nib annual report 2013 - havkom filenib annual report 2013 swedish accident investigation authority...

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.


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)


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


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


Date of

the event


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


Date of

the event


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


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


Date of

the event


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


Date of

the event


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


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


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.


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.


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.


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.


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.


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.


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


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.


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


Passengers: 0


Passengers: 0


Passengers: 0



Other damage: No



Recommendation

RJ 2013:02 R1

RJ 2013:02 R2

RJ 2013:02 R3

RJ 2013:02 R4


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.


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


Passengers: 0


Passengers: 0


Passengers: 0


Passengers: 0

Damage to rolling stock:

Damage to railway infrastructure:

Other damage: Damaged dolly



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.


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


Passengers: Not investigated.


Passengers: 0


Passengers: 0


Passengers: 0



Other damage: No



Recommendation

RJ 2013:04 R1


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.

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