Miguel A. Lopes / LUSA
Accident in the Glória Elevator, Lisbon
Report shows failures and omissions in maintenance, lack of employee training and supervision. Cabo did not respect Carris specifications.
The investigation into the accident in Lisbon detected maintenance failures and omissions of the elevator, also pointing out the lack of employee training and supervision of the work carried out by the company providing the service.
The incident with the Glória elevator, which occurred on September 3, caused 16 deaths and around two dozen injuries, including Portuguese and foreigners of various nationalities.
In the preliminary report on the accident, to which Lusa had access, the Office for the Prevention and Investigation of Aircraft Accidents and Railway Accidents (GPIAAF) says that the inspections scheduled for the day of the accident “are registered as executedalthough there is evidence that were not made during the time period indicated on the corresponding registration sheet”.
“During the lift’s operating period, a worker from the service provider observed the vehicles and spoke to the brakemen several times,” says the investigation, reporting the existence of a daily, weekly, monthly and semi-annual maintenance plan.
According to the researchers, “although the contractually foreseen and planned maintenance actions were being recorded as completed in its own registration system, to which Carris has direct access, evidence was collected that such registration does not match to the tasks that were actually performed.”
“There is evidence of execution of critical tasks in a non-standardized way with disparate execution and validation parameters”, reads the preliminary report.
The GPIAAF says that, on the day of the accident and the day before, the cabo was not observed in the pit, nor was this foreseen in the maintenance procedures, “although the specifications are contradictory in relation to this specific aspect”.
“A lubrication of the cable, scheduled on a weekly basis, is recorded as having been carried out on August 28th. The monthly cable inspection is recorded as having been carried out on September 1st,” the investigators found.
According to GPIAAF, “the local of the cable where it broke could not be observed in any of these inspections”, highlighting that, at this stage, it is not possible to conclude “whether or not any indication of an anomaly in the cable could be observed some time before the rupture in the visible part next to the work [ponto de fixação do cabo]”.
For more than 20 years, the maintenance of the Glória lift has been contracted by Carris to a service provider.
Maintenance has been carried out by the same company since 2019, with a staff of five workers, at the time of the accident.
“The training process of the five technicians, with experiences ranging from 11 years to 8 months in the company, is based on the transfer of practical knowledge in a work environment, without resorting to training actions theoretical or specific technical courses on the various equipment intervened under the current contracts”, says the GPIAAF.
O knowledge “has been passed on over the years to technicians from Carris to the service provider’s performers and from there in succession”.
The execution procedures (standards), designed by Carris, “have not been updated for many years, nor does the service provider have the necessary engineering staff with specialized technical knowledge in funiculars and means for developing, updating and adapting maintenance actions to the reality of the operation”.
“There is no guidance from the technical staff of the maintenance service provider regarding the specific way of carrying out the work, any guidance to workers or supervision, which is carried out by Carris supervision”, emphasizes the GPIAAF.
The provider’s quality system also does not ensure “the identification of weaknesses or the identification of opportunities for improvement with a focus on its maintenance activities, being mainly focused on issues of hygiene and safety at work”.
Corporal did not respect
O cabo that joined the two cabins of the Glória elevator and that gave way at its fixing point for the carriage that derailed did not respect Carris specifications, nor was it certified for use in transporting people.
According to the same report, “the cable installed did not comply with the specification” of Carris for use in the Glória lift, nor was it “certified for use in installations for transporting people”.
The GPIAAF adds that the cable “it was not recommended to be installed with swivels at its ends, as is the system in the Glória lift (and the Lavra lift)”.
The investigation detected failures in the process of acquisition cable via Carris and internal mechanisms of control of this company responsible for the lifts.
“The use of cables that do not comply with the specifications and usage restrictions were due to several flaws accumulated in its acquisition, acceptance and application process by CCFL [Companhia Carris de Ferro de Lisboa]whose organizational internal control mechanisms were not sufficient or adequate to prevent and detect such failures”, maintains the GPIAAF.
However, this organization remembers that, previously, cabos the same were in use for 601 days in the Glória lift (and 606 days in the Lavra lift), without incident.
“In this way, it naturally follows that, at this moment, It is not possible to say whether or what intervention was involved in the use of this type of cable. non-compliant in the rupture that occurred after 337 days of use, the investigation being certain that there were other factors that had to intervene”, points out the GPIAAF.
The investigation highlights that “the area where the cable broke was not subject to visual inspection without dismantling the upper swivel [zona de fixação do cabo]”.
“A macroscopic analysis of the ends of the ruptured cords shows progressive ruptures, therefore occurring gradually over time, and of different types. The metallographic examinations that will be carried out during the investigation will clarify the rupture mechanisms involved”, reads the preliminary report.
Far from maximum capacity
The GPIAAF also reveals that, “immediately before the preparation for the start of the journey” of the accident, in cabin 1, which was at the top of Calçada da Glória, there were 27 people, including a child and the brakeman, while inside cabin 2, next to Praça dos Restauradores, there were 33 people, including three children and the brakeman.
“Therefore, both well below its maximum capacity of 42 occupants”, emphasizes this organization, adding that on the day of the accident the lifts “had made 53 trips in total”.
“The average occupancy was 22 passengers in cabin 1 and 17 passengers in cabin 2, with the maximum capacity of 42 passengers being reached on two trips in cabin 1 and on one trip in cabin 2,” the investigation found.
In the preliminary report, the GPIAAF also states that both elevators “were equipped with four video surveillance, each one, and with a device equipped with accelerometers [equipamentos para medir a aceleração] of low precision”, noting that on Calçada da Glória “there are also several surveillance cameras”.
“This allowed the investigation to establish with sufficient rigor the sequence of events that preceded the accident”, indicates the document.
The first collision occurred at an estimated speed between 41 and 49 kilometers per hourwith 33 seconds having elapsed since preparation for the trip and 20 seconds since the beginning of the movement.
Stopped elevators
The investigation into the Glória elevator accident recommends that Carris do not reactivate the lifts in Lisbon “without a reassessment by a specialized entity”, and the Institute for Mobility and Transport (IMT) to implement an appropriate regulatory framework.
In the document, the GPIAAF recommends to Carris “not to reactivate the elevators without a reevaluation, by an entity specialized in funiculars, cable fixings and brakes, in line with European regulations in this matter, respecting the historical protection of those transports, but without compromising safety”.
This body recommends that the company responsible for Lisbon’s elevators also carry out “a reassessment and review of your internal control systemparticularly with regard to the processes of specification, acquisition, reception and application of critical components for vehicle safety”.
The investigation also recommends that Carris carry out “an assessment of the advantages of defining and implementing a safety management systemin line with best European practices, but adapted to the reality of your organization”.
“That allows an explicit and documented identification and analysis of the security risks of the operation and the measures implemented to guarantee their control at a level considered adequate, proceeding in accordance with the result of this assessment”, points out the GPIAAF.
The GPIAAF also recommends that Carris “clarification with the service provider for maintaining contractual obligations and exercising effective supervision and control over these obligations, in terms of maintenance management, its execution and quality control in accordance with applicable regulations”.
As for the IMT, the preliminary report states that it is a national public entity with the responsibilities of promoting the definition and updating of the normative and regulatory framework for the land transport sector, as well as approving, approving and certifying vehicles and equipment used in land transport systems, guaranteeing the required technical and safety standards.
The GPIAAF recommends that the IMT, in line with what is expressed in the European Union regulations, proceed “to promote an appropriate legislative, regulatory or other framework, which guarantees that all funiculars and other similar or assimilable public transport systems are properly framed from a technical and supervisory point of view”.
The investigation also recommends that the IMT proceed with “promoting a legislative framework that guarantees that electric cars on rails, whether historic, modernized or modern, that circulate on public streets, whether when they enter into service or during their lifetime, are subject to compliance with appropriate safety rules and conditions”.
“Following the best practices of other Member States in this area, and at an appropriate level of independent supervision”, indicates a preliminary report.
According to the GPIAAF, safety recommendations are proposals for improvement, being drawn up based on the conclusions, albeit preliminary if appropriate, of an investigation into one or more accidents or incidents.
