Report on serious railway incident during track works between Bolna and Dunderland stations on the Nordlandsbanen Line on 11 September 2023
Railway report 2024/05
At 17:30 on Monday 11 September 2023, a work team of three people and a 22-tonne road rail-excavator were close to being hit by freight train 5782. The line section had been reported as clear for trains while the work team were still on the track. The incident did not result in a fatal accident, as the work team happened to get off the track barely a minute before the freight train passed. There are no technical systems on this line section that could have contributed to detect that the work team was still on the section. The investigation has also revealed challenges with track works related to planning, coordination, rules and requirements. Partially conflicting interests among the involved parties contribute to unpredictability, which further poses a safety risk for personnel working in and near tracks.
The principal site safety supervisor (PSSS), who was responsible for keeping track of all work teams on the section, forgot the last work team when the work was finished. Several factors contributed to this, including little coordination in advance, no joint start-up meeting, unforeseen obstacles and the experience of time constraints. The procedure of handing over the track to the local traffic controller was carried out without using the log form. Subsequently, train 5782 received permission to run on the route. The investigation shows that sections without remote control lacks technical barriers aimed at this problem.
Further the investigation shows that rules and conditions for work in tracks are determined by different stakeholders in Bane NOR SF, partly independently of each other, and without anyone having an overall responsibility for the process. The NSIA believes this contributes to unpredictable terms and conditions for those performing track work. In addition, it can put a disproportionate amount of pressure on the PSSS, who has a safety-critical function.
Published 22.10.2024
Safety recommendation
Safety recommendation Rail No 2024/06T
On 11 September 2023, three people in a work team and an excavator were close to being hit by a freight train on the Nordland Line. A principal site safety supervisor (PSSS) was responsible for a total of three work teams on the day in question. The PSSS notified the local traffic controller that the section was clear for trains, but had forgotten that a work team still remained on the track. There are no technical support systems that a PSSS can use to prevent such situations.
The Norwegian Safety Investigation Authority recommends that the Norwegian Railway Authority ask Bane NOR SF to look into possible technical barriers that can strengthen safety in connection with track work, to avoid an oversight leading to a section being declared clear for trains when personnel, equipment or rolling stock remain on the track.
Safety recommendation Rail No 2024/07T
On 11 September 2023, three people in a work team and an excavator were close to being hit by a freight train on the Nordland Line. A principal site safety supervisor (PSSS) was responsible for a total of three work teams on the day in question. The PSSS notified the local traffic controller that the section was clear for trains, but had forgotten that a work team still remained on the track. The conditions for track work are influenced by a number of parties and interests, but no one has overall responsibility for safety. The unpredictability of track work and the inadequacy of systems to coordinate the various parties involved entail a poor starting point for planning and performing the work in a safe manner.
The Norwegian Safety Investigation Authority recommends that the Norwegian Railway Authority ask Bane NOR SF to establish overall process responsibility for work on and around tracks.
Facts
| Location | Between Dunderland and Bolna stations on the Nordlandsbanen line |
| Occurrence date | 11.09.2023 |
| Type of Transportation | Freight train |
| Type of occurrence | Track work |
| Rolling Stock | Arbeidsmaskin |