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2021/03

Thematic report on accidents related to the contact line in the period 2017-2019

During maintenance work on the catenary workers have been seriously injured due to contact with high-voltage components. In addition a number of incidents have been recorded. The investigation found weaknesses relating to the updating of system documentation. Furthermore, deficiencies were found in formalised processes for planning work operations, potentially giving rise to safety challenges in connection with the execution of the work.

The regulations for operation and maintenance of high-voltage systems are administered by several ministries and subordinate agencies. The regulations are partially overlapping and some of the interfaces between them are in need of further clarification.  

The investigation has identified weaknesses in how need for competence and education is mapped out in all functions involved in planning and carrying out work on the high-voltage equipment.

NSIA assesses that Bane NOR can mitigate safety issues by improving the management of reported deviations thus securing that measures are aimed at causes for the deviations. 

The Norwegian Safety Investigation Authority submits four safety recommendations following this safety investigation. The recommendations relate to processes for planning work operations, the handling of reported nonconformities, assessment of competence needs and updating of system documentation.


Photo: Bane NOR SF

Published 19.03.2021

Safety recommendation

Safety recommendation Rail no 2021/04T

Every year, a number of accidents and undesirable incidents occur in connection with work in the vicinity of overhead contact systems on the national railway network. The investigation has shown that faults and defects in the drawings that form the basis for high-voltage systems can contribute to accidents.

The Norwegian Safety Investigation Authority recommends that the Norwegian Railway Authority request Bane NOR SF to review the process for preparing and updating documentation of high-voltage systems in order to ensure that the drawings are correct.

Safety recommendation Rail no 2021/05T

Every year, a number of accidents and undesirable incidents occur in connection with work in the vicinity of overhead contact systems on the national railway network. Several incidents and incorrect actions can be ascribed to inadequate competence and understanding of the systems on the part of the different functions involved in planning and execution. The process for work on Bane NOR's high-voltage systems involves several disciplines and requires coordination between planning, traffic control and operational work in the field.

The Norwegian Safety Investigation Authority recommends that Bane NOR SF identify all functions that affect the safety of work on high-voltage systems and assess the need for competence, instruction, training and follow-up of these functions.

Safety recommendation Rail no 2021/06T

Every year, a number of accidents and undesirable incidents occur in connection with work in the vicinity of overhead contact systems on the national railway network. The investigation has shown that Bane NOR SF does not adequately analyse reported incidents with a view to organisational learning and improvement. Given the number of registered accidents, the number of reports on near-misses and condition reports should be higher.

The Norwegian Safety Investigation Authority recommends that the Norwegian Railway Authority request Bane NOR SF to assess its process for handling reported near-misses, conditions and accidents relating to high-voltage systems, so that these are considered both individually and together for the purpose of implementing targeted measures to remove the causes of such incidents.

Safety recommendation Rail no 2021/07T

Every year, a number of accidents and undesirable incidents occur in connection with work in the vicinity of overhead contact systems on the national railway network. The investigation has shown that inadequate planning has been a contributory cause of accidents. It is challenging to establish safety at work if the job is not ordered and planned in a structured way that enables coordination.

The Norwegian Safety Investigation Authority recommends that the Norwegian Railway Authority request Bane NOR SF to assess its process for planning works on power supply systems, so that all factors are taken into consideration prior to execution of the work.

Facts

Location The National Rail Network
Occurrence date 01.02.2020
Train No Accidents related to the contact line in the period 2017-2019
Type of occurrence Class investigation
Operator Bane NOR SF

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