Report on collision between road-rail excavator and train near Dallerud on the Dovrebanen line 11 March 2017

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Description

At 05.27 on Saturday 11 March 2017, train 304 collided with a road-rail excavator that was on the tracks near Dallerud south of Lillehammer on the Dovrebanen line. A misunderstanding between the principal site safety supervisor (PSSS) and the local safety supervisor (LSS), who was driving the excavator, lead to it being driven onto the tracks by mistake. The train driver applied the emergency brakes upon discovering the excavator, but it was not possible to stop the train in time. The excavator driver saw the lights of the train and managed to get out before the impact.

The Accident Investigation Board Norway (AIBN) is of the opinion that several factors contributed to this incident, including the work method, night work, unclear communication and failure to use contact magnets.

At the time of the accident, Veidekke AS was carrying out ditch clearing on assignment for Bane NOR SF. The work team had been allocated six short track possessions in between ordinary train operations. The work method involved great variations in the level of activity, and the AIBN believes that this may have had a bearing on alertness and on the risk of errors. The combination with night work over several nights where sleep during the day does not provide full recuperation also involved a possibility of accumulated sleep deprivation.

A misunderstanding arose between the PSSS and the LSS that resulted in the LSS not understanding that a train was going to pass before the next track possession. Bane NOR SF has a standard for communication in place that is intended to reduce the possibility of misunderstandings arising in verbal communication. At the time of the accident, the standard was applied in communication between the PSSS and the traffic controller, but after the accident, it has been decided that the standard should also apply to communication between the PSSS and the LSS.

The PSSS used contact magnets as required by the regulations, but the LSS did not. If the LSS had used contact magnets, that alone would not have been enough to prevent the accident, since the train already occupied the block section. However, the verbal feedback from the LSS to the PSSS that magnets had been applied might have uncovered the misunderstanding and reduced the chance of the excavator being driven back onto the tracks. Contact magnets and the pertaining procedure are intended to help to ensure both the safety of those working on the tracks and safe train operations.

In the AIBN’s opinion, track possessions can be useful when it comes to granting access to the tracks for repairs and maintenance work, but the efficient work time and the time spent on preparations and conclusion must be weighed against each other. The steps of the procedure must be complied with in order for this work method to be sufficiently safe. Time pressure must not result in steps being skipped in order to be able to carry out more work in the time available.

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Photo: AIBN

Safety recommendation

Safety recommendation JB No 2017/08T

At 05.27 on Saturday 11 March 2017, a passenger train collided with a road-rail excavator that was carrying out work for Bane NOR SF south of Lillehammer station on the Dovrebanen line. The work was carried out during the night, broken down into several short track possessions in between ordinary train operations. This work method involves great variations in the level of activity, which can in turn have a bearing on the workers' alertness and on the risk of errors. 

The Accident Investigation Board Norway recommends that the Norwegian Railway Authority request Bane NOR SF to conduct a risk assessment of track possessions as a work method in order to improve the safety of work involving great variations in level of activity.

Location
Dallerud, between Bergseng and Lillehammer station
Occurrence date
11.03.2017
Train No
304
Type of Transportation
Passenger train
Type of occurrence
Collision
Rolling Stock
Multippel Unit (MU)
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