year, an employee of a local agency twice warned of the risk of heavy equipment maneuvering around the same bend. Nobody did anything. Authorities are investigating whether the agency should have done more then, a prosecutor in the case, Chou Fang-yi, told The Times.
Lee should not have been hired for the job, according to the agency’s guidelines. According to the indictment, he illegally presented his company in the tender, using references from a larger and more experienced company to qualify for the project. The agency did not do enough due diligence to reveal the problem. “This accident could have been avoided,” Li Kang, a member of the Taiwan Transportation Safety Council, the government agency investigating the accident, said in an interview.
Since the disaster, Taiwanese President Tsai Ing-wen has vowed to address long-standing grievances over the Taiwan Railways Administration, which offered more than 500,000 trips a day before the pandemic. A report by Taiwan’s Ministry of Transportation released on Sunday pointed to flaws in the agency’s security processes and in the administration of construction projects.
The railway agency said it was implementing reforms. In May, he reprimanded 12 workers for “inadequate supervision and management” of the project at the crash site, but none were dismissed.
In a written response to questions, the agency said the reprimands were “a warning and an opportunity for officials to reflect on their breach of duty.”
Old promises of improvement have had little effect. Tsai’s government called for reforms in 2018 after a train crash in the northeast that left 18 people dead. While some recommendations have been instituted, structural changes have not.
Since 2012, the agency’s trains have suffered 216 major accidents, including collisions and derailments, according to an analysis by the Ministry of Transportation of Taiwan Data Times. The accidents killed 437 people. By comparison, Taiwan’s high-speed train, the island’s newest system on the west coast, did not experience any serious accidents during the same period.
“Usually when there is an accident, the reaction of TRA is to have a meeting, to discuss, to have a conference and an exercise, and to tell the workers that this is the correct protocol,” said Lu Chieh-shen, who worked at the agency. for 38 years and served as General Manager from 2016 to 2018. “Then they go back to their routine.”
On the morning of April 2, Lee was not supposed to work. It was Tomb Sweep Day, a holiday where people honor their ancestors. But he was late and did not want to be fined for missing the deadline, according to the prosecution. He hired several other workers, but no outside security supervisor was monitoring the site, as required by government regulations.
At least twice before, construction vehicles had stalled on the same road where Lee’s truck had stalled on the bend, according to the indictment. In January, a railway agency employee warned project safety supervisors to improve the grade and surface of the road and install protective fencing. This has not been done.
Lee shouldn’t have had the job in the first place. When the Taiwan Railway Administration looked for companies to strengthen the slope in 2019, Lee’s two companies were ineligible because they had no experience in this kind of work. Lee therefore used the license of a larger firm, Tung Hsin Construction, to apply, although this is illegal, according to the prosecution. In return, the promoters say, he offered the company a larger share of the profits.
Contractors and experts who spoke to The Times said the agency often awarded contracts to the lowest bidder, prioritizing savings over safety. The focus on costs, according to two entrepreneurs, deterred more reputable companies from showing up.
The agency “believes in using cheap labor to perform high-risk operations,” said Chen Hong-shan, an entrepreneur who has worked on several projects for railway management. . “It has been their practice for decades. He added that the agency’s budgets are often too little earmarked for security measures, contractors had to take shortcuts to make the work profitable, compromising the work.
The agency, in a written response, said that while some contracts went to the company that made the lowest bid, others went to the “most advantageous”. In these cases, the agency said, a contractor’s safety record and experience were deciding factors.
Prosecutors indicted Lee and six others with criminal liability; four were charged with manslaughter. If found guilty on all counts, Lee could face 12 years in prison.
In 2017, Liao Ching-lung, rail safety expert and government adviser, was studying a video of a train derailment on the east coast of Taiwan, when he noticed something alarming: the railroad tracks were in a mess. dismal condition. Worried, he asked for a meeting with officials from the Ministry of Transport. “I told them it was a matter of time before there was an accident on the railroad,” he said. Liao’s warning was premonitory.
In 2018, the Puyuma Express, another train operated by the rail agency, derailed on the same route, called the Northern Curva Line, killing 18 people. And the shock of April came in the same direction.
Although the safety council’s investigation into the Puyuma crash blamed the driver for disabling the automatic speed warning system, the council’s report also highlighted problems endemic to the agency, claiming that he regularly delayed or avoided repairs and maintenance of cars and rails. .
The council also cited the agency’s failure to provide workers with adequate equipment and safety training. The way the agency is organized “may make the company’s concern about rail safety a priority in decision-making,” the board warned in its final report, released last year.
Board investigators told The Times the agency had not fully implemented the changes it said it had made. For example, the agency, despite its allegations, does not yet have a comprehensive formal process for reporting maintenance issues, Li, one of the investigators, said. “They had only accepted the changes on paper – they had not put them into effect,” said Young Hong-tsu, chairman of the security council.
After the Taroko Express crash in April, the Ministry of Labor audited 195 projects underway at the railway agency and discovered 306 cases of security breaches on construction sites. These include the failure to install protective fencing and inadequate risk assessments. Work was suspended in 15 cases.
Since the April crash, the agency said it will install more barriers along the tracks to catch falling debris, as well as sensors to warn drivers of potential obstacles. She also said she would use surveillance technology to better monitor construction sites. The government plans to give more than $ 500,000 to the family of each person killed in the crash.