Occurrence Summary What Location Date of occurrence 29-04-16 Location name Alnabru terminal Local time 03:40 Latitude Event type Railway vehicle movement events Longitude Description On Friday 29 April 2016, at 03:31 at night, two trains belonging to GreenCargo AB collided at Alnabru shunting yard. One of the trains was what is known as a shunting stock, which in this context means freight cars that are being transported by a shunting locomotive to be parked or made up into a complete train. The other train was a freight train coming from Bergen. The collision occurred when the freight train was on its way in to park on the track next to the shunting stock. The shunting stock was about to park 18 cars, and backed too far so that it hit the freight train at the run-off point between the two tracks. The tracks at the place of the incident are not equipped with a signalling system, and it is Bane R SF s local traffic controller who controls train movements in the area. The recommended practice at Alnabru is that the local traffic controller notifies the shunting personnel of incoming trains, so that they can stop the shunting operation. This was not done in the case in question. Because there is no technical barrier in the form of a signalling system to prevent collisions, operational barriers are necessary. The submits a safety recommendation to the effect that Bane R SF should consider whether the recommended practice should become fixed instructions Direct Cause descrip The collision occurred when the freight train was on its way in to park on the track next to the shunting stock. The shunting stock was about to park 18 cars, and backed too far so that it hit the freight train at the run-off point between the two tracks. Final Report Other Attachments Nam Desc Type Size Last Orga Repo Nam Desc Type Size Last Orga Repo 0 ERAIL-REP PUBLIC 1 Sunday, February 11, 2018
What Title, 29-04-16, Alnabru terminal () Occurrence type Railway vehicle movement events Occurrence Class Accident Date of occurrence 29-04-16 Local time 03:40 Events Railway vehicle movement events - - Descriptions Language English Translation provider Information providers own translation Description On Friday 29 April 2016, at 03:31 at night, two trains belonging to GreenCargo AB collided at Alnabru shunting yard. One of the trains was what is known as a shunting stock, which in this context means freight cars that are being transported by a shunting locomotive to be parked or made up into a complete train. The other train was a freight train coming from Bergen. The collision occurred when the freight train was on its way in to park on the track next to the shunting stock. The shunting stock was about to park 18 cars, and backed too far so that it hit the freight train at the run-off point between the two tracks. The tracks at the place of the incident are not equipped with a signalling system, and it is Bane R SF s local traffic controller who controls train movements in the area. The recommended practice at Alnabru is that the local traffic controller notifies the shunting personnel of incoming trains, so that they can stop the shunting operation. This was not done in the case in question. Because there is no technical barrier in the form of a signalling system to prevent collisions, operational barriers are necessary. The submits a safety recommendation to the effect that Bane R SF should consider whether the recommended practice should become fixed instructions Language Norwegian Translation provider Original version Description ERAIL-REP PUBLIC 2 Sunday, February 11, 2018
Fredag 29. april 2016 klokken 0331 kolliderte to tog tilhørende GreenCargo AB på Alnabru skiftestasjon. Det ene toget var et såkalt skift, og betyr i denne sammenheng vogner som transporteres av et skiftelokomotiv for å parkeres eller settes sammen til et ferdig tog. Det andre toget var et godstog som kom fra Bergen. Sammenstøte skjedde da godstoget var på vei inn for å parkere i sporet ved siden av skiftet. Skiftet skulle parkere 18 vogner, og bakket for langt slik at det traff godstoget ved sporvekselen mellom de to sporene. Sporene på hendelsesstedet er ikke sikret med signalanlegg, og det er togekspeditør i Bane R SF som styrer togbevegelsene i området. Anbefalt praksis på Alnabru er at togekspeditør varsler skiftebetjeningen om ankommende tog, slik at de kan stoppe skifteoperasjonen. Det ble ikke gjort i dette tilfellet. Ettersom det ikke er en teknisk barriere mot sammenstøt i form av signalanlegg på området, er operasjonelle barrierer nødvendig. Havarikommisjonen fremmer en sikkerhetstilråding som retter seg mot at Bane R SF bør vurdere om den anbefalte praksisen skal bli en fast instruks. Location name Alnabru terminal Railway System type Railway Country Location type Marshalling yard Border Country Line type Multiple track Line number Allowed line speed Km number Latitude Longitude Location description Additional location in Location type details Fixed installations Occurrence details Railway vehicles Movement type Shunting operation Train number RU Train speed at mom Vehicle description Green Cargo AB Wagons overturned Passengers onboard ERAIL-REP PUBLIC 3 Sunday, February 11, 2018
Movement type Freight train Train number RU Train speed at mom Vehicle description Green Cargo AB Wagons overturned Passengers onboard Other objects involved in the occurrence Other objects Parties involved IM Involved - Jernbaneverket RU - Green Cargo AB - Green Cargo AB Passengers Staff Level crossing users Unauthorised persons Others Total Fatalities Serious injuries Minor injuries Material consequences Material Damage Estimated total mate 1500-2 0000 Damage description Images Name Description Type Size Last modified Organization Repository web02.jpg image/jpeg 1212237 5/4/2016 2:17:31 PM web01.jpg image/jpeg 1692768 5/4/2016 2:17:44 PM ERAIL-REP PUBLIC 4 Sunday, February 11, 2018
Causation Causes Language English Translation provider Information providers own translation Direct Cause description The collision occurred when the freight train was on its way in to park on the track next to the shunting stock. The shunting stock was about to park 18 cars, and backed too far so that it hit the freight train at the run-off point between the two tracks. Underlying and root causes description The tracks at the place of the incident are not equipped with a signalling system, and it is Bane R SF s local traffic controller who controls train movements in the area. The recommended practice at Alnabru is that the local traffic controller notifies the shunting personnel of incoming trains, so that they can stop the shunting operation. This was not done in the case in question. Causation classification Railway vehicle movement events - - 1 - Track-side signalling equipment (train detection system, block signalling etc) (The tracks at the place of the incident are not equipped with a signalling system) 2 - Procedures (The recommended practice at Alnabru is that the local traffic controller notifies the shunting personnel of incoming trains, so that they can stop the shunting operation. This was not done in the case in question.) Recommendations Recommendation Issuing information Recommendation title Safety recommendation JB No 2017/01T Recommendation REC-000139 End implementer NSA Status Sent to adressee Addressee Issue date 24-03-17 Recommendation texts Language English Translation provider Information providers own translation Recommendations text On Friday 29 April 2016, a shunting stock backed into the side of an incoming freight train at Alnabru. The tracks at the scene of the incident are not equipped with a signalling system. Bane R SF has specific instructions for how to manage train and shunting routes in this area. In addition, there exists a recommended practice for the local traffic controller at Alnabru that contains work procedures for how to avoid collisions. The recommends that the Norwegian Railway Authority ensure that Bane R SF has sufficient barriers against collisions in areas that do not have a signalling system. ERAIL-REP PUBLIC 5 Sunday, February 11, 2018
Implementation information Implementation status Implementation date NSA Response NIB Comment Causation links Railway vehicle movement events - - Subsystem - Control command & signalling - Track-side signalling equipment (train detection system, block signalling etc) (The tracks at the place of the incident are not equipped with a signalling system) Causal factors - Procedures (The recommended practice at Alnabru is that the local traffic controller notifies the shunting personnel of incoming trains, so that they can stop the shunting operation. This was not done in the case in question.) Investigation details Legal Basis Other reason descrip National rules imposed by implementing of the Safety Directive 2004/49/EC - in light of Article 19, 2 of SD - (a) the seriousness of the accident or incident Reporting Body National investigatio Occurrence creation 04-05-16 14:13:03 Investigator in charge Decision to investigate 04-05-16 Declaration date Date of IM/RU notific Report Type Final report Workflow Status Validated Report Version 2 Investigation Status Closed Other Attachments Name Descriptio Type Size Last Organizati Repositor 0 ERAIL-REP PUBLIC 6 Sunday, February 11, 2018
Final Report Name Descriptio Type Size Last Organizati Repositor 2017-01 Final PDF File 1868540 3/27/2017 Alnabru.p report 7:44:29 df AM Relevant for sharing No Sharing good practice Impact on EU Level Investigation practice Investigation findings Recommendations Investigation practic Investigation finding ERAIL-REP PUBLIC 7 Sunday, February 11, 2018