Investigation into the elevator accident on Glória in Lisbon uncovered maintenance failures and omissions, citing a lack of employee training and supervision of work performed by the service provider.
The accident, which occurred on September 3rd, resulted in 16 deaths and nearly two dozen injuries, affecting both Portuguese nationals and foreigners of various nationalities.
The preliminary accident report, released today by the Office for Prevention and Investigation of Aeronautical and Railway Accidents (GPIAAF), indicates that scheduled inspections on the day of the accident were recorded as completed, although evidence suggests otherwise.
During the elevator’s operation, a service provider employee frequently observed the vehicles and spoke with conductors, as part of a daily, weekly, monthly, and semiannual maintenance plan.
Investigators noted that while maintenance tasks were recorded as fulfilled in the system accessible to Carris, there is evidence indicating discrepancies between recorded and performed tasks.
Evidence shows critical tasks were executed non-standardly with varying execution and validation parameters, as stated in the preliminary report.
GPIAAF found that on the accident day and prior, the cable was not inspected in the pit, nor was this stipulated in maintenance procedures, despite contradictions in the contract specifications.
The cable lubrication, scheduled weekly, was recorded as completed on August 28th, and the monthly cable inspection was marked as conducted on September 1st.
According to GPIAAF, the cable’s break point was not observable in inspections, making it unclear if any anomaly indication could have been detected before the visible rupture near the fastening point.
Glória’s elevator maintenance has been contracted to a service provider by Carris for over 20 years, with the same company handling it since 2019, employing five workers at the accident time.
The training process for these technicians, who had been with the company for 11 years to 8 months, relied on practical knowledge transfer in the workplace, lacking theoretical or specific technical courses for equipment under existing contracts.
Knowledge was passed down over the years from Carris technicians to service provider workers.
Execution procedures, designed by Carris, have not been updated in years, and the service provider lacks a specialized engineering team to develop, update, and adapt maintenance actions to operational realities.
No technical guidance or supervision is provided by the service provider’s technical team, with Carris conducting oversight, emphasized GPIAAF.
The service provider’s quality system does not ensure identification of weaknesses or improvement opportunities in maintenance activities, focusing primarily on hygiene and safety issues at work.
