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

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.”

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.