When, days after the accident that killed 15 people, we wrote here that the derailment of the Elevador da Glória was also a derailment of responsibilities, only a first assessment by the Air and Railway Accident Prevention and Investigation Office (GPIAAF) had been released. Several questions remained unanswered. Who supervised, who inspected, who decided.
The preliminary report released this Monday by GPIAAF, the national authority that investigates railway accidents, answers some of these doubts and confirms the essentials. The disaster was not just mechanical. It was institutional. It was systemic. The break in the cable connecting the two cabins exposed serious control failures at Carris and a gap in supervision that the State never resolved.
From what is written, it is possible to conclude that there are failures that may have started within Carris and then spread due to the lack of public supervision. The cable that connected the two cabins, and whose rupture caused the tragedy, did not meet the company’s own technical specifications. It was not certified to transport people, and the manufacturer’s certificate warned that it could not be used in the elevator’s existing system. The nonconformity was neither detected nor stopped.
According to the GPIAAF, there are several responsibilities that have failed. From specification, to acquisition, reception and application of a critical component. All within the competence of Carris. “The use of cables that did not comply with the specifications and restrictions of use was due to several failures accumulated in their acquisition, acceptance and application process by Companhia de Carris de Ferro de Lisboa (CCFL), whose internal organizational control mechanisms were not sufficient or adequate to prevent and detect such failures”, it is written.
Regarding maintenance, it is clear that there are tasks recorded as completed that do not correspond to what was actually done. Others, of vital importance, were carried out “in a non-standardized way, with different execution and validation parameters”. Further: “The inspections scheduled for the day of the accident and antecedents are recorded as carried out and the service provider’s personnel were present, but the evidence does not support the time period indicated in the worksheets for their execution”.
Although it recognizes that there is still no evidence that these non-conformities could have had a direct impact on the cable break, the GPIAAF recommends that Carris review the entire internal control system and implement a true safety management system.
The report also points to the institutional void. This is because, as had already been established in the first report in September, the Elevador da Glória is not under the supervision of any public entity, nor the Institute of Mobility and Transport, nor any technical authority. It is a public passenger transport that operates without external supervision – an omission that ended up paving the way for its collapse.
The investigation expressly recommends that the IMT promote a legislative and regulatory framework that ensures technical supervision and certification of all funiculars and similar means of transport.
It is an obvious and late recommendation. This preliminary report does not determine criminal charges. This is the task of the Public Prosecutor’s Office, which we will wait for and not forget – 15 lives were the result of this chain of irresponsibility.
By pointing to institutional responsibilities, the GPIAAF highlights the portrait of a system failure. A public company that does not control what it buys, a State that does not supervise what it transports and a city that trusted a symbol without guaranteeing its safety. The tragedy was not inevitable. The signs were there. It was announced.