CHAPTER 14: THE ÅSTA TRAIN ACCIDENT, NORWAY, JANUARY 2000 – JON SIGURD JACOBSEN
‘Most disastrous train wrecks occur in Asia and Africa. Fatalities there are on the rise, whereas such deaths are decreasing in Europe. But accidents still happen in modern Western countries.’ – (Hammer, 2012).
The history books show that train crashes are nothing new and were regular events in the 19th century when the railways were in their infancy. Even now in the 21st century, accidents around the globe still abound. This case study looks at a head on collision shortly after the arrival of the new millennium, which resulted in one of Norway’s worst rail disasters.
Development of the Norwegian Railway Network
Norway’s first railway was commissioned in 1854 and it ran from Oslo to Eidsvoll, a distance of 68 km. The main part of the country’s railway system was built in the period 1854 to 1920. During this time, the railway had no serious competition from any other land-based transport system and the various lines were often in private ownership.
The Norwegian state established the Norwegian Railway Company (NSB) in 1883, which set about extending the railway network throughout the entire country. The golden era was a 20 year period from 1890. Thereafter competition from cars, buses and air traffic started to grow resulting in a gradual loss of market share, weakening NSB’s domination of the Norwegian transport industry. Still, the government continued to develop the railway system in the public interest, and in support of different district policy interests.
The network was maintained and upgraded, with the majority being completely electrified. A new signalling system was also introduced in this period although parts of the old infrastructure remained in situ.
Norwegian rail travel safety record
The safety of its passengers and staff are overriding objectives of NSB. In fact, in Norway, rail transport is considered safer than most other transportation systems and compares very favourably against car travel. In the ten year period immediately before the Åsta disaster, a total of 20 people had been killed on Norway’s railways. During the corresponding period after the disaster, that number had halved. In a 2011 comparison against other European countries’ rail network safety records, Norway also fared well. Taking account of the number of passengers and kilometres travelled against the number of fatalities, Norway came 8th across Europe. When considering the number of railway network incidents reported against the passenger/kilometres measure Norway was only average, coming in 15th. Even so, the 35 Norwegian incidents recorded in this 2011 review was double the number recorded the previous year.
Head-on collision
‘A train driver’s worst nightmare is being on a single-track line and seeing another train coming straight at you.’ – John Lillywhite, retired British Rail train driver.
On Tuesday 4 January, 2000 a head on collision occurred between two trains on a single-track line close to the Åsta station in Hedemark County, Norway. This stretch of railway goes through a sparsely populated part of the country to the north of Oslo. The line, named Rørosbanen, was managed by a centralised system although it did not incorporate an automatic train stop system (ATS). Unlike much of Norway’s rail network, this line was not electrified, necessitating the use of diesel-powered trains. The train heading in a southerly direction was a diesel locomotive with three cars travelling from Trondheim to Hamar. The second, proceeding north, was a diesel multiple unit travelling from Hamar to Rena.
The official log shows that at 1:07 pm the southbound train left Rena station on a green light. Meanwhile at Rustad station the northbound train was scheduled to arrive at 1:06 pm and then wait until 1:10 pm, allowing the southbound train to pass. The train left three minutes early at 1:07 pm. The log does not show that a green light was showing at Rustad station, although it did record that the points north of Rustad were forcibly opened by this train as it left the station.
At 1:12 pm the accident happened. The northbound train remained on the track but was completely destroyed. The southbound train was seriously damaged. Its front car was derailed and plummeted down an embankment, the second was also derailed but remained on the tracks while the third stayed on the tracks. Of the 86 passengers and railway staff on board the two trains, 67 survived.
‘The collision caused the fuel tanks on both trains to rupture and some 5,000 litres of diesel poured out and caught fire. The trains burned for several hours. 19 people were killed, some by the collision and some by the fire. Among these were the drivers of both trains.’ – (Halvorsrud, 2002).
The unfolding disaster
The traffic controller at Hamar Station had not been following the Røros – Hamar line on the screens in the control room. He also was also responsible for the much busier Eidsvoll – Hamar line, which had been taking up his attention. Moreover, there was no acoustic alarm installed in the control room to warn the controller that two trains were on a collision course.
An ‘imminent collision’ warning was showing on the screens in the control room at 1:08 pm although the traffic controller did not notice this until 1:11 pm, one minute before impact. Although both drivers from the doomed trains had made their mobile numbers available in line with standard operating procedures, this information had not been passed to the controller. With no automatic train stop system installed on the line and no radios in the drivers’ cabs, the controller was helpless to stop the tragedy unfolding. At 1:12 pm, the trains collided.
Subsequent investigation
The appointed commission considered that the accident could have been caused both by direct and indirect causes. The direct causes were most likely either human error or a malfunction in the signalling system. Numerous tests were conducted although no physical fault could be found with the signalling system. Moreover, with both drivers killed in the crash, establishing human error as the cause was always going to be difficult.
The level of safety, and the safety system, on the Rørosbanen were not considered satisfactory by the commission. For this reason alone the possibility of a short term operational malfunction could not be excluded. Furthermore, it was not possible to eliminate the prospect that the system had shown an incorrect green signal on the northbound line.
With no advanced train stopping system on the Rørosbanen, however, and no radios in the driver’s cabs, the network controller was totally reliant on contacting each driver via mobile phone. But a failure in the NSB notification process meant that the correct numbers had not been passed to the controller.
‘The direct cause of the accident is still not known and probably it never will be.’ – (Halvorsrud, 2002).
The incomplete evidence available made arrival at a firm conclusion regarding the accident’s cause virtually impossible. It was clear, however, that once that northbound train left Rustad the collision was inevitable. The Norwegian rail administration was heavily censored for its apparent lack of safety awareness and safety management, and for failing to have completed an effective risk assessment. It was also fined NOK 10 million (circa US$1.6 Million).
Trauma management
It is not unusual to find that survivors of life threatening disasters are traumatised and the Åsta incident was no exception. Crash survivors were found to be suffering from a variety of emotions including guilt and sorrow. A support group was created to provide counselling and afford the opportunity for members to share their experiences. An estimated 120 joined the group, approximately twice the number that actually survived the disaster.
Corporate manslaughter
Although corporate criminal liability was entered into the Norwegian Statute books in 1991, no record of prosecutions associated with the Åsta train crash can be traced. The law states that three conditions must be met for a prosecution to be successful:
- a crime has been committed
- a connection between the offender and the corporation is shown
- the offence formed part of the offender’s work for the corporation
It can only be assumed that, as the results of the investigation were inconclusive, it would have been difficult to build a case against NSB which met these three criteria.
Insurance claims
Insurance claims resulting from injury or trauma are not uncommon. One female survivor pursued a claim through the courts for eleven years. She finally won her case against insurance company Tryg, which was covering NSB at the time of the crash. A court awarded her NOK 4.5 million (around US$700,000) plus costs.
Lessons learned
While the reason for the premature departure of the northbound train from Rustad remains a mystery, either human error or signal failure are considered to be the most likely cause. The failure to pass on the drivers’ mobile phone details to the controller, however, was clearly a process failure. Moreover, with mobile phone communications not being possible, there were absolutely no other contingency measures in place to avoid the ensuing disaster.
It is debatable that in the one minute the Controller had between realizing a collision was imminent and the actual impact, whether he had sufficient time to warn both drivers even if he had had their correct mobile details. Perhaps if an audible alarm had been installed in the Control Room, or someone had been monitoring the Rørosbanen, those extra couple of minutes gained may have rescued the situation.
A report published in 1990 had recommended that all remote lines should have an automatic train stopping system installed. Due to other priorities nothing was done on the Rørosbanen and the Norwegian Rail Administration was duly criticised and fined. Following the Åsta crash, installation work for such a system did rather belatedly commence.
Given the prevailing circumstances, once that northbound train had prematurely left Rustad station the accident was inevitable. There was no way of stopping the collision.
What went well
- Norway’s rail safety measures were generally good, as reflected by their record in comparison with other European countries.
- A trauma management support group was set up to help survivors.
What could have been done better
- The traffic controller was able to monitor the affected line remotely, but his attention was taken up by a busier line. Without an acoustic alarm it was easy for him to miss the impending disaster.
- Communications equipment was completely inadequate – mobile phones were used exclusively, with no backup.
What did not go well
- No advanced train stopping system: when communications failed there was no way for the traffic controller to prevent the disaster.
- The drivers’ mobile numbers had not been passed on to the traffic controller – a clear failure of procedure.
- The safety systems on the line were later found to be unsatisfactory.
- An effective risk assessment had not been carried out prior to the crash. This might have identified some of the failings in NSB’s systems and procedures and reduced the potential for a crash.
Conclusion
It is difficult to take any positives from this study except that Norway’s rail safety record is one of the best in Europe. But clearly, had at least some of the various safety measures available to the rail industry been deployed on the Rørosbanen as elsewhere in the country, the tragedy could have been avoided.