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 the ATSB 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.