Report on a collision between a tram and the buffer stop at Fyllingsdalen terminus on 28 March 2023

Railway report 2024/03

On Tuesday 28 March 2023, a light rail vehicle on the Bergen Light Rail drove into the buffer stop at Fyllingsdalen terminus. Several people were transported to the emergency room or hospital after the collision with light to moderate injuries. The accident occurred because the vehicle was not being slowed down to full stop at the normal stop point at the platform. It continued beyond the short overlap between platform and buffer stop and collided in 16 km/h. In the investigation, the NSIA has not been able to determine the cause why the light rail vehicle did not stop where it was foreseen. The investigation revealed no technical faults on the vehicle. The on board data recorder shows that the driver used the controller to maintain a steady, weak braking of the light rail vehicle towards the platform. It is not recorded any increase of braking via the controller, as would have been seen with normal braking action towards full stop. Technical investigations revealed no faults on the vehicle.

A contibruting factor to the injuries and damages was the construction of the buffer stop. The design of the buffer stop in Fyllingsdalen deviates from Bergen light rail’s other buffer stops by being constructed as a very robust non-energy-absorbing concrete structure. The background for the deviant design was that a risk analysis had revealed a severe accient scenario. At the same time, the impact this construction could have on more frequent events, with lower consequences, was not assessed.

In the investigation, the NSIA has shown that risk analysis processes can be challenging. In this case, the potential of a major accident overshadowed more frequent dangers and challenges that were thus left unmanaged. The NSIA believes that a critical look at whether the identified major accident is really a realistic scenario is important. It can be difficult to distinguish between dangers that can happen and dangers that are realistic worst cases. It is therefore very important that analytical groups are properly and broadly composed in early phases, and that participation is given priority. In particular, this may be relevant in cases where there are not established standard solutions in the technical regulations, but where the infrastructure is designed in each case. The investigations has also shown that similar accidents has occored in Sweden and the Great Britain.

In the investigation, the NSIA uncovered what is described as a systemic safety problem related to the training of drivers in Tide Buss og Bane AS. Such safety problems are characteristics of the involved organisation or system, which the organisation can control or is responsible for. By addressing such systemic safety issues, the possibility of improving safety is also greatest. NSIA issues a safety recommendation on this topic. 

The tram after the collision
The tram after the collision. Photo: NSIA

The driver's seat after the collision
The driver's seat after the collision. Photo: NSIA

Published 03.04.2024

 

Safety recommendation

Safety recommendation Bane nr. 2024/04T

On 28 March 2023, an accident with injuries occurred on Bergen light rail´s line 2, when light rail vehicle 228 hit the buffer stop at Fyllingsdalen terminal. The investigation has not demonstrated a clear causal link between the lack of training in the use of the Variobahn light rail vehicles and the specific accident. However, a systemic safety problem has been uncovered in the organization in terms of a mismatch between the scope of the training curriculum and the time available for students learning. This may have contributed to misunderstandings about the vehicles functionality while driving in conditions with low adhesion.

The Norwegian Safety Investigation Authority recommends the Norwegian Railway Authority to ask Tide Buss og Bane AS to evaluate the training system, and if necessary, make changes, to ensure that future students reach the set learning goals.

Facts

Location Fyllingsdalen terminal
Occurrence date 28.03.2023
Type of Transportation Tram
Type of occurrence Collision
Rolling Stock Multippel Unit (MU)
Operator Tide Buss og Bane

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