Upload
tranlien
View
216
Download
0
Embed Size (px)
Citation preview
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only val-id version is the original version provided by the NIB
Postadress/Postal address Besöksadress/Visitors Telefon/Phone Fax/Facsimile E-post/E-mail Internet
PO Box 12538 Sveavägen 151 +46 8 508 862 00 +46 8 508 862 90 [email protected] www.havkom.se
SE-102 29 Stockholm Stockholm
Sweden
Ref. No A-154/14
NIB ANNUAL REPORT 2013
Swedish Accident Investigation Authority
SWEDEN
NIB ANNUAL REPORT 2013
Swedish Accident Investigation Authority Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
Contents
1 INTRODUCTION..................................................................................................... 4
1.1 Laws ............................................................................................................................... 4
1.2 Role and tasks ................................................................................................................ 4
1.3 Organisation .................................................................................................................. 5
2 INVESTIGATIONS .................................................................................................. 6
2.1 Investigations completed in 2013 .................................................................................. 6
2.2 Investigations completed in 2009-2013 ......................................................................... 6
2.3 Investigations launched in 2012-2013 but not completed in 2013 ................................ 9
2.4 Summaries of investigations completed in 2013 ......................................................... 10
2.5 Accidents and incidents investigated in the last five years .......................................... 16
3 Recommendations 2013 ........................................................................................... 17
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
4 (19)
1 INTRODUCTION
1.1 Laws
The Swedish Accident Investigation Authority (SHK) is an independent body. The SHK’s
activities are regulated by, inter alia, the Accident Investigation Act (1990:712), the
Accident Investigations Ordinance (1990:717), and Ordinance (2007:860) providing
instructions for the SHK.
The Railway Safety Directive (2004/49/EC) has been transposed into Swedish law through
these provisions.
1.2 Role and tasks
The Swedish Accident Investigation Authority (SHK) investigates trackbound traffic
accidents if they were caused by collisions between rail vehicles, derailments, or other
events of significance to safety that resulted in at least one fatality or at least five serious
injuries or which result in extensive damage to rail vehicles, track systems, property which
was not being transported by the rail vehicle, or to the environment and where the total costs
of such damage are estimated at an amount equal to at least EUR 2 million. An incident
must be investigated if:
it involved a serious risk for an accident,
it suggests serious faults in rail vehicles or track systems, etc., or it suggests other
significant safety deficiencies.
A coordinator from concerned supervisory bodies regularly observes the investigation.
The purpose of an SHK investigation is to:
Insofar as possible, clarify the course of events and cause(s) as well as damages and
other effects.
Provide a basis for decisions on measures aimed at preventing similar events from
occurring or at limiting their impact.
Provide a basis for an assessment of emergency services' actions in connection with
the event and, if necessary, for improvements in emergency services.
At the end of the fact-finding phase, the SHK convenes an incident meeting at which all the
facts are presented. All parties impacted by the event are invited to participate in this
meeting. Representatives from interest groups and labour unions are also usually invited.
When necessary, the SHK shall make recommendations to the respective supervisory body
or safety authority on which to base decisions for suitable measures.
The role of the SHK does not include taking a position on matters of liability or damage
claims. The investigations are aimed solely at improving safety.
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
5 (19)
1.3 Organisation
Under current provisions, an SHK investigation shall always consist of one Chair and at
least one additional investigator.
Considering the wide range of events that may be subject to an accident investigation, the
SHK must occasionally engage external experts who, using their respective expertise, work
for the SHK by gathering facts and performing analyses. The SHK has contracted experts in
various fields for the most common types of investigations.
Director-General (1)
Department 1
Maritime, rail, road, and
other serious accidents as
well as emergency services
(11)
Department 2
Aviation, military accidents,
and emergency services
(11)
Administrative
department
Record-keeping
Accounting
Personnel/HR
Administration
(5)
(4)
Secretariat
Chair (2)
Head of Admin. (1)
(2)
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
6 (19)
2 INVESTIGATIONS
2.1 Investigations completed in 2013
Type of
event
Number
of events
Property
damage in €
(estimate) Fatalities Seriously injured
Near-
collision
2 0
Derailment
incident
1 0
Other incidents
Technical fault
1 0
2.2 Investigations completed in 2009-2013
Basis for investigation:
i = in accordance with the Railway Safety Directive
ii = in accordance with national legislation (possible areas that are exempted under Article 2, § 2)
iii = voluntary investigations – other criteria (national laws not referred to in
the Railway Safety Directive).
Investigations completed in 2009
Date of
the event
Title of investigation Legal basis Completed
07/08/2007 Near-collision between trains 90161 and 52517
at Stockholm Central Station, Stockholm
County.
i 17/03/2009
26/09/2006 Accident during shunting in Hallsberg, Örebro
County.
iii 24/03/2009
11/04/2008 Near-collision at level crossing between lorry
with trailer and passenger train 3763 on the
Stora Höga-Kode section, Västra Götaland
County.
i 31/03/2009
09/06/2008 Near-collision between a blocked-line operation
for transport and train 3539 at Bryngenäs
Station,
Västra Götaland County.
i 09/06/2009
19/01/2006 Near-collision of train 2510 in
Västerhaninge, Stockholm County.
i 25/06/2009
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
7 (19)
17/06/2008 Near-collision between train 7081 and
blocked-line operation 76910 at Klockarbäcken
passing loop on the Umeå-Brännland section,
Västerbotten County.
i 06/10/2009
29/07/2008 Near-collision between blocked-line operation
for transport and train 10093 at Torneträsk
Station, Norrbotten County.
i 03/12/2009
21/12/2008 Derailment of blocked-line operation 73664 at
Kimstad station, Östergötland County.
i 15/12/2009
16/05/2005 Fire in metro train at Rinkeby Station,
Stockholm County.
i 22/12/2009
26/07/2007 Derailment of train 412 at Gnesta Station,
Södermanland County.
i 22/12/2009
Investigations completed in 2010
Date of
the event
Title of investigation Legal basis Completed
20/07/2007 Fire in tamping machine SPR 3208B on the
Bräckefors-Ed section, Västra Götaland County.
i 27/01/2010
24/11/2007 Fire in rail maintenance vehicle DSS 1866B,
Grötingen, Jämtland County.
i 31/03/2010
05/08/2007 Near-collision between passenger train 219 and a
shunting movement at Stockholm östra [East],
Stockholm County.
i 25/10/2010
04/06/2008 Accident, derailment of train 814 on the
Rotebro-Upplands Väsby section, Stockholm
County.
i 21/12/2010
Investigations completed in 2011
Date of
the event
Title of investigation Legal basis Completed
02/05/2009 Incident with rolling wagons on the
Östavall-Alby section, Västernorrland County.
i 02/02/2011
01/02/2010 Accident, track worker hit at Linghem interlocking
area, Östergötland County.
i 22/06/2011
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
8 (19)
13/03/2010 Near-collision between train 9765 and train 92 at
Skutskärs södra [south], Gävleborg County.
i 09/03/2011
09/09/2010 Level-crossing accident with train 3750
on the Solgården level crossing, Västra Götaland
County.
i 05/09/2011
Investigations completed in 2012
Date of
the event
Title of investigation Legal basis Completed
04/06/2010 Impact accident at Karlberg interlocking area,
Stockholm County.
i 01/08/2012
12/09/2010 Accident between train 505 and a backhoe
loader on rails at Kimstad interlocking area,
Östergötland County.
i 10/10/2012
17/11/2010 Impact incident involving personnel working
in the track at Skavstaby interlocking area,
Stockholm County.
i 25/10/2012
27/01/2011 Accident involving dropped load, train 9132 at
Frövi interlocking area, Örebro County.
i 05/11/2012
09/06/2011 Near-collision of two trains at
Nyhem interlocking area, Jämtland County.
i 01/06/2012
Investigations completed in 2013
Date of
the event
Title of investigation Legal basis Completed
01/11/2011 Near-collision of two blocked-line operations
between Hoting in Jämtland County and
Storuman in Västerbotten County.
i 29/01/2013
30/01/2012 Near-collision between train 6225 and a shunting
movement at Helsingborg freight yard, Skåne
County.
i 12/06/2013
02/11/2011 Derailment incident involving train 15003 on the
section between Malmö, Skåne County (Sweden)
and Helgoland (Denmark).
i 14/06/2013
24/05/2011
09/06/2011
Incident involving a technical fault in a metro
train at the Medborgarplatsen and Slussen metro
stations, Stockholm County.
i 21/11/2013
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
9 (19)
2.3 Investigations launched in 2012-2013 but not completed in 2013
Investigations launched in 2012
Date of
the event
Title of investigation Legal basis
09/02/2012 Accident involving train 614 and lorry between Hägernäs and
Rydbo, Stockholm County.
i
12/06/2012 Incident involving train 8005 and green zone work in the track
on the Fagersta-Smedjebacken section, Dalarna County.
i
20/09/2012 Accident to person involving a remote control locomotive at
the Sundsvall marshalling yard, Västernorrland County.
i
14/11/2012 Thematic investigation – safety in track environment work. iii
Investigations launched in 2013
Date of
the event
Title of investigation Legal basis
15/01/2013 Accident on Saltsjöbanan [the Saltsjö Line], Stockholm
County.
i
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
10 (19)
2.4 Summaries of investigations completed in 2013
On Tuesday, 1 November 2011 there was a near-collision of two blocked-line operations between
Hoting in Jämtland County and Storuman in Västerbotten County.
A crew that had been replacing sleepers on Inlandsbanan [the Inland Line] completed their work
earlier than expected. The crew supervisor contacted the dispatcher in Hoting to extend their time and
change the end location of the blocked-line operation to Hoting. The dispatcher approved the new
end time and end location. Later that morning, another supervisor requested a blocked-line operation
from the dispatcher in Hoting in order to tighten fish bolts with a motor trolley at the Hoting-Dorotea
boundary points. The dispatcher in Hoting approved the blocked-line operation without requiring
consultation.
At 13:15, the supervisors for the blocked-line operations caught sight of each other on a straight
section between Hoting and Storuman. Blocked-line operation 1 was moving at a low speed, the
driver braked and managed to stop before a collision occurred. Blocked line operation 2 was
stationary.
The incident occurred because the end location for blocked-line operation 1 was changed such that it
fell outside the blocked-line operation's boundary points without the supervisor or any of the
dispatchers taking notice of the fact.
One underlying reason is that blocked-line operation 1 was not completed before the end location
was changed. Another underlying reason is that the dispatcher who approved the change mixed up
the rows of boundary points and monitored sections in Etam and therefore did not notice that the new
end location landed outside the boundary points. Thus when granting blocked-line operation 2 the
permission to proceed, the dispatcher saw no need to call for the blocked-line operations to consult
with each other.
The safety management system for Inlandsbanan failed to detect that in some cases the Etam system
may be perceived as a control system and that the accuracy/attentiveness of dispatchers sometimes
falls short when handling the system. The safety management system for Inlandsbanan also failed to
detect that the transition to Etam was a type of substantial change which should have been notified to
the Swedish Transport Agency in order to assess whether or not a review was needed for
Inlandsbanan's authorisation as an infrastructure manager.
Report RJ 2013:01
Near-collision of two blocked-line opertions
between Hoting in Jämtland County and
Storuman in Västerbotten County on
1 November 2011.
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
11 (19)
Infranord's safety management system failed to detect shortcomings in local knowledge, management
of blocked-line operations, and alarm protocol.
On Monday, 30 January 2012 there was a near-collision between train 6225 and a shunting
movement at Helsingborg freight yard, Skåne County.
The shunting movement, which consisted of a single locomotive, was to be shunted from track 12 at
Helsingborg freight yard in order to be coupled with wagons and form train 4300. The shunting was
to be driven to dwarf shunting signal 154, which displayed ‘stop’ and was the shunting path's end
point. At the time of the incident, dwarf shunting signal 154 was located on the right side of the track
with a complementary sign in the shape of an arrow pointing towards the track to which the signal
belonged.
The shunting movement passed dwarf shunting signal 154 at danger while it displayed ‘stop’. A
second later train 6225 passed its final facing main signal and entered track 6. Approximately
30 seconds later, the shunting movement passed stop lamp 145 and entered track 6. The shunting
supervisor and the driver of train 6225 noticed each other and stopped their vehicles before a
collision could occur.
The cause of the incident was that the dwarf shunting signal was passed at ‘stop’ because it was not
noticed. Subsequent stop lamps also went unnoticed.
Contributing factors to the dwarf shunting signal going unnoticed: it was located on the right, which
the supervisor did not expect; the signal's complementary sign was small and indistinct; the
supervisor's local knowledge was limited; and visibility was limited by harsh sunlight, dirty windows
on the locomotive and – from a distance and to some extent – the ‘pre-heater’ that obstructed the
view. Since the supervisor had received ‘movement allowed’ at the previous dwarf shunting signal
and not noticed dwarf shunting signal 154, he probably did not keep an eye out for subsequent stop
lamps.
Report RJ 2013:02
Near-collision between train 6225 and
a shunting movement at Helsingborg
freight yard, Skåne County on
30 January 2012.
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
12 (19)
On Wednesday, 2 November 2011, there was a derailment incident on the section of Malmö, Skåne
County (Sweden) – Helgoland (Denmark).
A twinset that had an axle on a dolly because of wheel damage was coupled into a trainset – without
anybody noticing the dolly – in a train over the Oresund link. The train reached a maximum speed of
approximately 180 km/h. The unit with the dolly had a speed restriction in Sweden of 20 km/h on
straight track and 5 km/h through points. In Denmark, the speed was restricted to 40 km/h on straight
track and 10 km/h through points.
The direct cause of the incident was that the unit on the dolly was coupled together with two other
units into a train, even though it should not have been put there, and that the train movement then
started without the train being prepared and checked in accordance with the railway undertaking's
safety provisions.
A likely contributing factor is the differences in regulatory frameworks between Denmark and
Sweden as regards the steps included in clearing a train.
Another contributing factor may have been the shortage of time in the handovers from one shunter to
another during shift changes.
Report RJ 2013:03
Derailment incident on the section of
Malmö, Skåne County (Sweden) –
Helgoland (Denmark) involving
train 15003 on 2 November 2011.
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
13 (19)
Underlying causes were deficiencies at both DSB and ISS Trafficare regarding documented
procedures and instructions for transferring information, performance testing, clearing, and
follow ups on personnel knowledge in practice.
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
14 (19)
On two occasions in 2011 there were incidents in the Stockholm metro involving C20 metro trains
that departed from the platform with a double passenger door open.
On 24 May, a person with a walker alighted a metro train at the Medborgarplatsen metro station
while doors were closing and got stuck in the double doors. The person forced their way out of the
metro train. The metro train then started and departed from the platform with the double passenger
door 30-40 cm open.
On 9 June, a person with a bag/purse/suitcase at the Slussen metro station got stuck while trying to
board a metro train while the doors were closing. The person tugged out the bag/purse/suitcase but
the double doors did not close. The metro train started and departed from the platform with the
double doors 15-20 cm open. In both events, the doors closed later during the movement.
C20 metro trains are designed such that the driver shall only be able to drive the train when a go-
ahead signal has been obtained from the train's safety system. The train's safety system prevents
operation of the metro train by keeping the service brakes fully activated and giving a red signal to
the driver unless all parameters for a go-ahead signal are met. One of these parameters is that the
passenger doors shall be closed and locked. In both of these cases, the drivers reported that after door
closing was completed they were given a go-ahead signal and they could start the metro train.
The incidents were caused by a short between two electric conductors in the rear half coupler of
coach 2077. The short led to the safety system – which indicates that the passenger doors are closed
and locked – indicating ‘clear’ for all passenger doors behind the coupling in the rear half of coach
2077 and for all other coaches coupled after coach 2077.
An underlying cause was that the maintenance contractor, in an overhaul of the coupler, used
incorrect maintenance instructions that lacked certain steps to check the insulation between
conductors in the coupler.
The short could occur because the heat-shrink tubing used as insulation was the wrong size to be
shrunk over the cable lug that was used and the contact pins are fitted closely to each other rather
than mechanically and stably separated, which led to wear between the lugs and in turn created an
electrical contact between two pins in the coupler.
MTR's safety management system failed to detect that the maintenance contractor used deviating
instructions for maintenance of the coaches. Swedish Transport Agency oversight, in the form of
Final Report RJ 2013:04
Incident involving a technical fault in a metro train
at the Medborgarplatsen and Slussen metro
stations, Stockholm County, on 24 May and
9 June 2011.
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
15 (19)
audits, failed to detect these deviations in MTR's safety management system – despite the fact that
audits were performed on vehicle maintenance at MTR a short time prior to the aforementioned
events – because no verifications were performed in these audits.
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
16 (19)
2.5 Accidents and incidents investigated in the last five years
Rail traffic investigations 2009-2013
Investigations of accidents/incidents 2009 2010 2011 2012 2013 Total
Ser
iou
s ac
cid
ents
(Art
19
, 1
+ 2
)
Collision 1 1
Collision with an obstacle 1 1
Derailment 0
Level-crossing accident 1 1 2
Accident to person due to train
in motion
2 1 3
Fire in rolling stock 0
Substantial release of dangerous
goods
0
Fire 0
Incident 1 2 5 4 4 16
TOTAL 1 6 5 7 4 23
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
17 (19)
3 RECOMMENDATIONS 2013
Date and time: 01/11/2011 at 13:15
Location: Hoting, Jämtland County – Storuman, Västerbotten County
Type of event: Near-collision
Vehicle type and train number: Two blocked-line operations
Present on board
Number present on board: Personnel: Not investigated
Passengers: 0
Number of fatalities: Personnel: 0
Passengers: 0
Number of seriously injured: Personnel: 0
Passengers: 0
Number of slightly injured: Personnel: 0
Passengers: 0
Damage to rolling stock: None
Damage to railway infrastructure: None
Other damage: No
Summary: See Section 2.4
Publication of final report: 29/01/2013
Recommendation
RJ 2013:01 R1
RJ 2013:01 R2
RJ 2013:01 R3
The Swedish Transport Agency is recommended to:
particularly examine the prevalence of directly planned work (as opposed to
pre-planned) by infrastructure managers in order to elucidate the extent to which
such work is used in the absence of the conditions for it under JTF and, if
necessary, take appropriate measures;
review the approval process to ensure that the right skills are involved in
assessing whether an approval is needed so that both operative aspects and user
aspects are taken into account;
as part of the work initiated to increase interaction between the sections for
approval and permits, create procedures or equivalent to ensure that the
information transmitted to the Swedish Transport Agency is transferred between
different processes.
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
18 (19)
Date and time: 30/01/2012 at 12:58
Location: Helsingborg freight yard, Skåne County
Type of event: Near-collision
Vehicle type and train number: Freight train 6225 and shunting movement
Present on board
Number present on board: Personnel: 2
Passengers: 0
Number of fatalities: Personnel: 0
Passengers: 0
Number of seriously injured: Personnel: 0
Passengers: 0
Number of slightly injured: Personnel: 0
Passengers: 0
Damage to rolling stock: None
Damage to railway infrastructure: None
Other damage: No
Summary: See Section 2.4
Publication of final report: 12/06/2013
Recommendation
RJ 2013:02 R1
RJ 2013:02 R2
RJ 2013:02 R3
RJ 2013:02 R4
The Swedish Transport Agency is recommended to:
within the framework of its oversight, encourage infrastructure managers and
railway undertakings, in their deviation systems, to monitor the prevalence of
unauthorised stop signals passed at danger where the signal is located on the right
side of the track in order to determine whether signals located on the right are
passed at danger more often than signals located on the left;
within the framework of its oversight, encourage infrastructure managers to have
a look over right-side dwarf shunting signals to determine if such placement is
still warranted;
conduct oversight that railway undertakings clearly indicate signals with
deviating placement in local yard instructions;
conduct oversight of infrastructure managers' use of arrow signs designed
according JvSFS 2008:7.
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
19 (19)
Date and time: 02/11/2011 at 19:37
Location: Malmö, Skåne County – Helgoland, Denmark
Type of event: Derailment incident
Vehicle type and train number: Train 15003
Present on board
Number present on board: Personnel: 1
Passengers: 0
Number of fatalities: Personnel: 0
Passengers: 0
Number of seriously injured: Personnel: 0
Passengers: 0
Number of slightly injured: Personnel: 0
Passengers: 0
Damage to rolling stock:
Damage to railway infrastructure:
Other damage: Damaged dolly
Summary: See Section 2.4
Publication of final report: 14/06/2013
Recommendation
RJ 2013:03 R1
RJ 2013:03 R2
Within the framework of its oversight, the Swedish Transport Agency is
recommended to:
take the measures necessary to ensure that the railway undertakings and their
engaged contractors have appropriate procedures for transferring information,
performance testing, and clearing, as well as for follow-ups on personnel
knowledge in practice;
take the measures necessary to ensure in particular that the personnel of railway
undertakings or their engaged contractors that perform work in Sweden that is of
importance to traffic safety – but who are employed or trained in another country
– have the necessary training on the regulations and procedures for performance
testing and clearing that apply in Sweden and that the application of their
knowledge in practice in these respects is regularly followed up on by the
responsible railway undertaking.
Translation provided for information purposes, by the Translation Centre for the bodies of the EU. The only valid version is the original version provided by the NIB
20 (19)
Date and time: 24/05/2011 at 13:45 and 09/06/2011 at 14:40
Location: Medborgarplatsen and Slussen metro stations, Stockholm County
Type of event: Incident involving a technical fault in a metro train
Vehicle type and train number: C20 metro train, vehicle 2077
Present on board
Number present on board: Personnel: 2
Passengers: Not investigated.
Number of fatalities: Personnel: 0
Passengers: 0
Number of seriously injured: Personnel: 0
Passengers: 0
Number of slightly injured: Personnel: 0
Passengers: 0
Damage to rolling stock: None
Damage to railway infrastructure: None
Other damage: No
Summary: See Section 2.4
Publication of final report: 21/11/2013
Recommendation
RJ 2013:04 R1
The Swedish Transport Agency is recommended to:
in its efforts to analyse and evaluate its practices, particularly consider whether
oversight form R1 (‘brevtillsyn’, an inspection of all relevant paperwork) and
corporate meetings are sufficient to verify that operators in the rail traffic sector
meet their obligations to have expedient procedures to notice shortcomings and
deviations in vehicle maintenance.