Safety recommendation RW no. 2011/02T
The barriers established to prevent rail cars without brakes from breaking loose and rolling away from Alnabru have been inadequate.
The Accident Investigation Board Norway recommends that the Norwegian Railway Authority order the Norwegian National Rail Administration to analyse the operational situation at Alnabru and to establish necessary barriers so that runaway rail cars cannot roll out of the station.
Safety recommendation RW no. 2011/03T
Alnabru was not covered by the NNRA’s system for risk identification because minor changes had taken place over time and not been significant enough for the need for an analysis to be apparent, and because the section analyses did not encompass the activities at Alnabru. The risk analyses available for Alnabru from both the NNRA and CargoNet AS are also inadequate with respect to work processes and barriers. They are excessively based on establishing risk figures for top events (top-to-bottom approach) and previous incidents.
The Accident Investigation Board Norway recommends that the Norwegian Railway Authority order the Norwegian National Rail Administration and CargoNet AS to review and improve their systems for risk assessments and analyses.
Safety recommendation RW no. 2011/04T
Alnabru lacked an overall safety management that could identify the risk that followed from the many changes that had taken place over time. There was no safety function that could address and deal with safety-related information from both the NNRA and the railway undertakings at the overall level. The safety work was divided between many different line and support functions, and forums, internally and between the various organisations.
The Accident Investigation Board Norway recommends that the Norwegian Railway Inspectorate order the Norwegian National Rail Administration and CargoNet AS to review and improve the way safety work is organised, in order to ensure the overall safety of freight terminals and shunting yards.
Safety recommendation RW no. 2011/05T
The investigation has uncovered a lack of trust in and social acceptance of the reporting and nonconformity system in the NNRA and CargoNet AS. In the case of both the NNRA and CargoNet AS, the main problem concerns the ability to communicate information between the various levels that are involved in identifying, assessing and reducing risk.
The Accident Investigation Board Norway recommends that the Norwegian Railway Authority order the Norwegian National Rail Administration and CargoNet AS to improve their safety management, with a particular emphasis on collecting and processing information in order to improve the safety culture.
Safety recommendation RW no. 2011/06T
The immediate cause of the accident was a misunderstanding between the local traffic controller and the shunter. Neither the NNRA nor CargoNet AS had defined what should constitute safety-critical information, and they had not emphasised the establishment of a common reference framework to ensure unambiguous and efficient communication. No procedures had been established for the use of standard phrases and readback-hearback.
The Accident Investigation Board Norway recommends that the Norwegian Railway Authority order the Norwegian National Rail Administration and the railway undertakings to review communication in connection with shunting operations, define safety-critical information, and establish barriers to prevent/detect misunderstandings.
Safety recommendation RW no. 2011/07T
Two provisions that could potentially have prevented loss of control of the freight car set were not in use or known to the operating personnel at Alnabru. This shows that there were weaknesses in how governing documents were prepared, and in the way in which they are currently maintained and distributed in the NNRA’s own organisation and in CargoNet AS. Governing documents do not adequately distinguish between barriers and information of a more general nature.
The Accident Investigation Board Norway recommends that the Norwegian Railway Authority order the Norwegian National Rail Administration and CargoNet AS to update and distribute governing documents and ensure that they are understood.
Safety recommendation RW no. 2011/08T
There are no barriers in the tracks towards Loenga or Oslo S that can divert, derail or stop runaway rolling stock in a controlled manner so as to prevent loss of human life and serious personal injuries. It is not possible for the traffic controller to release any main train routes instantly.
The Accident Investigation Board Norway recommends that the Norwegian Railway Authority order the Norwegian National Rail Administration to consider whether it is necessary to establish barriers in order to protect the freight train track from Alnabru to Loenga, Hovedbanen and Oslo S station. |