Report on run-off-the-road accident on fv. 651, Svineroivegen near Rjukan, Tinn municipality on 2 September 2018
Vei rapport 2019/06 eng
English translation now available. On 2 September 2018, a Cadillac 1959 model drove off the road on its way down from Gaustatoppen towards Rjukan. The car drove off the road in the last hairpin bend before Rjukan and all five occupants of the car died as a result of the powerful clash with the rock cutting. The AIBN believes that the combination of prolonged use of the service brake and inadequate maintenance of the brakes contributed to the car losing part of the braking effect somewhere between the last two hairpin bends on the way down from Gaustatoppen towards Rjukan. The car was first registered before 1960 and thus exempted from periodic vehicle inspection requirements. The AIBN's assessment is that a technical inspection of the brakes would have revealed that the brakes were inadequately maintained. The car was not equipped with seat belts, nor was this required in this vehicle. The AIBN's investigation has shown that seat belts could have reduced the scope of injury in this accident.
The investigation has shown that the brakes were gradually weakened and that the car most likely lost almost all braking effect on the last stretch of the road down to the site of the accident. The reduced braking power of the car was the result of prolonged use of the service brakes in combination with high wear on several components of the braking system. The car therefore entered the final hairpin bend at too high a speed to make the turn and collided with the rock face in the rock cutting.
The AIBN's investigation has shown that the brakes of the accident car were poorly maintained and the brakes on the right front wheel were worn out. The brake fluid was clearly contaminated and had a high water content and low boiling point. This also contributes to braking failure under high loads.
The accident car was equipped with automatic transmission, and the gear selector was in the "drive" position when the car was examined after the accident. Seen in conjunction with other findings, this indicates that the driver did not use the gears to brake the car, but used the service brakes on the long, steep descent towards Rjukan.
The road side terrain was designed in such a way that there was no possibility of driving off the road to reduce speed without risking significant damage to both car and passengers.
The AIBN submits two safety recommendation following this investigation.
Sikkerhetstilråding
Sikkerhetstilråding VEI nr. 2019/17T
Undersøkelsen av utforkjøringsulykken ved Rjukan 2. september 2018 har avdekket at bilens bremser var mangelfullt vedlikeholdt. Mangler ved bilens bremser var en av flere faktorer som bidro til at ulykken skjedde. Det er ingen krav til oppfølging av teknisk tilstand på kjøretøyet, utover eiers eget ansvar. Undersøkelsen har påvist behov for en barriere som kan fange opp sikkerhetskritiske tekniske feil ved eldre kjøretøy.
Statens havarikommisjon for transport tilrår at Samferdselsdepartementet i samarbeid med interesseorganisasjoner for eldre kjøretøy gjennomgår regelverket for oppfølging av teknisk tilstand på eldre kjøretøy.
Sikkerhetstilråding VEI nr. 2019/18T
Undersøkelsen av utforkjøringsulykken ved Rjukan 2. september 2018 viste at kvaliteten på bilens bremsevæske var forringet. Testing av kokepunkt på bremsevæske inngår per i dag ikke i periodisk kjøretøykontroll (PKK). Bremsevæskens kvalitet forringes over tid og er sentralt med tanke på at bilens bremser skal fungere i alle situasjoner. SHT mener at testing av kokepunkt bør inngå i kontroll av bremser.
Statens havarikommisjon for transport tilrår at Statens vegvesen vurderer å inkludere kontroll av bremsevæskens kokepunkt i kontrollinstruksen for periodisk kjøretøykontroll.
Fakta
| Sted | Fv 651 Rjukan, Telemark county |
| Hendelsesdato | 02.09.2018 |
| Ulykkestype | Utforkjøringsulykke |
| Veitype | Fylkesvei |
| Fylke | Telemark |
| Politidistrikt | Telemark |
| Kjøretøy/trafikant | Personbil |
| Type transport | Privat transport |
| Veiregion | Region sør |
| Ulykkeskategori | Annen ulykke |