Report on runaway train in Stavanger shunting yard 18 June 2017

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Description

During shunting at the shunting yard in Stavanger the 18th of June 2017, three wagons rolled uncontrolled and collided with parked wagons in track 26. One person onboard the runaway wagons had to jump off the train and sustained serious fractures in both legs.

Delays and changes during the process had made the driver's work situation stressful. He was responsible for all couplings in addition to the driving, and felt a strong sense of responsibility for planning the different steps of the shunting operation during the process. At one point, there was a misunderstanding about who was to connect the coupling between two wagons, and this resulted in the task not being carried out.

Personnel with the qualifications required to shunt and couple wagons should participate in such extensive shunting operations. This would allow the driver to focus more on the driving.
The advance description and risk assessment of this assignment were inadequate, and clearer communication could have reduced the driver's stress level. In a project that involves many parties, there is always a risk of the parties developing different understandings of how activities influence each other and interpreting messages differently.

Runaway rolling stock was not clearly emphasised in Bane NOR SF’s safety, health and working environment (HSWE) plan, and the driver did not participate in the safe job analysis conducted before the work. If he had participated, it would have been possible to discuss compensatory measures in connection with potential changes to the plans. The investigation has shown that perceived time pressure and changes during the process increased the driver’s stress level.

The AIBN submits two safety recommendations to BANE NOR SF. They concern asking Bane NOR SF to strengthen its safety management with a view to identifying changes in projects where the enterprise is the construction client, and assessing the consequences of changes of rules.

Safety recommendation

Safety recommendation JB No 2018/08T

On Sunday 18 June 2017, an employee was seriously injured when wagons started to roll uncontrolledly during shunting at Stavanger shunting yard. Bane NOR SF was the construction client and had overriding responsibility for safety in connection with the construction work. Runaway rolling stock was not assessed as a risk in the construction client’s safety, health and working environment plan. Moreover, the driver was not involved in the safe job analysis conducted the day before the work started, and subsequent changes to the assignment were not sufficiently communicated between the parties involved.

The Accident Investigation Board Norway recommends that the Norwegian Railway Authority request Bane NOR SF to strengthen its safety management system with a view to detecting changes in circumstances in projects where the enterprise is the construction client.

Safety recommendation JB No 2018/09T

On Sunday 18 June 2017, an employee was seriously injured when wagons started to roll uncontrolledly during shunting at Stavanger shunting yard. A change in Bane NOR SF’s regulations resulted in changes to the competence requirements for personnel qualified to assist during shunting. During this shunting operation, the driver had to carry out many of the tasks of a shunter. An increased workload can result in increased risk of incidents or accidents.

The Accident Investigation Board Norway recommends that the Norwegian Railway Authority request Bane NOR SF to consider the consequences of the change in regulations regarding shunting competence.

Location
Stavanger shunting yard
Occurrence date
18.06.2017
Type of Transportation
Shunting
Type of occurrence
Runaway train
Operator
Bane NOR SF
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