Report on Railway Accident with Freight Car Set That Rolled Uncontrolledly from Alnabru to Sydhavna on 24 March 2010
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Issued March 2011 REPORT JB 2011/03 REPORT ON RAILWAY ACCIDENT WITH FREIGHT CAR SET THAT ROLLED UNCONTROLLEDLY FROM ALNABRU TO SYDHAVNA ON 24 MARCH 2010 Accident Investigation Board Norway • P.O. Box 213, N-2001 Lillestrøm, Norway • Phone: + 47 63 89 63 00 • Fax: + 47 63 89 63 01 www.aibn.no • [email protected] This report has been translated into English and published by the AIBN to facilitate access by international readers. As accurate as the translation might be, the original Norwegian text takes precedence as the report of reference. The Accident Investigation Board has compiled this report for the sole purpose of improving railway safety. The object of any investigation is to identify faults or discrepancies which may endanger railway safety, whether or not these are causal factors in the accident, and to make safety recommendations. It is not the Board’s task to apportion blame or liability. Use of this report for any other purpose than for railway safety should be avoided. Photos: AIBN and Ruter As Accident Investigation Board Norway Page 2 TABLE OF CONTENTS NOTIFICATION OF THE ACCIDENT ............................................................................................. 4 SUMMARY ......................................................................................................................................... 4 1. INFORMATION ABOUT THE ACCIDENT ..................................................................... 6 1.1 Chain of events .................................................................................................................... 6 1.2 Scene of the accident ........................................................................................................... 9 1.3 Notification and rescue efforts ........................................................................................... 10 1.4 Injuries ............................................................................................................................... 11 1.5 Personnel involved ............................................................................................................. 11 1.6 Rolling stock involved ....................................................................................................... 12 1.7 Infrastructure and roads ..................................................................................................... 12 1.8 Traffic control .................................................................................................................... 14 1.9 Weather .............................................................................................................................. 15 2. INVESTIGATIONS CARRIED OUT ............................................................................... 15 2.1 The investigation – process, methods and limitations ....................................................... 15 2.2 Railway infrastructure – design, conditions and use ......................................................... 16 2.3 Condition and functionality of the technical systems ........................................................ 23 2.4 Traffic control and communication ................................................................................... 28 2.5 Recordings ......................................................................................................................... 29 2.6 Documentation of operational conditions .......................................................................... 32 2.7 Rescue operations .............................................................................................................. 35 2.8 The Norwegian National Rail Administration (NNRA) .................................................... 36 2.9 CargoNet AS ...................................................................................................................... 45 2.10 Oslo Havn KF .................................................................................................................... 49 2.11 Interaction between the organisations ................................................................................ 50 2.12 Structural changes and growth in freight traffic by rail ..................................................... 51 2.13 Risk picture for Alnabru .................................................................................................... 54 2.14 Supervision by regulatory bodies ....................................................................................... 64 2.15 Acts and regulations ........................................................................................................... 68 2.16 Relevant theory .................................................................................................................. 74 2.17 Other information ............................................................................................................... 77 3. ANALYSIS ........................................................................................................................ 78 3.1 Introduction ........................................................................................................................ 78 3.2 Event analysis .................................................................................................................... 78 3.3 Barrier analysis .................................................................................................................. 82 3.4 Impact analysis and analysis of survival aspects ............................................................... 85 3.5 Work practice and operational conditions ......................................................................... 86 3.6 Safety management ............................................................................................................ 97 3.7 Culture .............................................................................................................................. 106 3.8 Internal and inter-organisational collaboration ................................................................ 110 3.9 History and development ................................................................................................. 114 3.10 Supervisory authority ....................................................................................................... 116 Accident Investigation Board Norway Page 3 4. CONCLUSIONS .............................................................................................................. 117 4.1 Investigation results ......................................................................................................... 117 4.2 Main conclusion ............................................................................................................... 121 5. MEASURES TAKEN AFTER THE ACCIDENT .......................................................... 122 5.1 Measures taken by the NNRA after the accident ............................................................. 122 5.2 Measures taken by CargoNet AS after the accident ........................................................ 123 5.3 Measures taken by Oslo Havn KF after the accident ....................................................... 124 6. SAFETY RECOMMENDATIONS ................................................................................. 125 REFERENCES..................................................................................................................................... 1 LIST OF DEFINITIONS ..................................................................................................................... 3 ANNEXES ........................................................................................................................................... 6 Accident Investigation Board Norway Page 4 REPORT ON RAILWAY ACCIDENT Train number: Freight car set for trains 5806–5807 Train data: Weight 435.5 tonnes Length 458.4 metres Rolling stock involved: Special freight cars for containers, semi-trailers and swap bodies Registration: Norwegian Owner: CargoNet AS User: CargoNet AS Crew: None Passengers: None Accident site: Port of Oslo, Sydhavna Time of accident: Wednesday, 24 March, at approximately 13:13:15 NOTIFICATION OF THE ACCIDENT The Accident Investigation Board Norway (AIBN) was notified of the accident by the Norwegian National Rail Administration (NNRA) at 13.15 and by CargoNet AS some time afterwards. Three members of the AIBN travelled to Sydhavna. Later that day another three people were sent for, to assist with the preliminary investigation, which continued at Alnabru throughout that afternoon. Loenga and Alnabru yards were closed after the accident. All the relevant communications logs and signal logs were secured. The technical investigations were undertaken jointly by the police and the NNRA. An additional three people joined the AIBN's investigating group on the following day. The parties concerned were informed by letter of 29 March 2010 that the AIBN was launching a safety inquiry into the accident. SUMMARY On Wednesday, 24 March 2010, a freight car set consisting of empty container freight cars rolled uncontrolledly from Alnabru shunting yard, down to Loenga and into the sea at Sydhavna in the Port of Oslo. The AIBN has carried out a safety inquiry into the accident and is submitting a total of seven safety recommendations based on this. The accident was triggered by a misunderstanding between the local traffic controller