Full Version: Runaway cars smash into harbor terminal in Oslo, 3 killed
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boppa Wrote:what kind of brakes do these cars have??

I worked for the SRA in NSW (government railways) and uncoupling a cars airlines automatically put the brakes on full bore

Normally the cars have both air brakes and manual brakes. Air brake pressure lines are charged when a train is running out on the road, and the air brakes go if the brake line pressure drops. Brake usage on the road is mandated by the "rules on train movement" (public regulation FOR 2008-02-29 nr 240: http://www.lovdata.no/cgi-wift/ldles?doc...-0240.html)

Air brakes are not used during switching in yards. The presence of parking brakes capable of holding the car when parked is mandated by rule 13.3 in the national train safety regulations (FOR 2005-12-19 nr 1621, http://www.lovdata.no/cgi-wift/ldles?doc...-1621.html)

In this case, it seems like the manual brakes were not used - the switching crew seemingly trusted the track brakes along the side of the track to hold the cars.

Rechecking the comments on the regulations, the following is said about parking brakes:

" Rullende materiell som parkeres skal alltid være sikret mot å komme i bevegelse uavhengig av hvor materiellet skal parkeres. Parkeringsbremsen skal være dimensjonert slik at den kan holde materiellet med maksimal last sikkert fast inntil den bevisst frigjøres.
Også andre hensiktsmessige måter å sikre at materiellet ikke kommer i bevegelse på kan benyttes. "

Rough translation: "Rolling stock being parked must be secured so they cannot move, no matter where the rolling stock is parked. Parking brakes must be dimensioned to hold rolling stock with maximum load until it is deliberately released. Other suitable ways of preventing movement may also be used".

I suspect that using track brakes only until now has been consider "a suitable way of holding rolling stock". I also suspect that this interpretation of the rules no longer will be allowed.


Quote:we dont have these `hump yards' either- for a carriage to move it has to be coupled to a diesel shunter

seems to me that any system that gives a carriage a shove and lets it roll till it bangs into something is bound by its nature to go horribly wrong sooner or later.....

Well - hump yards are used many places in the world - it wasn't the hump yard as such that was the main problem. The main problem was that the cars got out of the hump yard.


Quote:(all shunting done now has the loco with a horn blast that its moving the carriage and the loco itself has one of those annoying `beep beep' style beepers whenever its in motion)

Of course, with people being what they are, you still will have someone get run over who ignored or didn't hear the sounds, maybe listening to an ipod or wearing new and improved ear protectors or some such thing.

No system or procedure can totally remove all risk from life. As Mark Twain observed: "it is hard to make things fool proof, because fools are so damned ingenious".

The only thing you can do is to make it harder to make mistakes that have critical consequences. And clearly something should be done to ensure that runaway cars cannot so easily get out of the yard and onto the main.

Stein
Two of the rail unions here in the UK, those representing the engineering staff and the signallers have given notice of strikes in a few days time. They say that new working practises that Network rail want to implement will compromise safety. The word "safety" gives the unions a good bargaining point.
Thank You, Stein, for your time and effort reporting, researching and explaining this (perhaps) painful accident...and maybe taking a little heat from some of us with or without railroad experience. Cars to be classified by a "Hump" yard, must have all air bled out and hand brakes released to roll to rest in the "destination" or outbound tracks - hence the automatic (powered)"retarders" to control speed, and at the far end of tracks, mechanical retarders and "skates" or other stopping mechanisms, watched over by a yard employee. This yard apparently has equipment on the A/D tracks to hold the cars to be "humped" until the hump pusher locomotive is tied on, so car brakes can be released in advance, or not applied after a "trimmer" move to a ready cut of cars to facilitate "efficiency"...this procedure will likely be banned or modified now. The Old Heads always told me, "Every Railroad Rule has blood on it." Thanks, again Stein, and prayers and condolences to the families and friends of those taken. Bob C.
Bob C Wrote:Thank You, Stein, for your time and effort reporting, researching and explaining this (perhaps) painful accident...

You are welcome, Bob.

And you are right - it does feel a painful. I have never worked on the railroad myself - life took me in a different direction after a round in the army signal corps as an electronic warfare operator.

But quite a few family members during the last four generations have been railroaders. My great grandpa and his brother, my grandpa and several of his brothers and in-laws, both in Norway and in America, three of my uncles, my brother, his wife, his wife's parents and several cousins. My dad was born in a station agent's home at a rural railroad station. I have been around trains most of my life. Several of my friends happen to work on the railroad.

Even though I am not related in any way (as far as I know) to the tower operator or the switching crew that was on duty when it happened, and even though I am perfectly aware that it is a pretty irrational feeling, I guess I identity with the railroad, and it feels like a family member has done something that I am not very proud of.

I know - totally irrational. Anyways - the important thing about accidents is to try to learn from them, so we try to avoid doing the same mistakes many times.

Stein
The brakes over there must work differently to ours then, our air brakes lock full on as soon as the airlines are disconnected ie the air pushes the brake shoes off the rim, making it then possible for to carriage to be moved- thus without a shunter attached(ie supplying air) they wouldnt roll unless you manually wind the brakes off.
And there is not easy way of doing that (I helped one of our mechanics to do one as an apprentice- EVERY individual brake shoe had to by wound off with a spanner before he could drag it off the sidings and into the shed)
Some are, it seems, unfamiliar with "Hump" classification yards...the cars air brakes are bled out, and hand brakes released. Cars are then pushed (by a locomotive) over a hill (or "Hump"), uncoupled - sometimes in motion, to roll free down an engineered grade through power retarders (pneumatic usually), controlled by an operator and/or a computer to adjust speed, through ladders of switches into a class track, for a specific destination or other purpose. Cars are "retarded" so they will roll with appropriate force - enough to reach the end of available track length, and couple to cars already on the track. When the "class" track is full, or when a train is made up including that destination, the cars are picked up by a switch engine, and placed on a "departure" track, and "sufficient" hand brakes set to arrest movement. The car department then blocks and "Blue-Flags" the track, couples hoses, inspects the physical condition of the cars, tests the function of each car's air brake, (an Initial Terminal Test) and reports the train ready for power. boppa, the Australian brake systems must be somewhat different - from your explanation, a "Hump" yard operation, and a lot of other switching we do, could not be accomplished. The volume demands of a main classification yard can be 600 to 1000 cars per hump per 8 hour shift, impossible productivity with all "on-air" movements. Guess I've still got a lot of new stuff to learn about ! I'd better hurry... 35 Bob C.
Just an update to this thread.

According to an anonymous source taking part in the investigation after the fatal accident with runaway cars in Oslo, quoted by the Norwegian TV channel TV2, the investigation team from the transportation safety board seems to be leaning towards exonerating the people who worked at Alnabru yard the day the accident happened, and instead blaming the railroad company for insufficient maintenance of equipment and inadequate procedures.

The source is quoted as saying : "the accident would have happened no matter who was on duty that day - it is related to systems and routines, not to personal errors by any of the operators working there that day".

I don't know when the formal report will be forthcoming, but I fully intend to read it as soon as it is published.

Stein
Please keep us posted.
Bob C Wrote:Some are, it seems, unfamiliar with "Hump" classification yards...the cars air brakes are bled out, and hand brakes released. Cars are then pushed (by a locomotive) over a hill (or "Hump"), uncoupled - sometimes in motion, to roll free down an engineered grade through power retarders (pneumatic usually), controlled by an operator and/or a computer to adjust speed, through ladders of switches into a class track, for a specific destination or other purpose. Cars are "retarded" so they will roll with appropriate force - enough to reach the end of available track length, and couple to cars already on the track. When the "class" track is full, or when a train is made up including that destination, the cars are picked up by a switch engine, and placed on a "departure" track, and "sufficient" hand brakes set to arrest movement. The car department then blocks and "Blue-Flags" the track, couples hoses, inspects the physical condition of the cars, tests the function of each car's air brake, (an Initial Terminal Test) and reports the train ready for power. boppa, the Australian brake systems must be somewhat different - from your explanation, a "Hump" yard operation, and a lot of other switching we do, could not be accomplished. The volume demands of a main classification yard can be 600 to 1000 cars per hump per 8 hour shift, impossible productivity with all "on-air" movements. Guess I've still got a lot of new stuff to learn about ! I'd better hurry... 35 Bob C.


thanks for that BobC- I had often wondered what these `hump yards' were- I just thought they were a sorting sidings group like I was used to- obviously not
The preliminary report of the accident investigation committee has just been published. Here is what happened:

1) At the yards at Alnabru, there are two yards side by side. The hump yard consists of 5 A/D tracks (named A1-A5) north of (above) the hump, and 25 bowl tracks south of (below) the hump. The intermodal terminal consists of 5 A/D tracks along the eastern side of the bowl tracks (also below the hump), plus the container terminal parallel to the hump yard A/D tracks (not quite as high as the hump A/D tracks).

2) Over time, traffic in the hump yard has decreased, and traffic for the intermodal yard has increased. Also, most of the hump yard bowl tracks has been used for long term storage of cars. A practice had developed by which available capacity in the hump yard A/D tracks has been used for temporary storage for container cars.

3) On the day of the accident, a container train consisting of 15 cars arrived at 0310 hrs, and the containers were unloaded at the container terminal. At 0420 hours the containers had been unloaded, and the switching crew stashed the empty cars at in the hump yard terminal track A5 (at the top of the hump), where it was supposed to remain until the following evening, when a switcher engine would haul the cars down to the intermodal yard and then shove them into the container terminal for loading.

4) A little before 1 pm, about 8 1/2 hours later, a new switching crew requested a path to take their switcher (and one additional empty container car) to the north end of track A5 (ie the end furthest away from the hump). They got their permission, and took their switcher past the 15 stored cars before backing into track A5 from the north end, coupling the 16th car to the other 15. They then uncoupled from the 16 empty cars, expecting the cars to stay put, held by the track brakes.

5) Then the fatal error happened. The switching leader requested from the tower operator a path from A5 north down to track G5 in the intermodal yard. His intent was to run the switcher around the 16 empty cars and to go down to the intermodal yard to start processing a train that was inbound in track G4 of the intermodal yard.

For some reason, the tower operator made the assumption that the switching engine was still coupled to the north end of the 16 empty cars, and that he was requested to line the switches from the southern end of track A5 for a shoving move by the switcher pushing 16 cars down the hills to intermodal yard track G5.

6) The instructions for that move is that the route will not be laid until the switching crew confirms that they have the train under control. The tower operator ignored that part of his instructions, and laid the switches from A5 to G5. He then transferred his attention to other tasks (the inbound train in track G4).

7) The switching crew had their attention directed towards the north end of track A5, waiting for the clear signal. After about 2 minutes, the switching leader got back on the radio to check why he hadn't gotten his permission. He then sees that the 16 cars are heading down the hill from A5 into G5, and yells an alarm to the tower operators, who tries to activate track brakes to stop the train.

8) It is too late - the train is already heading downhill and gathering speed. If it had been directed into tracks G1, G2 or G3, it could have been diverted into a buffer at the south end of the yard. Tracks G4 and G5 does not have a way to direct the cars into a end track.

The accident has already happened - all that was left was desperate (and futile) attempts at derailing the train as it for 7 minutes were gaining speed going down the hill and into the harbor, before careening into the harbor area at 120 kph, killing three people on the ground.

9) Preliminary recommendations from the accident committee includes the obvious things - "use standardized message formats", "read messages back", "don't park cars on top of a hill without setting the hand brakes", "build a derail at the south end of tracks G4 and G5" and stuff like that.

10) In my opinion, the main reason for the accident was damned poor communication procedures between the switching leader and the tower operator, combined with the unfortunate practice of using the hump yard A/D tracks as overflow tracks for the container terminal.

The tower operator did not know what the switching leader was trying to do, so he made assumptions. Assumptions can be lethal.

Time will tell whether any of the personnel on duty will face criminal charges.

Stein
Thanks for the summary Stein. As you say, assumptions can be lethal, but if the use of those tracks for those purposes had become the norm, the dangers obviously never occurred to them. As to possible prosecutions, there were definite infringments of rules and gross negligence.
Thanks, Stein!!
Thanks again, Stein, for the follow up. It seems, of all the things we make, assumptions are the most deadly...(the voice of almost-experience !) I hope all whose lives were changed by this event find peace, and will remember and spread the lesson of the bad assumption. Bob C.
One last followup. Following the formal Accident Investigation of the incident where a cut of runaway container flatcars killed three people in Oslo, Norway in march 2010, the district attorney for the city and province of Oslo has just announced that he is assessing relatively hefty (by Norwegian standards) fines against Jernbaneverket (the track & infrastructure owning auhority) and Cargonet (which owned the runaway cars) for the unsafe practices which lead to the accident.

Jernbaneverket was fined 15 million Norwegian Kroner (about 2.5 million American dollars), and Cargonet was fined 7 million Norwegian Kroner (about 1.25 million American dollars).

The district attorney has debated whether to charge the tower operator or not. The tower operator was following established procedures, but the prosecution authority was still in doubt about whether he should be charged with criminal negligence.

In the end they ended up deciding to let him off with a formal warning. Which of course is not the same as being found innocent - he will always have that warning on his record, along with the knowledge he already has had since this incident - that his actions contributed to the deaths of three people.

Since the accident, routines has been changed at the yard, and new barriers to runaway cars established.

Stein
Thanks, Stein, for following this and posting the final resolution. No matter what one feels about responsibility and justice, it seems a sad circumstance for all concerned. Again the adage seems re-enforced that "every railroad rule and procedure has been written in someone's blood." Bob C.
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