A report on a 2015 incident in Western Australia has stressed the need for effective communication to ensure train staff can properly carry out operations and avoid safety dangers.
The incident occurred in September 2015 on a Brookfield Rail line and involved a freight train carrying bulk grain between Avon Yard and the port at Kwinana.
According to the Australian Transport Safety Bureau’s report, track re-railing work (contracted out to John Holland) was in progress along the route, involving the closure of the Up Main line between Moondyne and Jumperkine and the diversion of train movements to an adjacent track. Single line block working was thus implemented under the rules applicable to train order working.
The freight train crew received a train order to proceed from Moondyne to a station limits board, and along with this order they received additional instructions regarding their approach to worksites beyond this limit point.
On the approach to the limit point, the train crew were reportedly discussing the additional instructions when the driver suddenly sighted a station limits board and a track closed warning device (marking the limit of the authority).
“With little time to respond,” the report states, “the driver applied an emergency brake application … The train collided with the track closed warning device before coming to a stop approximately 400 metres past the limit of authority.”
The ATSB investigation found that the additional information attached to the train order had distracted the crew and led to their failure in stopping the train at the appropriate location. Furthermore, the report states that no visual cues had been erected on the approach to the authority limit point which could have warned the train crew that they were nearing the location.
“Communication of information through non-standard practices and/or the addition of information irrelevant to the intended task may reduce clarity and introduce a source of distraction,” the report states.
“In an operational environment, effective communication, crosschecking and shared understanding by train crew, together with appropriate environmental cues contribute to ensuring the effective performance of tasks.”
As a result of the incident, Brookfield Rail reportedly set up non-crossing indicator boards on all approaches to the station limits board. Moreover, infield protection on both ends of the section of closed track was added, including three track-warning devices 20 metres apart on each rail in advance of the track closed warning sign.
In March last year, Brookfield also introduced a new system of safe working rules and procedures consistent with the Australian Network Rules & Procedures, which means that it similar protective measures have and will be repeated.
The train operator, Watco, has also reportedly worked on emphasising a Crew Resource Management (CRM) program in the aftermath of the incident, which includes “cab situational awareness monitoring” carried out through periodical locomotive data downloads, and has provided additional checkpoints to their already existing Operational Check Ride form that also relates to cab situational awareness.