Accident report from Saltsjöbaden train accident finished

[Bobjork]

The Swedish Accident Investigation Authority have finished their report of the train accident, where a runaway train crashed into a building, in Saltsjöbaden last year.
It is available here:
http://www.havkom.se/virtupload/reports/RJ2014_03.pdf
Page 9-11 is an english extended summary for those (all of?) you that don't understand bureaucratic Swedish

My summary below:
During the night between 14th and 15 january 2014 a shunter and a cleaner was on duty in Neglinge depot.
Empty trainset 7587 (Unit 2887-88) arrived Neglinge at 01.44. It was coupled to another unit (2893-94).
The points was left in this position, to avoid the points freezing and preventing the first unit to exit the depot. After this, the traffic controller for Saltsjöbanan went off
duty and, according to plan, left the traffic control center unmanned for the
duration of the time when there were no train services.

There was snowfall that night, and -3 degrees celsius. The special euipment to enable a trainset to be parked without applied brakes, avoiding the blocks to freeze to the wheels), was not working. The shunter therefore decided to solve the problem in his own creative way. (Although he is not the first one)
He activated the driver's controls
in the cab facing Saltsjöbaden, engaged the driver's safety device ("dead man's
switch") using a loose brake block and closed the doors, to enable brake release.
The doors were then released for individual control, to prevent engagement of
tractive power. Sometime during the process the the train control lever was
placed in the "Full power" position (probably when he or the cleaner pulled the drivers seat forward to enter the passenger compartment). The doors being in "Individual control" prevented the train from starting.

The shunter left the train in this way and went into the depot to do some paperwork while the cleaner sweeped the floors.
In her job description it is stated that after sweeping the floors, she should close the doors to see that there are no sand preventing the doors to shut.
When she pressed the close button, the train started to accelerate.
Because the points where left pointing onto the line, the train could accelerate towards Saltsjöbaden.
The cleaner did not react at first, as trains often where shunted while she was cleaning them, but soon realized that it was going fast, and not in the depot.
She had however no idea how to stop the train and did not know where to find the emergency brake, and the cab was unlit. After trying to pull out the key (which is impossible without deactivating the train first) she took cover under a seat directly behind the cab.
After reaching a speed of 80 km/h it stopped abruptly (80-0 in 3 seconds) inside a building, with the cleaner injured and stuck.

http://www.railwayforum.net/gallery/...ge.php?i=30224

When the shunter returned to the yard he found that the train, and the cleaner, had disappeared. He called a supervisor that rushed to the scene. While the shunter stood there, he saw rescue vehicles going with sirens and blue lights towards Saltsjöbaden. He then called "Trygghetscentralen" (the Public Transport Security Centre) and they told him a train had crashed in Saltsjöbaden.

Feel free to ask any questions.

[jayar]

What an astonishing sequence of events, no matter what fail-safe equipment and procedures are in place, these extraordinary things will happen. Thank you for posting.

[richard thompson]

Makes interesting reading. Just shows there is no such think as "Totally failsafe".
Richard

[boilersuit]

And we had all assumed it was the cleaner's fault for messing with the controls. Just goes to show... she did nothing wrong.

[Bobjork]

Originally Posted by boilersuit

And we had all assumed it was the cleaner's fault for messing with the controls. Just goes to show... she did nothing wrong.

Yes. And I knew that already in january but it was not official (and people also believe what they read and then don't care to read the updates so some people still thinks she stole it)

Originally Posted by richard thompson

Makes interesting reading. Just shows there is no such think as "Totally failsafe".

Exactly, as long as humans are involved nothing can be failsafe (and I belive a totally computerised world also will have accidents. After all: It is humans that build and program computers...) and if something is unclear in the rulebook, something will happen sooner or later.

[hereward]

Will anyone be prosecuted Bobjork?

[Beeyar Wunby]

Originally Posted by the report

In her job description it is stated that after sweeping the floors, she should close the doors to see that there are no sand preventing the doors to shut.
When she pressed the close button, the train started to accelerate.

So she knew how to operate the door buttons, but not any of the passenger Emergency Alarm handles.

Unbelievable.

I can't help but be staggered that someone who works onboard trains had not been shown how to stop a train, i.e. operate a PassComm or Egress handle within the passenger areas.

Originally Posted by also

The shunter therefore decided to solve the problem in his own creative way. (Although he is not the first one)
He activated the driver's controls in the cab facing Saltsjöbaden, engaged the driver's safety device ("dead man's
switch") using a loose brake block and closed the doors, to enable brake release.

I'll bet it seemed like a really good idea at the time....and he regrets it now. Good job no one was killed or it would be manslaughter.


BW

[27vet]

The shunter carried out an unapproved procedure I'm sure, and is lucky that no one was killed. He's still in hot water I bet.

[Bobjork]

Originally Posted by Beeyar Wunby

So she knew how to operate the door buttons, but not any of the passenger Emergency Alarm handles.

Unbelievable.

I can't help but be staggered that someone who works onboard trains had not been shown how to stop a train, i.e. operate a PassComm or Egress handle within the passenger areas.

Well, probably thats because usually the trains are stationary when being cleaned (sometimes shunted though, and made her first believe that was the case, but soon she realized that something was wrong).
They did tests afterwards, and If you didn't know how they looked or where they were placed, the emergency brake handles were hard to find in a dark cab...

Originally Posted by hereward

Will anyone be prosecuted Bobjork?

I haven't heard of anyone being prosecuted actually. Probably there is a good reason for it.