Need for proper processes highlighted in latest ATSB investigations

The need for proper processes to be established and followed to ensure rail safety has been highlighted in two recently completed rail safety investigations by the Australian Transport Safety Bureau (ATSB).

In an investigation into how a passenger train passed through a level crossing in North Geelong in January 2019 without activating flashing lights and boom gates at the level crossing, the ATSB found a lack of supporting instructions contributed to the error.

“The contractor undertaking the work did not provide signalling testers with specific instructions detailing the scope of work to be conducted at each stage of a project, but rather, only provided packaged isolation plans for the entire project,” said ATSB director transport safety Kerri Hughes.

Work to upgrade signalling required the level crossing for the broad and dual gauge tracks, managed by V/Line, at Thompson Road, North Geelong to be isolated. The adjacent standard gauge tracks, managed by the ARTC, were to be operating as normal.

The contractor, UGL Engineering, which was undertaking the work on behalf of VicTrack, had incorrectly isolated the level crossing for all of the lines. Fortunately, no vehicles were on the crossing at the time.

“Work instructions are step-by-step guides on how to perform a specific task or activity, in support of a process or procedure. They are important defences within a safety system for ensuring work is performed safely and as intended,” said Hughes.

VicTrack has updated their processes to include specific work instructions for each task associated with level crossing isolation plans.

In a separate incident in November 2019, thirty freight train wagons rolled unattended for 1,425 metres along a siding in Bordertown, South Australia. In its investigation, the ATSB found that a misunderstanding led to the wagons being uncoupled before a full application of the train’s air brakes.

ATSB director transport safety Stuart Godley said the incident highlighted the need to follow procedural steps and processes.

“The non-application of handbrakes increased the train’s reliance on the full application of wagon air brakes to prevent a runaway,” he said.

“However, a slight out of sequence implementation of the air brake process resulted in only partial application of the wagon air brakes and the subsequent runaway of unattended wagons.

“It is essential that all procedural steps are undertaken when uncoupling wagons for run-around movements.”

Rail operator, Bowmans Rail issued a safety alert in response, and the rail track manager, the Australian Rail Track Corporation (ARTC) has also since installed an arrestor bed at the Bordertown dead end.

ATSB Commissioner

New commissioner appointed to ATSB board

Catherine Scott has been appointed as a new commissioner on the governing board of the Australian Transport Safety Bureau (ATSB).

Scott replaces Carolyn Walsh, who was the ATSB’s longest serving commissioner having begun her role in 2010.

Scott is also a board member of the Office of the National Rail Safety Regulator and the National Heavy Vehicle Regulator and was previously on the board of V/Line.

In addition to her role on various boards, Scott has a background in investment banking and finance.

Deputy Prime Minister and Minister for Infrastructure, Transport and Regional Development Michael McCormack, who appointed Scott, said that Scott would bring significant experience to the role.

“Scott has 14 years rail experience, serving eight years as member of the Office of the National Rail Safety Regulator, six years as Non-executive Director at V/Line and is currently a board member of the National Heavy Vehicle Regulator,” he said.

“I look forward to continuing to work closely with Ms Scott and the ATSB Commission to ensure Australia’s transport sector remains among the safest in the world.”

ATSB chief commissioner Greg Hood said Scott would be welcomed to the safety investigator.

“I have no doubt Ms Scott will make a significant contribution to the ATSB’s work of improving transport safety in Australia,” Hood said.

“I look forward to working with Scott as we position the ATSB to support and advance the national transport safety agenda.”

Both McCormack and Hood thanked Walsh for her work on the board and contribution to transport safety.

“During Walsh’s time as Commissioner, more than 160 rail safety investigation and reports have been finalised, each of which has contributed to enhancing Australia’s rail safety,” said McCormack.

“I wish Walsh all the best with her future endeavours and thank her for her exemplary contribution to Australia’s transport safety.”

Investigations begun and completed into freight rail incidents

Investigations into two freight rail incidents have begun and been completed this week.

The completed investigation targeted the dewiring of over a kilometre of overhead powerlines in 2018. In this case, the ATSB investigation found that the collapsible walls of the flat racks were not secured by personnel at the Acacia Ridge terminal.

When passing through Cooroy on the North Coast line in Queensland, the rear end wall of the top of a stack of flat racks was extended, leading to it becoming entangled with overhead line equipment (OHLE), including copper wire. The wires were dragged along the platform at Cooroy, where luckily no one was present, however a south-bound train was due to arrive in 30 minutes.

Another concern in the incident was train crew entering the three-metre exclusion zone around the OHLE, before the wires were isolated and earthed. Although de-energised, the cables were not electrically safe.

ATSB director transport safety Mike Walker said the incident showed the need for effective processes for emergencies and in freight terminals.

“This occurrence has highlighted the importance of having checklists for rarely conducted tasks and emergency response tasks in the rail environment, and ensuring these checklists are readily available and used by operational personnel,” said Walker.

Aurizon, which operates the Acacia Ridge terminal and the train in the incident, has updated its safety processes in response to the incident and investigation. Network manager Queensland Rail has also mandated a network control officer checklist for OHLE emergencies.

Another investigation has been opened into a freight train derailing near Lake Bathurst. The Pacific National-operated service, a loaded garbage waste train, derailed after a wheel bearing assemble on the trailing axle of the lead bogie of one of the wagons failed.

The derailment lasted for a distance of roughly 2,500m. No one was injured however there was damage to the wagon’s bogie and frame and minor damage to track infrastructure. The NSW Office of Transport Safety Investigations (OTSI) is conducting the investigation on behalf of the ATSB.