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.

flood

Monitoring processes improved following rail flood incident

An out of service water level sensor led an Aurizon freight train to plough through flood waters that had inundated a rail bridge near Tully, Queensland, in 2018.

The Australian Transport Safety Bureau (ATSB) found that the driver had attempted to stop the train before the flooded bridge, but as the bridge was soon after a curve, applying the emergency brake was not enough to stop the Brisbane-bound train.

Following investigations unearthed that the water level sensor at the bridge had been out of service for several weeks, and the crew was not informed that the bridge was flooded. A CCTV camera also installed had an out-of-service illuminator, so was ineffective at night.

Further inquiries by ATSB established that Queensland Rail (QR), the infrastructure operator, could not effectively ensure that network control staff knew that monitoring systems were working or not, especially during conditions such as wet weather. The ATSB also noted that control staff were not required to actively search for information about track conditions ahead of a train when there was a realistic potential that conditions had deteriorated.

“This investigation highlights the importance of having serviceable weather monitoring stations at known flooding locations on a rail network, and ensuring that if these systems are not functioning all relevant parties need to be aware of the defect,” said ATSB director transport safety Mike Walker.

The incident occurred on March 7, 2018, after a significant period of wet weather, the Tully area is also one of the wettest towns in Australia, with an average March rainfall of 756mm. A flood watch had been issued on the afternoon of March 6 for that area.

Due to these conditions QR had placed a speed restriction on the area, limiting the speed of trains so that they could stop short of an obstruction within half the distance of a clear line that was visible ahead.

“Operating under a condition affecting network (CAN) requires effective communication between all relevant parties,” said Walker. “Train controllers need to ensure that all relevant information associated with the network conditions are passed to train crews and track maintenance personnel so that they can effectively perform their roles.”

The train driver and crew were not injured, and following the incident moved the train to the Tully yard.

QR has improved its processes to ensure weather systems are reliable, and that control personnel are aware of any faults. Network control staff have also been trained to proactively monitor network conditions.

investigations

Incidents highlight need for effective track and infrastructure monitoring

Recent investigations by the Australian Transport Safety Bureau (ATSB) have highlighted the importance of ensuring effective track monitoring and infrastructure maintenance.

The ATSB recently concluded two separate investigations, one into a derailment of a grain train in north-western NSW that occurred in 2017.

The train, travelling from Nevertire to Manildra derailed causing substantial damage to wagons and track infrastructure, however there were no injuries. The investigation, conducted on behalf of ATBSI by the NSW Office of Transport Safety Investigation (OTSI), found that maintenance of identified defects did not prevent these defects from re-occurring.

The train was also travelling 20km/h above the 60km/h speed limit for that section of track.

OTSI CEO and chief investigator Mick Quinn said that defects around a rail joint as well as speed contributed to the derailment.

“The incident highlights the importance of ensuring that track is free of defects that effect safety and that trains travel at or below the speed specified in rail network standards.”

Following the derailment, the Australian Rail Track Corporation (ARTC), which manages that section of track, has made changes to its track maintenance systems and processes, and is replacing sleepers and removing rail joints.

In a separate incident, at Eagle Junction in Brisbane, a newly replaced points machine resulted in an incorrect authority displayed by a signal.

The driver and signal electrician at the time, in 2018, noticed the irregularity, and reported it, however a short time later another train approach and crossed over the conflicting route.

An ATSB investigation found that the master circuit diagram had not been updated to reflect modifications. ATSB director transport safety Stuart Godley said that to avoid this, safety critical infrastructure must be supported by precise documentation.

“Accurate and up-to-date engineering documents correlating with in‑field equipment are fundamental to the effectiveness of an engineered interlocked signalling system to maintain train separation.”

broken rail

ATSB finds broken rail caused freight train derailment

The Australian Transport Safety Bureau (ATSB) has found that a broken rail led to the derailment of a freight train near Goulburn on March 31, 2019.

As the SCT Logistics freight train, travelling from Melbourne to Brisbane, exited a refuge loop in Goulburn, NSW five wagons derailed, obstructing both the Up and Down main lines.

The driver of the train had just been authorised to pass the immediately preceding signal at Stop, which could not be cleared due to a track circuit fault. Another train had passed through the refuge the night before when the fault occurred. The network controlled and the on-call signal electrician had consulted and agreed that trains could continue passing the Stop signal.

After the derailment, the NSW Office of Transport Safety Investigation (OTSI) had conducted an investigation on behalf of the ATSB. OTSI found that the immediate cause of the derailment was a broken rail, which had likely occurred after the previous train, and the break had caused the signal to be stuck at Stop. The broken rail had not been detected.

The point where the rail in question had broken was where a crack had formed between two different sized rails that had been joined in an aluminothermic junction weld. Further examination of the track found that the existing crack was not easily detectable through continuous ultrasonic testing or routine maintenance.

The Australian Rail Track Corporation (ARTC), which managed the section of track engaged an independent metallurgist to study the rail after the derailment. The metallurgist found there was a lack of weld fusion on the foot of the rail between the two rail types and was undetected at the time of welding. This, along with the difficulty detecting the crack afterwards, reinforced the need for thorough inspection said OTSI COO and deputy chief investigator Kevin Kitchen.

“It is critical that areas of the rail that cannot be easily inspected during scheduled continuous ultrasonic testing are tested thoroughly at the time of welding to ensure that the weld is free from defects,” said Kitchen.

The investigation also found that other factors increased the risk in relation to the occurrence. OTSI and ATSB noted the network rules were one of these factors.

“Network rules that permit degraded operations must be assessed to ensure that the application of these rules do not increase risk to an unacceptable level,” said Kitchen.

“Personnel responsible for implementing these rules should have sufficient guidance to assess when it is safe to continue operating trains, or under what conditions operations can continue.”

The investigation also found that the sleepers underneath the track were decayed and the ballast appeared fouled with mud and dirt.

Preliminary report into Jumperkine collision released

The Australian Transport Safety Bureau (ATSB) has released its preliminary report into a freight train collision at Jumperkine in Western Australia.

The collision occurred on 24 December, 2019, when a Pacific National freight train travelling towards Perth collided with the rear of a stationary grain train, operated by Watco. The driver of the Pacific National train, Greg Reid, suffered fatal injuries.

Prior to the collision the freight train passed a signal set at caution, then a temporary speed restriction ahead sign warning of a 30km/h speed restriction. The preliminary report then establishes that the freight train passed a signal set at stop when travelling at 72km/h.

Roughly 60 metres after the stop signal, the freight train passed a temporary speed restriction start sign, and the driver applied the brake three seconds later. This slowed the train down as it travelled around a left hand curve and then onto a straight section of track. The report then notes that the rear of the grain train would have come into view, leading the driver to apply the emergency brake. 13 seconds after the brake was applied the freight train collided with the grain train.

The collision occurred at 2am and the driver was acknowledging the vigilance system alerts. Before the collision a network controlled had attempted to contact the driver, but there was no response.

ATSB director transport safety Stuart Godley said that further investigations would be undertaken.

“In the coming months transport safety investigators will examine the functionality of the locomotive’s braking and vigilance control systems and undertake further analysis of event data recorders and video recordings,” said Godley.

A spokesperson for Pacific National said the company acknowledges the report.

“At Pacific National the safety of our employees and contractors is our highest priority and as a business we are devastated by the loss of our train driver Greg Reid in this very unfortunate incident.  We continue to offer support to Greg’s family.”

Arc Infrastructure, the operator and manager of the accident site, also noted the report.

“Arc Infrastructure fully cooperated with the ATSB in their investigation including providing an internal investigation report into the Jumperkine incident. Arc Infrastructure remains committed to working with industry to continue to improve the safety of the rail industry,” said an Arc Infrastructure spokesperson.

“We wish to thank the ATSB for the detailed factual information contained in the report and for their ongoing commitment to safety in our industry.”

Proactive safety actions have been taken by both Pacific National and Arc Infrastructure and cover operations carried out between midnight and 6am, the calling of train routes, and processes for when a train has stopped.

ATSB releases preliminary report into Wallan train derailment

The Australian Transport Safety Bureau (ATSB) has released the preliminary report into the Wallan train derailment.

Although the report does not contain findings, the report does note that signals at Wallan were reversed, causing the XPT train to enter a passing loop at a speed of more than 100km/h when the speed limit for entering the loop was 15km/h, and exiting the loop was 35km/h.

“Earlier that afternoon, the points at either end of the Wallan loop had been changed from their ‘Normal’ position to their ‘Reverse’ position, which meant that rail traffic, in both directions, would be diverted from the Main Line into the loop track,” said ATSB chief commissioner, Greg Hood.

“A Train Notice reflected this change and also specified a 15 km/h speed limit for entry into the loop.”

Prior to the derailment, the XPT service had travelled through a section from Kilmore East that was being managed using an alternative safeworking system. During this section, an accompanying qualified worker (AQW) boarded the lead power car and joined the driver at the head of the train. Before proceeding, the driver and the network control officer communicated via radio about the train authority for the section to Donnybrook.

After passing Kilmore East, the train sped up to 130km/h, the line speed for this section. Then, the train travelled to Wallan and was diverted onto the Wallan Loop, the points for which had earlier been changed from Normal to Reverse.

The emergency brake was applied a short distance before the points, which slowed the train a small amount, however the train entered the turnout travelling at above 100km/h, leading the train to derail.

The alternative safeworking system was implemented on the section of track from Kilmore East to Donnybrook due to damage to the signalling infrastructure, caused by a fire on February 3, 2020.

Investigations into the incident are ongoing, and are being led by Victoria’s Chief Investigator, Transport Safety (CTIS), along with the New South Wales Office of Transport Safety Investigations (OTSI). The Office of the National Rail Safety Regulator is also continuing to investigate.

CEO of the ARTC, John Fullerton, said that the ARTC would learn from the incident.

“Accidents of this nature are complex and can hardly ever be attributed to just one cause, and this investigation is one important way of ensuring lessons are learned, and systems and processes are put in place to avoid something similar from happening again.”

The derailment killed the driver, John Kennedy, and the AQW, Sam Meintanis.

“ARTC joins with all in the rail industry in again extending our sincere condolences to the families, friends and colleagues of John and Sam,” said Fullerton.

“The main focus of all in the rail industry – whether it is rail network operators like ARTC, the passenger and freight rail customers who use it, or the many rail contractors – is to operate safely.”

A Transport for NSW spokesperson noted the report.

“We continue to engage with the investigators on what is a complex set of circumstances that led to the loss of a NSW TrainLink employee and a contracted ARTC staff member,” said the spokesperson.

“Our thoughts are with the families and friends of those who lost their lives in this accident and we await the final report by the ATSB due in 2021.”

Hood noted that the full investigation could take over 18 months to complete.

“However, should any safety critical information be discovered at any time during the investigation, we will immediately notify operators and regulators, and make that publicly known.”

Further investigation by the ATSB will inquire into the derailment sequence, track condition, rollingstock condition, crew and passenger survivability, train operation, and management of train operations. So far, the investigation has not found a fault with the rollingstock or the track itself that directly contributed to the derailment.

Union supports speed restrictions in Wallan following fatal derailment

The Rail, Train and Bus Union (RTBU) stated that it is pleased that the rail industry is taking the union’s concerns seriously.

The union wrote to the Australian Rail Track Corporation (ARTC), Pacific National, V/Line and NSW Trains to request detailed information regarding plans for resuming services services through Wallan following the fatal XPT derailment last week.

ARTC advised the union on Thursday, February 27 that it would be imposing a 20km/h speed limit through Wallan. It also advised that the signalling infrastructure through Wallan was now operational.

Pacific National has advised the RTBU that it has imposed an 90km/h speed restriction between Seymour and Albury, and drivers are being instructed to adhere to an ARTC’s temporary speed restriction of 20km/h.

An RTBU spokesperson said the union’s Victorian branch has commenced discussions with V/Line, and the union’s NSW branch has also begun discussions with NSW Trains.

“At this point, we’re pleased that ARTC, PN, V/Line and NSW Trains are taking our concerns seriously. In particular, the companies have taken action on our concerns regarding track speed and signalling,” an RTBU spokesperson said.

The Office of the National Rail Safety Regulator (ONRSR) has inspected the corridor and consented to the recommissioning of the track.

An ARTC spokesperson said services on the North East Rail Line resumed on Friday, February 28, with the first Melbourne-Brisbane freight service passing through at 2.50am on Friday morning. 

An RTBU spokesperson said there are still more questions that need to be answered.

“It is important that all workers involved in services along the corridor are fully informed, and are able to raise any safety-related concerns,” an RTBU spokesperson said. 

On Monday, March 2, John Fullerton, ARTC CEO appeared before the Senate Standing Committee on Rural and Regional Affairs and Transport, Canberra to address ARTC’s response over the past eleven days following the XPT derailment.

Fullerton said despite working hard to prevent accidents and prepare extensively in case they happen, the worst possible outcome happened earlier this month.

He said over the past 11 days, ARTC have supported staff and contractors, been working with emergency services and Transport for NSW to safely remove the train, repairing the track so it is available again for use and cooperating with investigations underway.

In terms of supporting staff and contractors, many of our staff personally knew the people who were killed in the accident, and many others were involved in the first response,” Fullerton said to the committee.

We are very aware of the potential impact that this could have on staff, and have been widely advising those who need to, to access the services they need through our Employee Assistance Program. We have also been asking them to take care of one another.”

Fullerton said the industry collectively owes it to John Kennedy, the driver from Canberra, and Sam Meintanis, the pilot from Castlemaine, to work with the investigators to understand what happened and what actions need to be taken to prevent it ever happening again, as they were “two employees in our industry who went to work and never came home”.

He said ARTC has been providing full support to investigators from the Australian Transport Safety Bureau (ATSB), ONRSR and the Victorian coroner.