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.

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.

TAIC investigates KiwiRail derailment

A distracted driver and excessive speed caused a KiwiRail freight train to derail in March last year.

The Transport Accident Investigation Commission (TAIC) found that the freight train had exceeded the maximum permissible track speed when exiting the crossing loop.

The TAIC report said this was due to the driver becoming distracted and the downhill gradient of the track allowing the train to accelerate to above the maximum permissible line speed.

The incident occurred on March 29, 2019 when the three rear wagons of the KiwiRail freight train derailed as the train exited a crossing loop at Clinton on the way from Invercargill to Dunedin, New Zealand.

Two of the three derailed wagons overturned onto their sides, causing damage to the wagons, track, and a signal.

“A train driver can become distracted even when carrying out tasks specific to their role which, if poorly timed, can have unintended consequences,” the commission said in the investigation report.

The TAIC reported in its investigation findings that a phenomenon known as dynamic interaction was very likely the cause of the derailment.

Dynamic interaction occurred where the excessive speed combined with the track geometry at the point of derailment and the centre of gravity of the fully loaded coal wagons caused the wagon to oscillate from side to side. One or more wheels then lifted and climbed the rail, resulting in derailment.

The wagon condition and loading were found to be within KiwiRail’s maximum permissible limits, the TAIC found.

A similar derailment occurred at the Clinton crossing loop in 2016, which was not investigated by the TAIC.

“At that time KiwiRail took a number of safety actions after the incident, including speed monitoring and track repair,” the TAIC stated.

“However, a procedural control measure to ensure that loaded trains did not use the crossing loop was not adopted.”

The TAIC acknowledged in the investigation report that KiwiRail has taken a number of safety actions that addressed the issues raised in this report and that therefore no new recommendations needed to be made.

“To avoid repeat accidents and incidents it is important to learn from previous incidents,” the TAIC stated.

“This requires a focus on implementing corrective action in accordance with the hierarchy of controls.

“However, when procedural control measures have been identified they should be implemented, checked and monitored properly to ensure the desired results are achieved.”

Siva Sivapakkiam, KiwiRail executive general manager operations told Rail Express that the derailment of three wagons last year at Clinton was a serious incident, and KiwiRail has treated it as such.

“As the TAIC report notes, we have already made a change to our operating procedures to ensure that fully laden coal trains heading to Dunedin use only the main line when passing through Clinton,” she said.

Sivapakkiam said this avoids fully laden trains having to proceed through the crossing loop points, and it also means that the speed of empty Invercargill bound trains entering the loop is reduced by the uphill geometry of the track.

“Drivers have again been briefed on the need to ensure that the whole length of the train remains within the appropriate speed limit when entering or exiting crossing loops,” she said.

“We have instituted a non-technical skills training programme which provides staff with the knowledge to identify and manage distraction.

“In addition a redesign of the points configuration at Clinton is planned. We note that TAIC did not make any new recommendations for further action.”

V/Line driver’s near-miss with a train after failing to stop at signals

An Australian Transport Safety Bureau (ATSB) rail safety investigation found a V/Line driver ran through a level crossing before the boom gates were down at Marshall, Victoria.

On January 2nd 2018 at around 2pm, V/Line train 7750 travelling to Geelong and 1305 V/Line travelling to Warrnambool were heading towards each other on a single track in suburban Geelong.

The two trains were 940m apart from colliding when a control room worker in Melbourne issued an emergency call instructing the drivers to stop.

The ATSB found that the driver of train 7750 did not respond to the Stop indications of signals MSL10 and MSL8 at Marshall.

The driver of train 7750 entered the single line section between Marshall and South Geelong and then into the Marshalltown level crossing before the crossing booms had lowered.

At approximately the same time, The 1305 V/Line Melbourne to Warrnambool service with two crew and 166 passengers on board had departed Geelong and was headed towards Marshall on the same single line section.

The trains were scheduled to cross using the loop track at Marshall.

The investigation report stated that in preparation for the cross of the two trains at Marshall, the train controller “was observing the signalling control and CCTV VDU when he saw train 7750 go through Marshall platform travelling too fast to stop at MSL10,”

“Realising that train 7750 would not be able to stop, the train controller made a fleet radio transmission to all trains in the area to ‘Red Light’ (Stop), the CCTV also allowed the train controller to confirm that train 7750 had stopped beyond the Marshalltown Road level crossing.”

The investigation concluded that the driver of V/Line train 7750 was most likely influenced by symptoms associated with nicotine withdrawal, having not applied a nicotine patch on that day.

“Following this incident, the driver of train 7750 tested positive for an inactive metabolite of cannabis, with levels suggesting use within the previous 7 days,” the report stated.

It could not be determined whether that had affected the driver’s performance at the time of the incident.

Report authors say attempts by V/Line safety critical workers to stop smoking should be managed under medical supervision.

As a result of the incident, V/Line has installed a train protection system at Marshalltown Road level crossing to stop a train that has passed a signal at Danger, which has over-speed sensors to prevent a train entering the crossing when unprotected.

V/Line has continued with planning for the provision of three-position signalling for this section as part of other infrastructure projects.

The driver of train 7750 no longer works for V/Line.