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1992 Gothenburg tram derailment

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Coordinates: 57°41′57″N 11°58′10″E / 57.699170°N 11.969427°E / 57.699170; 11.969427
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57°41′57″N 11°58′10″E / 57.699170°N 11.969427°E / 57.699170; 11.969427

Vasaplatsen tram accident
Map
Details
Date12 March 1992
c. 9:10 a.m. CET (UTC+01:00)
LocationVasaplatsen, Gothenburg
CountrySweden
Line7
OperatorGöteborgs Spårvägar
Cause
  • Power failure
  • Human error
  • Runaway tram
Statistics
Trains1 tram (4 carriages)
Vehicles4 cars
Deaths13
Injured42
Map
The route of the runaway tram, from stop Wavrinskys plats in the south to stop Vasaplatsen in north.
Two trams of the same M21 model.

The tram accident at Vasaplatsen in Gothenburg, Sweden, occurred on 12 March 1992, when a tram with non-functional brakes rolled 1.5 kilometres (0.9 mi) downhill, travelling backwards against traffic along Guldhedsgatan and Aschebergsgatan. Reaching speeds of up to 100 km/h (62 mph), it ploughed sideways across the Vasaplatsen tram platform, crushing over 50 waiting commuters as well as two cars and their passengers on a parallel road. The accident remains the deadliest in the history of Gothenburg's tramway, killing 13 people and injuring 42.

Course of event

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Lead-up to the accident

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The accident originated when a tramway segment used by line 7 lost power, due to a malfunctioning pantograph that burned an overhead wire near the Medicinaregatan stop. This caused a power outage along an extended section of track.[1][2] The accident tram, designated tram train number 19 and consisting of the M21 duo-carriage sets 235 and 245, came to a sudden halt near the Wavrinskys plats stop when the outage triggered an automatic brake, partially blocking a roundabout.[2][3][4] Shortly after, the driver evacuated the tram to allow passengers to find alternative ways of transport.[5]

As the track behind it belonged to a different segment that was unaffected by the power outage – other trams had begun building a queue and were waiting. A traffic controller began sending these into service one by one by reversing them down street Aschebergsgatan. The auxiliary switch from the west along street Vasagatan had been changed, allowing the trams to reverse along street Vasagatan and then continue in service towards Valand and Kortedala.

However, the accident tram at stop Wavrinskys plats could not be reversed, as it was without power. Its brakes were automatically engaged. A traffic controller manually disengaged the brakes via the outside so that the tram could roll downhill about 20–30 metres (70–100 ft) down street Guldhedsgatan, in the direction of stop Chalmers, where the overhead line had power.[6] The driver was asked to ride along so he, when given signal, could pull the emergency brake under the live wires.[7]

A police patrol, consisting of officers Birgitta Apelqvistα and Stefan Karlsson – who were on site to manage traffic around the obstructing tram – was asked to drive along the tram to prevent traffic from interfering with the manoeuvre.[2][8]

This order was a violation of existing regulations. The brakes of a powerless tram should only be disengaged when it was connected to another tram or a recovery vehicle.[9] The traffic controller's assumption that the brakes would automatically re-engage upon re-entering a powered section was also incorrect. This required the tram to be restarted from the driver's console. However, this was not possible because the fuse in the control panel blew when the tram entered the powered section, preventing the tram motor from starting.[10]

The accident

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Street Guldhedsgatan

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The tram rolled backwards down street Guldhedsgatan, past stop Chalmers, and continued on Aschebergsgatan, against traffic, unable to brake.

The police patrol, positioned alongside the tram, recognised the danger almost immediately and drove ahead to warn others.[11] Inside the tram, the driver frantically ran through the carriage, pulling all four emergency handles – though none of them were functional now – as the tram continued to gain speed.[12]

Intersection Engelbrektsgatan

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At the intersection of Aschebergsgatan and Engelbrektsgatan, the police vehicle narrowly avoided a collision with a Ford Escort – which, unaware of the danger, had pulled over into the opposite lane to give way to the police car behind him – but was instead struck by the tram.[13] The car gets demolished, but the driver survives the crash with only a sprained foot and injuries from flying glass.[14][15] This is also where the police choose to stop driving in front of the tram and pull to the side. Partly due to the high speed, but also because they have nowhere left to go.[16][17]

Intersection Vasagatan

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At the next intersection, with Vasagatan, the tram crashes into a taxi standing still, which lands on its roof.[18] This is also where the tram hits a junction at an estimated speed of 100 km/h (62 mph), derails, and continues moving sideways through the street.[19][20]

Tram stop Vasaplatsen

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At the Vasaplatsen tram stop people were waiting for a tram towards Tynnered. Only a few manage to notice the runaway tram in time, since most are looking down at the ground, shielding themselves from the falling snow.[21]

The 54-tonne tram ploughed sideways across the platform at Vasaplatsen stop. It mowed down over 50 people, crossed a parallel roadway, crushing two cars – including several parked ones – and finally crashed into a nearby building.[22]

Two cars were crushed beneath the tram, one of which had its fuel tank punctured and caught fire. The fire spread to the tram. Police attempted in vain to extinguish it. There were three people in the cars, all of whom died. Within 40 minutes, all the injured had been taken to hospital. In video footage, flames could be seen along the tram rails – it was burning petrol flowing downhill towards street Parkgatan.

Thirteen people were killed and forty-two were injured.[23]

Rescue operation

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The first emergency call from the public arrived at SOS Alarm at 9:17 a.m., followed shortly by twenty additional calls. Emergency services were dispatched at 9:18 a.m., and hospital wards were notified a couple of minutes later.[24] Initial estimates of the number of injured ranged from 100 to 200.[25][26] Some of the first emergency personnel to arrive initially believed the scene was a training exercise, due to the large number of injured spread across the street and the extensive destruction. Even experienced responders described the scene as surreal and unlike previous real incidents.[27][28]

No medical assembly point for the injured was established, and no advanced medical care was provided at the scene. Instead, ambulance personnel followed the rapid evacuation strategy known as “load and go”, in which basic first aid was administered and the patient was immediately transported to hospital. This approach was considered the most appropriate, as on-site care was not time-efficient due to the high number of severe injuries and the close proximity of Sahlgrenska Hospital, Östra Hospital, and Mölndal Hospital.[29][30] At 10:03 a.m., the last patient was picked up and transported to hospital.[31] Later forensic examination of the 13 deceased showed that none could have been saved through medical intervention at the scene of the accident.[32]

Aftermath

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A memorial stone at Vasaplatsen, near the site of the accident.

The same evening, the function to manually disconnect the mechanical brakes from the outside was removed. Since this had been widely covered in the media, they did not dare keep it as it was, as anyone would have been able to disconnect the brakes with relative ease.[33][34]

During the subsequent investigation, two opposing opinions arose about who, or what, was to blame:

  • One side considered that the fault lay with the traffic controller. The policy included several safety regulations stating that only technicians were allowed to disconnect the mechanical brakes, and the traffic controller should have known this.[35][36][37]
  • The other side believed the fault lay within the system, citing insufficient policies and training, and argued that the traffic controller could not reasonably have known about the knock-on effects. Part of this argument was that neither the driver nor 13 of the 18 other controllers knew about the full consequences – among other things, that the emergency brakes would also be disconnected – when manually disconnecting the mechanical brakes, and that there were no warning systems to inform them of this.[38][37][39]

The Swedish Accident Investigation Authority concluded that the company had not provided its staff with sufficient training on the affected M21 tram model.[40]

Two years after the accident, the managing director and the traffic controller of Göteborgs Spårvägar were prosecuted. The charges were gross negligence manslaughter and gross public endangerment (transl. grovt vållande till annans död och grov allmänfarlig vårdslöshet). The court ultimately argued that the fault lay with the traffic controller, as the rules approved by Järnvägsinspektionen (transl. The Railway Inspectorate) were clear, and that the traffic controller "should have known better".[39] However, since there were deficiencies in both the regulations and the training provided, and because the brakes could be disconnected with relative ease, the court concluded that the offence did not constitute a gross violation.[41] As such, the managing director was acquitted. The traffic controller, however, was convicted of causing another person's death, causing bodily harm, and reckless endangerment (transl. vållande till annans död, vållande till kroppskada och allmänfarlig vårdslöshet), and was given a suspended sentence along with a fine of kr 5,000.[42][43]

A 2010-hour-long episode of P3 Dokumentär about the accident summarises the issue of blame and responsibility as follows:

And in that way, this case is complex, because it's not easy to determine whose responsibility it really was. The accident claims the lives of 13 people and injures 42 others. The actual cause was a disconnected brake – and the traffic controller who disconnected the brake was the only one convicted, even though he didn't know that the emergency brake was also being disconnected. Göteborgs Spårvägar was then criticised for the staff's lack of knowledge. But since their rules and training had been approved by an authority, they didn’t realise what a safety risk it posed. And no better answer than that is given to the question of blame.[44]

— Ida Lundqvist, P3 Dokumentär

Today, a memorial stone stands on the grass in the park next to the tram stop where the accident occurred.

Miscellaneous

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  • The traffic controller went on sick leave and later received a new position at a subsidiary company.[45]
  • The driver returned to work after three weeks, initially driving together with an instructor by his side.[45]
  • Police officers Birgitta Apelqvistα and Stefan Karlsson were awarded the Medal for Noble Deeds, fifth class in gold, by the Swedish government for their actions.[46]
  • The fire service's old crane truck SDO 428, a 1969 Magirus Kranwagen, was used in active duty for the last time during this incident.
  • A similar accident occurred on the same street in the 1930s, when a trailer car became detached from a turning loop then located at stop Kapellplatsen. Fortunately, there were no passengers aboard the runaway trailer. A driver in a motorised tram travelling up street Aschebergsgatan noticed what was happening and managed to reverse his tram at relatively high speed to intercept the free-rolling trailer. He succeeded reasonably well, and only material damage occurred. Since then, all Albert couplings in the tram system have been equipped with a safety chain.
[edit]
  • Path of the runaway tram (June, 2025).
  • Stop Wavrinskys plats, where the runaway tram started rolling.
    Stop Wavrinskys plats, where the runaway tram started rolling.
  • Upper part of street Guldhedsgatan after Wavrinskys plats.
    Upper part of street Guldhedsgatan after Wavrinskys plats.
  • Lower part of street Guldhedsgatan towards stop Chalmers.
    Lower part of street Guldhedsgatan towards stop Chalmers.
  • The upper part of street Aschebergsgatan, after stop Chalmers towards stop Kapellplatsen.
    The upper part of street Aschebergsgatan, after stop Chalmers towards stop Kapellplatsen.
  • Street Aschebergsgatan after stop Kapellplatsen, towards stop Vasaplatsen.
    Street Aschebergsgatan after stop Kapellplatsen, towards stop Vasaplatsen.
  • Stop Vasaplatsen, where the runaway tram crashed into platform D.
    Stop Vasaplatsen, where the runaway tram crashed into platform D.

Notes

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^α At the time of the accident, the police officer's name is Birgitta Apelqvist. Later, for unrelated reasons, she changed her surname and is referred to as Birgitta Norrman in some sources.

Sources

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  • Forsberg, Anders (2006). Linje 7 [Line 7] (in Swedish). Stockholm: Trafiknostalgiska Förlaget. ISBN 9185305189.
  • Hansson, Jan, ed. (1999). Millennium - årtusendets bok [Millennium – the book of the millennium] (in Swedish). Gothenburg: Göteborgs-Posten. p. 288. ISBN 9789197336321.

References

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  1. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (documentary) (in Swedish). Sveriges Radio. Event occurs at 08:02.
  2. ^ a b c National Board of Health and Welfare; The Disaster Medical Organisation Committee; Almersjö, Olle (1994). Spårvagnsolyckan i Göteborg den 12 mars 1992 – Kamedo-rapport 62 [The Gothenburg Tram Accident on 12 March 1992 – Swedish Disaster Medical Report No. 62] (PDF) (in Swedish). Stockholm: Modin-Tryck. ISBN 91-38-11363-5. ISSN 1100-2808. SoS-rapport 1994:2. Archived (PDF) from the original on 19 June 2025. Torsdagen den 12 mars 1992 omkring kl 08.00 inträffade ett kontaktledningsbrott för spårvägen på Medicinargatan i Göteborg. Ett spårvagnståg blev stående i rondellen på Wavrinskys plats och hindrade trafiken. Inga passagerare fanns kvar i vagnarna. En polispatrull dirigerade biltrafiken förbi spårvagnståget. [On Thursday, 12 March 1992, at around 8:00 a.m., an overhead line fault occurred on the tramway at Medicinargatan in Gothenburg. A tram train came to a stop in the roundabout at Wavrinsky's Place, obstructing traffic. There were no passengers left in the carriages. A police patrol was directing road traffic past the stationary tram train.]
  3. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 09:08.
  4. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 09:37.
  5. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 10:45.
  6. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 12:57.
  7. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 15:45.
  8. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 11:12.
  9. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 14:08.
  10. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 18:40.
  11. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 16:00.
  12. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 16:52.
  13. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 19:09.
  14. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 23:43. Ja, det är helt otroligt att han levde få jag säga, för den bilen, den finns inte längre i princip. [Yes, it’s absolutely unbelievable that he survived, I must say, because that car, it basically doesn’t exist anymore.]
  15. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 24:04. Det visar sig att han klarar sig med en stukad fot och splitterskador. [It turns out he escaped with just a sprained foot and shrapnel injuries.]
  16. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 25:49. Men precis när vi kommit i det läget då där, då är vi ju princip i korsningen, och där hade vi ingen stans att ta vägen – och då gick det så fort också. [But just as we got to that point, we were basically in the intersection, and we had nowhere to go – and by then, it was going really fast.]
  17. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (in Swedish). Sveriges Radio. Event occurs at 27:02. Birgitta Norrman och hennes kollega vågar inte längre köra före spårvagnen. Det är för mycket människor ivägen och det går för fort. De stannar polisbilen vid vägkanten. [Birgitta Norrman and her colleague no longer dare to drive in front of the tram. There are too many people in the way, and it's going too fast. They stop the police car by the side of the road.]
  18. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 25:27. Sen när vi kommer ner vid korsningen med Vasagatan, så är det en taxibil som står där nere – och den hinner ju inte undan, så att den tar ju spårvagnen. Jag kan inte säga om det var i sidan, bak eller för – och den far upp och landar på taket och snurrar runt. [Then when we get down to the junction with Vasagatan, there's a taxi standing down there – and it doesn’t have time to get out of the way, so it gets hit by the tram. I can’t say if it was in the side, the back, or the front – and it goes flying, lands on its roof, and spins around.]
  19. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 26:00. Och antagligen var det i växeln in till Vasagatan, eller någonting sånt där, den spårar ur och ställer sig på tvären i princip och åker på tvärsan mer eller mindre ner mot Vasaplatsens spårvagnshållplats. [And probably it was at the switch into Vasagatan, or something like that, that it derails and basically ends up sideways, more or less sliding sideways down towards the Vasaplatsen tram stop.]
  20. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 26:47. Spårvagnen kommer skenande i drygt 100 kilometer i timmen. En växel strax ovanför Vasaplatsen är det som får spårvagnen att spåra ur och kana ut på asfalten. [The tram comes hurtling along at just over 100 kilometres per hour. A switch just above Vasaplatsen is what causes it to derail and skid out onto the asphalt.]
  21. ^ Lundqvist, Ida (2 December 2021). Spårvagnsolyckan i Göteborg (doumentary) (in Swedish). Sveriges Radio. Event occurs at 27:14. Och genom framrutan ser [polisen] männsikorna som väntar nere vid Vasaplatsen. Dom flesta tittar ner i backen och gömmer sig från blötsnön som faller. Bara ett fåtal hinner upptäcka vagnen som kommer farande. [And through the windscreen, [the police] the people waiting down at Vasaplatsen. Most of them are looking down at the ground, shielding themselves from the wet snow that's falling. Only a few manage to notice the tram coming hurtling towards them.]
  22. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Sveriges Radio. Event occurs at 28:50. Spårvagnen viker sig på mitten och plöjer sig över Vasaplatsen. Den krossar flera bilar på vägen. Det dånar av kraften och hastigheten. Och först när den kraschar in i fasaden på ett hus får den stopp. Då har den mejat ner över 50 människor. [The tram bends in the middle and ploughs across Vasaplatsen. It crushes several cars on the way. It thunders from the power and speed. And only when it crashes into the facade of a house does it stop. By then, it has mown down over 50 people.]
  23. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Sveriges Radio. Event occurs at 1:08:39. Olyckan berövar 13 människor livet och skadar 42 personer. [The accident claims the lives of 13 people and injures 42 others.]
  24. ^ National Board of Health and Welfare; The Disaster Medical Organisation Committee; Almersjö, Olle (1994). Spårvagnsolyckan i Göteborg den 12 mars 1992 – Kamedo-rapport 62 [The Gothenburg Tram Accident on 12 March 1992 – Swedish Disaster Medical Report No. 62] (PDF) (in Swedish). Stockholm: Modin-Tryck. p. 12. ISBN 91-38-11363-5. ISSN 1100-2808. SoS-rapport 1994:2. Archived (PDF) from the original on 19 June 2025. Urspårningen inträffade c:a kl 09.10. Första meddelandet kom kl 09.17 till SOS-centralen via 90 000 från en privatperson: "... En fruktansvärd olycka har inträffat på Aschebergsgatan med en spårvagn i brand och ...bilar krossade ...hur många döda som helst ...". SOS-centralen överförde larmet till polisens ledningscentral och till brandförsvarets alarmeringscentral (brand-AC), som slog "stort larm" kl 09.18. [The derailment occurred at approximately 9:10 a.m. The first message reached the SOS emergency centre at 9:17 a.m. via 90 000, from a member of the public:"... A terrible accident has happened on Aschebergsgatan with a tram on fire and ... cars crushed ... countless dead ..." The SOS centre relayed the alarm to the police command centre and to the fire brigade's alarm centre (fire-AC), which issued a “major alarm” at 9:18 a.m.]
  25. ^ National Board of Health and Welfare; The Disaster Medical Organisation Committee; Almersjö, Olle (1994). Spårvagnsolyckan i Göteborg den 12 mars 1992 – Kamedo-rapport 62 [The Gothenburg Tram Accident on 12 March 1992 – Swedish Disaster Medical Report No. 62] (PDF) (in Swedish). Stockholm: Modin-Tryck. p. 15. ISBN 91-38-11363-5. ISSN 1100-2808. SoS-rapport 1994:2. Archived (PDF) from the original on 19 June 2025. 09.20 – Besättningen från OLA-ambulanser rapporterar: "... kanske 50-tals döda och 100-tals skadade… katastroflarm!! " [9:20 a.m. – The crew from the accident and emergency ambulance service reported: "... perhaps fifty-some dead and hundreds injured… disaster alert!!"]
  26. ^ National Board of Health and Welfare; The Disaster Medical Organisation Committee; Almersjö, Olle (1994). Spårvagnsolyckan i Göteborg den 12 mars 1992 – Kamedo-rapport 62 [The Gothenburg Tram Accident on 12 March 1992 – Swedish Disaster Medical Report No. 62] (PDF) (in Swedish). Stockholm: Modin-Tryck. p. 16. ISBN 91-38-11363-5. ISSN 1100-2808. SoS-rapport 1994:2. Archived (PDF) from the original on 19 June 2025. 09.20 mottog avdelningsföreståndaren på kirurgiska akutmottagningen [på Östra Sjukhuset] larm från SOS-centralen att 100-200 skadats vid en kollision mellan två spårvagnar varvid brand uppstått. [9:20 a.m., the head of the surgical emergency department [at Östra Hospital] received an alert from the SOS emergency centre stating that 100–200 people had been injured in a collision between two trams, which had resulted in a fire.]
  27. ^ National Board of Health and Welfare; The Disaster Medical Organisation Committee; Almersjö, Olle (1994). Spårvagnsolyckan i Göteborg den 12 mars 1992 – Kamedo-rapport 62 [The Gothenburg Tram Accident on 12 March 1992 – Swedish Disaster Medical Report No. 62] (PDF) (in Swedish). Stockholm: Modin-Tryck. p. 45. ISBN 91-38-11363-5. ISSN 1100-2808. SoS-rapport 1994:2. Archived (PDF) from the original on 19 June 2025. Även rutinerad räddningspersonal uppfattade synen de mötte som overklig och en vid skadeplatsarbete rutinerad läkare fick ett första intryck av att det var en övning. Det var situationen med ett stort antal skadade utspridda efter gatan och de många demolerade fordonen som stämde mer med stora övningar än med erfarenheterna från tidigare olyckor. [Even experienced rescue personnel perceived the scene they encountered as unreal, and a doctor with extensive experience in accident site operations initially had the impression that it was an exercise. The combination of a large number of injured scattered along the street and the many wrecked vehicles resembled major training exercises more than any previous real-life accident.]
  28. ^ National Board of Health and Welfare; The Disaster Medical Organisation Committee; Almersjö, Olle (1994). Spårvagnsolyckan i Göteborg den 12 mars 1992 – Kamedo-rapport 62 [The Gothenburg Tram Accident on 12 March 1992 – Swedish Disaster Medical Report No. 62] (PDF) (in Swedish). Stockholm: Modin-Tryck. p. 22. ISBN 91-38-11363-5. ISSN 1100-2808. SoS-rapport 1994:2. Archived (PDF) from the original on 19 June 2025. Även den erfarna sjukvårdspersonal som deltog i insatsen vid spårvagnsolyckan vittnar om den känsla av overklighet som dominerade vid anblicken av olycksplatsen och om svårigheterna att handla rationellt. Den först anländande läkaren säger: "Det var omöjligt att avstå från att börja med återupplivningsförsök trots att jag insåg ..." Ledningsläkarens första reaktion var: "Detta måste vara en övning igen! ... Alla dessa utspridda skadade ... brand och demolerade fordon! Nar verkligheten blev uppenbar var det oerhört svårt att gå förbi många svårt skadade för att i stället skaffa sig en översikt ..." [Even the experienced medical personnel involved in the tram accident recall the overwhelming sense of unreality upon seeing the accident site and the difficulties in acting rationally. The first doctor to arrive said that it was impossible to refrain from starting resuscitation attempts despite knowing. The medical incident commander’s initial reaction was that this must be a drill again, given all the injured scattered around, the fire, and the wrecked vehicles. When reality became clear, it was extremely difficult to pass by many severely injured people in order to gain an overview of the situation.]
  29. ^ National Board of Health and Welfare; The Disaster Medical Organisation Committee; Almersjö, Olle (1994). Spårvagnsolyckan i Göteborg den 12 mars 1992 – Kamedo-rapport 62 [The Gothenburg Tram Accident on 12 March 1992 – Swedish Disaster Medical Report No. 62] (PDF) (in Swedish). Stockholm: Modin-Tryck. ISBN 91-38-11363-5. ISSN 1100-2808. SoS-rapport 1994:2. Archived (PDF) from the original on 19 June 2025. Någon uppsamlingsplats organiserades inte. Ingen avancerad medicinsk behandling gavs på skadeplatsen. "Load and go-principen" tillämpades i stället. Transporttiden till de tre närmsta sjukhusen är 5-15 minuter. [No assembly point was organised. No advanced medical treatment was provided at the scene of the incident. Instead, the "load and go" principle was applied. The transport time to the three nearest hospitals was 5–15 minutes.]
  30. ^ National Board of Health and Welfare; The Disaster Medical Organisation Committee; Almersjö, Olle (1994). Spårvagnsolyckan i Göteborg den 12 mars 1992 – Kamedo-rapport 62 [The Gothenburg Tram Accident on 12 March 1992 – Swedish Disaster Medical Report No. 62] (PDF) (in Swedish). Stockholm: Modin-Tryck. p. 25. ISBN 91-38-11363-5. ISSN 1100-2808. SoS-rapport 1994:2. Archived (PDF) from the original on 19 June 2025. Endast basal ABC-sjukvård meddelades i de allra flesta fall följt av omedelbart avtransport till sjukhus enligt den s k "load and go"-principen. Ingen organiserad prioritering för omedelbara åtgärder eller för avtransport förekom. Avgränsad uppsamlingsplats användes ej och prioritetsmarkering förekom inte. Ambulanssjukvårdsjournaler fördes inte systematiskt [Only basic ABC medical care was provided in the vast majority of cases, followed by immediate transport to hospital in accordance with the so-called “load and go” principle. No organised triage for immediate treatment or for transport took place. No designated assembly area was used, and no priority markings were applied. Ambulance medical records were not kept systematically.]
  31. ^ National Board of Health and Welfare; The Disaster Medical Organisation Committee; Almersjö, Olle (1994). Spårvagnsolyckan i Göteborg den 12 mars 1992 – Kamedo-rapport 62 [The Gothenburg Tram Accident on 12 March 1992 – Swedish Disaster Medical Report No. 62] (PDF) (in Swedish). Stockholm: Modin-Tryck. p. 14. ISBN 91-38-11363-5. ISSN 1100-2808. SoS-rapport 1994:2. Archived (PDF) from the original on 19 June 2025. 10.03 – Olof 50 meddelar: "Inga fler patienter att hämta från olycksplatsen" [10:03 – Olof 50 reports: “No more patients to collect from the accident site.”]
  32. ^ National Board of Health and Welfare; The Disaster Medical Organisation Committee; Almersjö, Olle (1994). Spårvagnsolyckan i Göteborg den 12 mars 1992 – Kamedo-rapport 62 [The Gothenburg Tram Accident on 12 March 1992 – Swedish Disaster Medical Report No. 62] (PDF) (in Swedish). Stockholm: Modin-Tryck. p. 9. ISBN 91-38-11363-5. ISSN 1100-2808. SoS-rapport 1994:2. Archived (PDF) from the original on 19 June 2025. Rättsmedicinsk undersökning av de 13 omkomna visar att ingen hade kunnat räddas genom medicinska åtgärder på. [sic] olycksplatsen. [Forensic examination of the 13 deceased showed that none could have been saved through medical intervention at the scene of the accident.]
  33. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Sveriges Radio. Event occurs at 56:19. Det togs ju naturligtvis bort samma kväll som olyckan hade hänt, eftersom detta var ju mycket åskådliggjort i tv och allting, så att – vi vågar ju inte ha det kvar, för dagen efter skulle vem som helst kunna gå och koppla ur de här bromsarna. [It was, of course, removed the same evening the accident happened, since this had been widely shown on TV and everything – so we didn’t dare keep it, because the next day anyone could have gone and disconnected those brakes.]
  34. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Sveriges Radio. Event occurs at 59:28. Asså den mekaniska bromsen som då satt på utsidan utav den här spårvagnen, den var just förhållandevis enkel och lätt att lossa på – och det kan man då ju säga i en utredning efteråt att hur kan man ha en broms som är så lätt att justera eller lossa på? [So, the mechanical brake that was on the outside of this tram was relatively simple and easy to release – and you can say in an investigation afterwards, how can you have a brake that’s so easy to adjust or release?]
  35. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Sveriges Radio. Event occurs at 55:28. Det är alltså uppenbart att någon har gjort något som inte är tillåtet. Den mekansika bromsen sitter på utsidan av spårvagnen och den får bara kopplas ur i nödfall. Om detta ska göras finns en rad säkerhetsföreskrifter som i detta fallet inte hade följts. [It is clear that someone has done something that is not allowed. The mechanical brake is located on the outside of the tram and may only be disconnected in an emergency. If this is to be done, there are a number of safety regulations that, in this case, were not followed.]
  36. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Willy Nicklasson, technical manager at Göteborgs Spårvägar. Sveriges Radio. Event occurs at 57:06. [Hur hade man tänkt sig att man skulle undvika att ett sånt här misstag skulle ske?] Hade man bestämt att det bara var tekniker som får göra det här. En tekniker, han vet ju hur man gör när man kopplar i den. Men han vet ju också det viktigaste – som är mycket mer viktigt att veta – det är ju hur man kopplar i den igen. Men det visste ju inte den trafikledaren vid detta tillfället.
  37. ^ a b Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Willy Nicklasson, technical manager at Göteborgs Spårvägar. Sveriges Radio. Event occurs at 57:43. [Fanns det nån typ av varningssystem som varnade en person att om du kopplar ur den här bromsen så kommer detta och detta ske?] Nej, det fanns inte. Det hade vi hoppats skulle vara inbyggt i varje skalle på alla människor som höll på med sånthär. [[Was there any kind of warning system to alert someone that if you disconnect this brake, this and that would happen?] No, there wasn’t. We had hoped that would be built into the heads of everyone involved in this kind of work.]
  38. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Kristina Pollack, psychologist and expert on the human factor at the Swedish Accident Investigation Authority. Sveriges Radio. Event occurs at 59:28. Och spårvagnsföraren, så vitt jag kommer ihåg, sprang ju han också att försöka få hejd på den här spårvagnen under resans gång. Men det fungerade ju inte så. Det här är ju ett tydligt exempel på att han inte riktigt visste vad det innebar när man hade lossat de mekaniska bromsarna. [Frågade ni andra trafikledare om de kände till att nödbromsen inte funkade när man kopplade ur den mekaniska bromsen?] Ja, det framgick ju tydligt att det här var en generell historia. [And the tram driver, as far as I recall, was also trying to stop the tram while it was moving. But that didn’t work. This is a clear example that he didn’t really know what it meant to have the mechanical brakes disconnected. [Did you ask other traffic controllers if they knew that the emergency brake wouldn’t work when the mechanical brake was disconnected?] Yes, it was clear that this was a general issue.]
  39. ^ a b Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). A news broadcast from Ekot in 1994. Sveriges Radio. Event occurs at 1:00:49. Göteborgs Tingsrätt ger en trafikförman vid Göteborgs Spårvägar villkorlig dom, men friar spårvägsbolaget och dess chefer för den svåra olyckan på Vasaplatsen i Göteborg i mars 1992. Han har hävdat att dålig utbildning och oklara regler gjorde att han inte visste bättre. 13 av 18 trafikförmän har i förundersökningen sagt att inte heller dom kände till bromssystemen bättre. Åklagaren åtalade därför både spårvägens VD och en hög chef. Men tingsrätten friar dom från skuld. Förmannen borde har förstått bättre. [The Gothenburg District Court gives a traffic foreman at Göteborgs Spårvägar a suspended sentence but acquits the tram company and its managers of responsibility for the serious accident at Vasaplatsen in Gothenburg in March 1992. He has claimed that poor training and unclear regulations meant he didn't know any better. In the preliminary investigation, 13 out of 18 traffic foremen said that they too were not familiar with the braking systems. The prosecutor therefore brought charges against both the managing director of the tram company and a senior manager. But the district court acquits them of responsibility. The foreman should have known better.]
  40. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Sveriges Radio. Event occurs at 1:00:28. I Haverikommissionens utredning hävdar psykologierna att det är företaget ansvar att instruktioner och utbildning för den här nya vagntypen varit otillräckliga. [In the Accident Investigation Authority’s report, the psychologists argue that it is the company’s responsibility that the instructions and training for this new type of tram were inadequate.]
  41. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Sveriges Radio. Event occurs at 1:01:22. Rätten anser att reglerna var tydliga och därför kan man inte fälla Göteborgs Spårvägar. Och även om det fanns brister i både regler och utbildning, så var dom godkända av Järnvägsinspektionen som är tillsynsmyndighet. Men samtidigt säger rätten faktiskt att trafikledaren inte har fått tillräcklig kunskap om bromssystemen. Och dessutom var bromsarna för enkla att koppla ur. Därför bedömer tingsrätten att det inte kan vara frågan om grova brott. [The court considers that the rules were clear and therefore Göteborgs Spårvägar cannot be held responsible. And even though there were deficiencies in both the regulations and the training, they were approved by Järnvägsinspektionen, the supervisory authority. At the same time, however, the court states that the traffic controller had not received sufficient knowledge of the braking systems. Moreover, the brakes were too easy to disconnect. For these reasons, the district court judges that the case cannot be considered a gross offence.]
  42. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Sveriges Radio. Event occurs at 1:01:56. Trafikledaren döms alltså för vållande till annans död, vållande till kroppskada och allmänfarlig vårdslöshet. [The traffic controller is thus convicted of causing another person’s death, causing bodily harm, and reckless endangerment.]
  43. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Sveriges Radio. Event occurs at 1:06:12. [Vad menar du med att "det inte blev något"?] Det blev ingenting, han som lossade bromsarna han fick böta 5000, men det fick han ju betalt av facket då – och alla högre gubbar där på spårvägen gick fria. [[What do you mean by "nothing came of it”?] Nothing came of it, the guy who released the brakes was fined 5,000, but the union paid that for him – and all the higher-ups at the tram company walked free.]
  44. ^ Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Sveriges Radio. Event occurs at 1:08:30. Och på så vis är det här fallet komplex, för det går inte på ett enkelt sätt att avgöra vems ansvaret egentligen är. Olyckan berövar 13 människor livet och skadar 42 personer. Själva orsaken var en lossad broms – och trafikledaren som lossade bromsen var den enda som blev dömd, trots att han inte visste att nödbromsen också kopplades ur. Göteborgs Spårvägar får då kritik för att personalen var okunnig. Men eftersom deras regler och utbildning hade godkänts av en myndighet insåg dom inte vilken säkerhetsrisk det innebär. Och bättre svar än så får inte skuldfrågan. [And in that way, this case is complex, because it's not easy to determine whose responsibility it really was. The accident claims the lives of 13 people and injures 42 others. The actual cause was a released brake – and the traffic controller who released the brake was the only one convicted, even though he didn't know that the emergency brake was also being disconnected. Göteborgs Spårvägar was then criticised for the staff's lack of knowledge. But since their rules and training had been approved by an authority, they didn’t realise what a safety risk it posed. And no better answer than that is given to the question of blame.]
  45. ^ a b Lundqvist, Ida (2 December 2021) [2010]. P3 Dokumentär: Spårvagnsolyckan i Göteborg (Radio broadcast) (in Swedish). Sveriges Radio. Event occurs at 1:10:49. Trafikledaren som lossade på bromsen blev sjukskriven och fick såsmåning om en ny tjänst inom ett av spårvägens dotterbolag. Föraren som satt inne i vagnen började däremot jobba igen efter tre veckor. [The traffic controller who released the brake went on sick leave and eventually received a new position within one of the tramway company's subsidiaries. The driver who had been inside the tram, on the other hand, returned to work after three weeks.]
  46. ^ Government Offices of Sweden (2006). Regeringens belöningsmedaljer och regeringens utmärkelse Professors namn [The Government's Reward Medals and the Government's Honorary Title of Professor] (PDF) (in Swedish). p. 50. SB PM 2006:1. Archived (PDF) from the original on 31 May 2025. Birgitta Apelqvist, polisassistent, Stefan Karlsson, polisassistent – För sitt modiga och rådiga ingripande vid spårvagnsolyckan i Göteborg den 12 mars 1992, då de körde sin polisbil längs spåret före en skenande spårvagn [Birgitta Apelqvist, Police Constable, Stefan Karlsson, Police Constable – For their brave and decisive intervention during the tram accident in Gothenburg on 12 March 1992, when they drove their police car along the tracks ahead of a runaway tram.]

Further reading

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