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.