The preliminary report by the Office of Prevention and Investigation of Aircraft Accidents and Rail Accidents (GPIAAF) details the tragic incident involving the Glória elevator in Lisbon on September 3, which resulted in 16 fatalities and approximately twenty injuries, affecting both Portuguese and foreign nationals.
The document disclosed today outlines Carris’s acquisition process started in March 2022 for a batch of two cables. One cable functioned normally for 600 days, while the second failed after 337 days of use.
GPIAAF notes, “For reasons Carris could not explain during the investigation and which lacked documentary evidence from supplier consultations, the specification for these two items, corresponding to the cables for the Glória and Lavra elevators, was based on data provided by the Electrical Mode Maintenance Directorate (DME) of Carris for one of the Santa Justa elevator cables, merely changing the diameter.”
The report states that on March 17, 2022, DME identified the absence of the needed cables for remotorizing the Santa Justa elevator, prompting an alert to the Directorate of Logistics and Heritage (DLP) for “urgent procurement.”
DLP consulted four companies regarding the Santa Justa elevator cables, as requested by DME, including two additional items “pertinent to the Glória and Lavra elevator cables,” justified by a pending purchase request dated November 18, 2021.
GPIAAF considers it “noteworthy” that this consultation only included the two files provided by DME with specifications for the Santa Justa elevator cables and applicable standards.
The contract between Carris and the selected supplier was signed on April 14, 2022.
“Yet again, discrepancies between the grade and steel certification standards requested by Carris and proposed by the supplier went undetected by the signatories. Inventory numbers of specified articles versus those to be supplied did not raise concerns,” GPIAAF reports.
The cables were received and accepted in Carris’s warehouse on August 9, 2022, “without organizational quality control mechanisms detecting the various discrepancies present.”
“During the initial installation of the cable in the Glória elevator in December 2022, service provider workers and Carris field inspectors immediately noticed its different composition and handling behavior, notably its fiber core and increased flexibility for easier manipulation,” explains GPIAAF.
Once subjected to the cabin weight, “the cable significantly lengthened beyond the nominal dimension, necessitating a 4.5-meter segment cut to position the cabins correctly.”
“However, the workers did not possess the knowledge needed to identify the cable’s non-conformity with specifications,” the investigation notes.
Conversely, GPIAAF emphasizes, “the engineering department, when informally consulted by the maintenance area about its different behavior, assumed the cable corresponded to the synthetic fiber core alternative specified, never suspecting it did not match the specification,” considering “such behavior normal and expected.”
