The railway accident investigation process in Norway

The Accident Investigation Board Norway (AIBN) is a Norwegian Government agency under the Ministry of Transport and Communications, responsible for investigating accidents and incidents in the transport sector. The history of the Board dates back to 1989.

History

Earlier ad hoc investigation commissions only investigated fatal aviation accidents. At that time a representative from the police was a permanent member of the commission, together with experts from relevant stake – holders. In the marine sector, accidents were handled by the Institute of Maritime Enquiry and a Permanent Investigation Board for Special Accidents in the Fishing Fleet. In the railway sector, accidents and incidents were mainly investigated by the police and the state railway company NSB. NSB was responsible for the infrastructure, the rolling stock and operations.

Railway accidents

Several serious train accidents have occurred on the Norwegian railway network. On 15 November 1950, the Hjuksebø train disaster caused 14 fatalities. This was the worst railway accident in peacetime until the Tretten train disaster on 22 February 1975. With 27 fatalities, including seven children, and 25 injured, this remains the worst train crash ever in peacetime in Norway.

The Aasta accident on the Røros line occurred on 4 January 2000. Nineteen people lost their lives while 67 survived. One day after the accident, an investigation commission, independent of the infrastructure manager (Jernbaneverket – the Norwegian National Rail Administration) and the railway undertakings (NSB BA), was appointed by Royal Decree. At the time, Norwegian legislation did not regulate the investigation of railway accidents.

The mandate stated that the investigating commission was to ascertain the facts and the causes of the accident, based on its findings. Other contributory factors should be part of the final report. Finally the commission was to make recommendations with a view to preventing similar accidents from occurring in future.

The final report was handed over to the Ministry of Justice on 6 November 2001. One of the commission’s recommendations was that the establishment of a permanent commission of inquiry for serious train accidents should be considered. The commission also recommended that the permanent commission should be independent, but administratively organised under a ministry. Its independence of the police authority investigating the accident should be clearly defined.

The Accident Investigation Board Norway (AIBN)

On 27 April 2001, the Ministry of Transport and Communications’ proposed amendments to the Railway Act were adopted by the Storting. The amendments included establishing a permanent body for investigating railway accidents co-located with the existing body for investigating aviation accidents. Recruitment to the railway department started shortly after the decision was made and the first railway accident investigation started on 1 July 2002. Directive 2004/49/EC of the European Parliament and the Council was implemented with effect from 1 March 2006.

Today, the AIBN is a multi-modal body investigating accidents and incidents in different transport sectors, specifically aviation, railways (including trams and metros), road transport and the marine sector. The different transport modes are organised in different departments within the AIBN and they report to the Director General. The multi-modal concept has been very successful in relation to stimulating cooperation, how to approach an investigation, methodology, sharing relevant safety issues and learning from the other transport sectors.

The investigation process

The AIBN’s management holds regular meetings with the train operators and infrastructure manager, as well as with the National Railway Authority (the national safety authority – NSA). The AIBN’s railway department holds annual meetings with the railway sector at which matters such as notification, accident and incident reporting, information during investi – gations are on the agenda.

Often, accidents and incidents have more than one causal factor. In the railway industry the train operator, the infrastructure manager, external and internal procedures etc. may contribute to an accident. The AIBN needs to know where to obtain the necessary infor – mation before an investigation is started. It is therefore essential to work with the whole industry. The safety problem is ‘owned’ and shall be solved by the relevant infrastructure manager or railway undertakings. However, it is important that the information is available and easily accessible to all parties in the event of an accident. Mutual trust is a key factor in accident reporting and investigation, and the aforementioned meetings are valuable in this respect.

The investigation is carried out with as much transparency as possible. All parties are heard and can share the results. The involved parties are regularly informed about the investigation, and given an opportunity to submit their opinions and views on the investigation. The draft report and the draft safety recommendations are sent to the involved parties for consultation and comments. If necessary, consultation meetings are organised.

The safety recommendations clearly state whom the safety recommendation is addressed to, the organisation or type of organisation to whom a recommendation is addressed and recommended measure(s). Most of the safety recommendations are addressed to the NSA. When an addressee is not one of the bodies under the umbrella of the NSA, the AIBN addresses its recommendations directly to other bodies or authorities.

The investigation report and safety recommendations are sent to the Ministry of Transport and Communications. The NSA is normally assigned responsibility for following up the safety recommendations. The AIBN receives a report with information about the status of the safety recommendations once every six months.

The final report is made public shortly after it has been communicated to the relevant parties. The report should also include measures implemented after the accident occurred.

The AIBN is obliged to keep the NSA informed about safety findings made during the investigation.

In an average year, the railway department investigates between 10 and 15 accidents and/or incidents. Over the years, the investi – gations have increasingly addressed the human element, focusing on the system of interaction between human factors, technology and organisational factors. The human element is highlighted in order to better understand why an accident or incident occurred, and not to apportion blame and liability. Learning from experience and preventing accidents from recurring are the most import elements in railway safety investigations.

The investigation reports and safety recommendations are made available to all EU and European Economy Area Member States through the European Railway Agency Database of Interoperability and Safety (ERADIS).

The AIBN considers whether to investigate all incidents with obvious potential and accidents such as train collisions, train derailments, accidents on level crossings involving motorised vehicles and pedestrians struck by rolling stock in motion, and fires in trains.

Incident types that have a clear potential to lead to serious accidents include broken wheels, broken axles, wrong side signalling failures, track buckles, broken rails, runaway trains or wagons and track workers having to jump clear of rolling stock in motion.

Investigations in progress

On 16 June 2011, an express train from Bergen to Oslo drove in to Hallingskeid station on the Bergen line. The station is located on the Hardangervidda plateau in an unpopulated area without road access. The altitude is approxi – mately 1,110m above mean sea level.

When the train approached the Hallingskeid station area there was a catenary power loss and, at the same time, the driver observed that the wooden snow tunnel was on fire. The emergency brakes were activated and the train came to a standstill inside the snow tunnel next to the station platform. The 257 passengers were evacuated while the driver called the train control centre and informed it about the loss of electric power and the fire.

No passengers were injured, but the train was totally wrecked. The track, the points, catenaries and cables were also destroyed. The snow tunnel burnt down completely.

The AIBN released a preliminary report approximately three weeks after the incident. The report included one immediate safety recommendation concerning emergency preparedness on the national railway network.

The investigation is still in progress and is considering information obtained from the infrastructure manager, sub-contractors, the train company and others.

On 13 January 2012, a freight train from Oslo to Trondheim derailed at point number 3 while approaching Dombås station on the Dovre line. One Traxx locomotive and five freight wagons derailed. The derailed locomotive was pulled by another Traxx locomotive due to technical problems. After the derailment, the torque and safety retention holding the engine were found to be damaged.

During the line inspection after the accident, damage to points and level crossings was observed as far as 2km south of Dombås station. The AIBN issued a safety alert through the ERA Safety Information System.

On 15 February 2012, a Flirt passenger train derailed on the Vestfold line southwest of Oslo. The train was on a trial run as part of the final acceptance testing.

The five persons who were on board the train were injured, while the train and the infrastructure were extensively damaged. The accident happened in an area with relatively sharp curves where the maximum speed is 70km/h. The derailment occurred approximately 50-60m after the point at which the maximum line speed is reduced from 130km/h to 70km/h.

The train was operating at a speed of 135km/h when the brakes were activated. It came to a standstill in 11 seconds and a distance of approximately 340m after the brakes were activated. The AIBN is still in a very early stage of the investigation and, so far, no final conclusions have been drawn as to why the train was operated at this speed.

In addition to the accidents presented in this article, the AIBN also investigates other accidents and incidents, such as derailments, fire and smoke development, collision caused by rolling stock in motion, level crossing accidents, signals passed at danger (SPAD) etc. The AIBN’s railway department is currently working on 10 different investigations.

About the author

Kurt A. Olsen has been Director, Head of Rail Department of Accident Investiga – tion Board Norway since 2007. Prior to this, Kurt held an Engineer-in-Chief position in the Oslo Transportation System working with repair and main – tenance of the metro and tram rolling stock. He has also held numerous positions in the Air Navigation Service Provider of Norway as well as the Coastal Administration.