Shocking Report Reveals Critical Safety Failures in Lisbon's Gloria Elevator Accident

Preliminary Investigation Uncovers Multiple System Failures

According to the preliminary report by GPIAAF (Office for the Prevention and Investigation of Accidents with Aircraft and Railway Accidents), the cable that broke in Cabin No. 1 of the Gloria Elevator, causing the derailment, was incorrectly purchased by Carris and showed signs of wear.

The report specifically points to multiple failures in the acquisition, acceptance, and installation process of the cable by Carris. "The use of cables that were repeatedly non-compliant with specifications and usage restrictions was due to various accumulated failures in their acquisition, acceptance, and application process by CCFL (Companhia Carris de Ferro de Lisboa, E.M, S.A), whose organizational internal control mechanisms were not sufficient or adequate to prevent and detect such failures," it states.

The report reveals that the type of cable, used since 2022, is not certified for passenger transport installations and is not suitable for the system of either the Gloria or Lavra ascensors, which have the same type of cable installed.

Emergency Systems Failed to Prevent Tragedy

The office indicates, however, that "identical cables were in use for 601 days in the Gloria Ascensor (and 606 days in the Lavra Ascensor) without incidents," concluding that, "for this reason, it is not possible at this time to state whether the non-conformities in the use of the cable are or are not relevant to the accident."

It adds that, "at this moment, it cannot be stated whether the use of this type of cable intervened, or what intervention it had, in the rupture that occurred after 337 days of use, although it is certain for the investigation that there were other factors that necessarily had to intervene."

The document, "essentially factual," was published at the end of the 45-day period established for presenting the first results of its investigation.

Recommendations for Safety Reevaluation

The office recommends that Carris not reactivate Lisbon's ascensors "without a reevaluation by a specialized entity," and to the Institute of Mobility and Transport (IMT) that it implement an appropriate regulatory framework.

Specifically, GPIAAF recommends to Carris "not to reactivate the ascensors without a reevaluation, by an entity specialized in funiculars, of the cable fixings and brakes, in line with European standards on this matter, respecting the historical protection of these transports, but without prejudice to safety."

It points out the need for Carris to conduct "a reevaluation and revision of its internal control system, particularly regarding the processes of specification, acquisition, reception, and application of components critical to vehicle safety."

GPIAAF also recommends to Carris the "clarification with the maintenance service provider of contractual obligations and the exercise of effective supervision and control over these obligations, at the level of maintenance management, its execution, and quality control in accordance with applicable standards."

The report indicates that the investigations will continue and that a final report will be published up to one year after the accident.

Details of the Fatal Accident

In the first informative note, published three days after the accident, it was described that the cable connecting the two cabins gave way. And that, despite the activation of the brakes and the emergency system, the redundancy could not prevent the tragedy.

The accident at the Gloria elevator killed 16 people.

The preliminary report now published, after investigation by the Office for the Prevention and Investigation of Accidents with Aircraft and Railway Accidents, confirms the initial conclusion, stating that "the traction cable connecting the two cabins broke inside the untwister of the upper tram, a few centimeters from its mooring pine."

"At the time of the accident, it had 337 days of use," it adds.

It also indicates that "the braking system of the cabins was not effective in immobilizing them, despite all existing ones, automatic and manual, having been applied in cabin 1".

"Even among the oldest technicians still in service, there is currently no memory in CCFL of the emergency brake ever being tested for the situation of cable failure." Nor "are there known calculations of the brake systems of the cabin brakes."

"The historical information that was possible to access suggests that the brake system of the vehicles was modified some decades after the electrification of the Ascensor, with a decrease in their capacities. There are also indications that the weight of the cabins increased in a non-negligible way since the time of electrification, with disparate indications regarding the current weight," adds the document.

Among the technicians, there was the perception that "the safety of the system depended entirely on the cable and that the brake system was not effective."

Carris's Exclusive Responsibility

For GPIAAF, Carris holds the exclusive responsibility for the maintenance of the elevator. However, it points to lacks in the legal framework for inspection operations and of "the competence of technicians to detect failures or denounce the execution of work outside standardized norms."

Emphasizing that "the safety aspects of the operation of both ascensors [Gloria and Lavra] were under the exclusive responsibility of CCFL as the operating entity," the document recalls the lack of legislative framework on the maintenance of both Elevators, classified as "monuments of historical interest."

The ascensors were handed over to CCFL "without being supervised by any independent entity, public or private, and without an effective legal framework for their operation while no significant alteration was introduced in their infrastructure and subsystems," states the office.

"The use of a new type of cable in 2022 could be considered a significant alteration of one of its subsystems. However (...) this alteration was made by CCFL inadvertently and without awareness of it being so," sustains the investigation.

It also states that both elevators are "of a very rare, if not unique, variant of the type designated in specialized literature as self-propelled funicular."

Despite this, it adds, "nothing prevented the same rules from being applied to them as to other installations, with due adaptations to their specificities, including supervision."

The investigation also concluded that "the maintenance and safety conditions of the trams, historical, modernized, or modern, that circulate on public streets in common with road vehicles, both at their entry into service and during their life, are not, in Portugal and as declared by IMT, subject to compliance with any rules other than those defined by the Company itself, nor, mainly, to any type of independent supervision."

"The situation in Portugal contrasts flagrantly with the reality" in other states that have collaborated with the office's investigation. In these, "the generality of funiculars is subject to compliance with technical rules and periodic supervision by national or regional authorities, regardless of the date of their entry into service or historical interest," also points out GPIAAF.

Maintenance Challenges and Subcontracting Issues

GPIAAF also underlines difficulties in analyzing the cable in use, stating that "the area where the cable broke was not amenable to visual inspection without disassembly of the untwister of the upper tram."

A circumstance that led Carris technicians to base the recommendation for cable replacement on the number of days of use.

The report even states that "among various technicians and workers of CCFL linked to the ascensors, there was the perception that the safety of the system depended entirely on the cable and that the brake system was not effective in immobilizing the cabins without the cable".

"For this reason," the preliminary conclusions continue, "there was a high care in the control of the cable, namely limiting its use to 600 days, well below the expected duration for that component. But this perception never materialized organizationally in a reevaluation of the safety conditions of the system."

"CCFL has subcontracted the maintenance of the ascensors to a service provider, with the current one ensuring maintenance since 2019," points out the investigation, and that "the workers of the service provider act essentially as collaborators of CCFL, being trained on the job and executing interventions under the direct guidance of that company's supervision."

The execution of the work was, however, carried out "without supervision" and there being "evidence that maintenance tasks recorded as completed do not always correspond to the tasks actually performed, as well as critical tasks for safety being executed in a non-standardized way, with disparate execution and validation parameters."