Report on runaway work machine at Ensjø Metro station 7 June 2018
Bane rapport 2019/04 eng
At 16:20 on Thursday 7 June 2018, a mobile elevating work platform (MEWP) collided and derailed on tunnel track 1 between Ensjø and Carl Berners plass.
The MEWP operator had not received adequate instruction in how the brake system worked, and operated the machine in a way that caused the parking brakes to be deactivated during on-tracking. Examination of the MEWP showed that it lacked technical barriers against incorrect operation, which meant that it was possible to deactivate the parking brakes. In the course of the investigation, the MEWP supplier has introduced technical barriers against incorrect operation, and it is claimed that this will prevent future recurrence of similar incidents.
The AIBN has found weaknesses in Oslo Metro AS's control mechanisms relating to supplier management, with inadequate control of operators' level of competence and the condition of hired vehicles.
The AIBN submits one safety recommendation for more extensive verification by infrastructure owners that hired personnel have the correct training and qualifications.
Sikkerhetstilråding
Sikkerhetstilråding JB nr. 2019/02T
Torsdag 7. juni 2018 kolliderte og sporet en lift av i tunnelspor 1 mellom Ensjø og Carl Berners plass. Under påsporing i 40 ‰ fall begynte den å rulle ukontrollert. Operatøren hadde fått mangelfull opplæring i virkemåten til bremsesystemet, og betjente liften slik at parkeringsbremsene ble deaktivert.
Statens havarikommisjon for transport tilrår Statens jernbanetilsyn å be infrastrukturforvaltere styrke sin leverandørstyring for å fange opp manglende sikkerhetskritisk kompetanse hos innleide operatører av denne typen kjøretøy.
Fakta
| Sted | Ensjø Metro station |
| Hendelsesdato | 07.06.2018 |
| Driftsform | Strekning med fjernstyring |
| Stillverksanleggstype | Stillverk |
| ATC | FATC |
| Type transport | Arbeidstog |
| Type hendelse | Løpsk materiell |
| Materiell kategori | Arbeidsmaskin |
| Operatør | Sporveien T-banen AS |
| Banestrekning | Annet |