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2020/09

Report on fatal railway accident at Storforshei on the Nordlandsbanen 7 Descember 2019

On Saturday 7 December 2019, an excavator driver was killed when a freight train collided with an excavator engaged in maintenance work for Bane NOR at Storforshei between Mo i Rana and Ørtfjell on the Nordlandsbanen line. The excavator driver was part of a three-person team working on the site before the accident. The NSIA has not found an obvious and decisive causal factor behind the accident, but the investigation has identified several safety issues that may have contributed to the accident.

Before the accident, a timetable graph was used to plan the final track possession for the day. The train operations in the area where the work took place differ between weekdays and Saturdays. The principal site safety supervisor (PSSS) used the timetable graph for the day before, and the team's impression of the train operations that were to be carried out before they could resume work on the track was formed on that basis. The timetable graph is not intended as a tool for detailed planning of track possessions.

In order to grant access and track possession for this type of work, Bane NOR SF must issue an announcement of the concrete work to be carried out. Local traffic controllers may not grant access to the tracks without such an announcement. 

According to Bane NOR SF's instructions, principal site safety supervisors have an oversight function in that they are to ensure that the track is clear when a train is about to pass and that work teams are notified a train is approaching. The principal site safety supervisor left the work area to prepare for the track possession. A cutting in the area where the principal site safety supervisor was located caused him to lose view of the work site. It was therefore not possible for him to intervene at an earlier stage when the excavator entered the tracks, or notify the team that a train was about to pass the work site. 

The NSIA has also uncovered failure to use safe job analysis as a tool to manage residual risk that remains after previous risk assessments and SJAs. This finding has also been made in connection with previous investigations.

The Norwegian Safety Investigation Authority submits two safety recommendations following this investigation. One safety recommendation concerns the use of information to plan work that does not fall within its intended purpose, and the fact that this could result in an incorrect situational awareness and basis for decision-making. The other safety recommendation concerns measures to indicate that a work team has been granted track possession on a section.

Photo: NSIA

Published 01.12.2020

Safety recommendation

Safety recommendation JB no 2020/10T

On Saturday 7 December 2019, a person was killed when a freight train collided with the excavator he was sitting in. The person was employed by a contractor carrying out maintenance work for Bane NOR SF at Storforshei on the Nordlandsbanen line. The work was carried out through track possession between ordinary train operations. The work team used the timetable graph to plan their work as a supplement to the announcement.

The Norwegian Safety Investigation Authority recommends that the Norwegian Railway Authority request Bane NOR SF to map whether an unfortunate practice of using alternative sources of information to plan work on tracks has developed.

Safety recommendation JB no 2020/11T

On Saturday 7 December 2019, a person was killed when a freight train collided with the excavator he was sitting in. The person was employed by a contractor carrying out maintenance work for Bane NOR SF at Storforshei on the Nordlandsbanen line. The work was carried out through track possession between ordinary train operations. A permission to work on tracks is communicated verbally.

The Norwegian Safety Investigation Authority recommends that the Norwegian Railway Authority request Bane NOR SF to look into possible measures to make work teams aware of track possession.

Facts

Location Storforshei, Nordland county
Occurrence date 07.12.2019
Train No 5797
Type of Transportation Freight train
Type of occurrence Collision
Rolling Stock Locomotive

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