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Contributing Factors in NSW Rail Incidents 2004 – 2013 i

RAIL SAFETY SUMMARY REPORT

CONTRIBUTING FACTORS IN NSW RAIL INCIDENTS

2004 – 2013

RAIL SAFETY SUMMARY REPORT

CONTRIBUTING FACTORS IN NSW RAIL INCIDENTS

2004 – 2013

Released under the provisions of Section 45C (2) of the Transport Administration Act 1988

Investigation Reference 04679

Published by: The Office of Transport Safety Investigations

Postal address: PO Box A2616, Sydney South, NSW 1235

Office location: Level 17, 201 Elizabeth Street, Sydney NSW 2000

Telephone: 02 9322 9200

Accident and incident notification: 1800 677 766

Facsimile: 02 9322 9299

E-mail: [email protected]

Internet: www.otsi.nsw.gov.au

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contained in this Report, its contents may be copied, downloaded, displayed, printed,

reproduced and distributed, but only in unaltered form (and retaining this notice). However,

copyright in material contained in this Report which has been obtained by the Office of

Transport Safety Investigations from other agencies, private individuals or organisations,

belongs to those agencies, individuals or organisations. Where use of their material is

sought, a direct approach will need to be made to the owning agencies, individuals or

organisations.

Subject to the provisions of the Copyright Act 1968, no other use may be made of the

material in this Report unless permission of the Office of Transport Safety Investigations has

been obtained.

THE OFFICE OF TRANSPORT SAFETY INVESTIGATIONS

The Office of Transport Safety Investigations (OTSI) is an independent NSW agency whose purpose is to improve transport safety through the investigation of accidents and incidents in the rail, bus and ferry industries. OTSI investigations are independent of regulatory, operator or other external entities. Established on 1 January 2004 by the Transport Administration Act 1988, and confirmed by amending legislation as an independent statutory office on 1 July 2005, OTSI is responsible for determining the causes and contributing factors of accidents and to make recommendations for the implementation of remedial safety action to prevent recurrence. Importantly, however, OTSI does not confine itself to the consideration of just those matters that caused or contributed to a particular accident; it also seeks to identify any transport safety matters which, if left unaddressed, might contribute to other accidents. This OTSI rail safety summary report was initiated in accordance with the provisions of the Transport Administration Act 1988.

OTSI Rail Safety Summary Report

Contributing Factors in NSW Rail Incidents 2004 – 2013 i

TABLE OF CONTENTS

TABLE OF FIGURES iii

Abstract 1

Introduction 2

Contributing Factors Framework 2

Occurrence categories 3

Analysis of contributing factors from OTSI rail reports 5

Individual/team actions 6

Technical failures 7

Local conditions/organisational factors 8

Local conditions 10

Organisation factors 15

Investigation report summaries and contributing factors 20

1. Baan Baa - Level Crossing Collision - 4 May 2004 21

2. Port Botany - Shunting Fatality - 1 July 2004 23

3. Bethungra - Derailment - 22 December 2004 25

4. Lapstone/Wauchope - Derailment – 1 & 7 March 2005 27

5. Old Burren - Derailment - 6 April 2005 29

6. Grawlin Plains - Level Crossing Collision - 31 May 2005 31

7. Bloomfield- Opposing movement - 20 August 2005 33

8. Steel sleepers – Systemic report -2005 36

9. Conoble- Derailment - 16 October 2005 38

10. Lidcombe - Derailment – 4 November 2005 40

11. Ariah Park – Shunting fatality – 15 April 2006 42

12. Baan Baa – Ballast wagon fatality – 22 May 2006 45

13. Town Hall Tunnel - Self harm fatality - 30 August 2006 47

14. North Strathfield – Opposing movement – 2 September 2006 49

15. Thirroul – SPAD and derailment – 11 September 2006 51

16. Nyngan – Derailment – 1 October 2006 53

17. Sandgate – Track work injury – 7 November 2006 55

18. Leeton – Derailment – 11 January 2007 57

19. Euabalong West – Derailment – 14 January 2007 60

20. Connemarra – Derailment – 8 February 2007 62

21. Singleton – Track worker fatalities – 16 July 2007 64

22. Breeza – Derailment – 8 January 2008 67

23. Homebush – SPAD and Derailment – 7 January 2009 69

24. Unanderra – SPAD and Derailment – 24 January 2009 71


Contributing Factors in NSW Rail Incidents 2004 – 2013 ii

25. Peak Hill – Derailment – 8 February 2009 74

26. Goobang – SPAD and collision – 10 May 2009 77

27. Temora – Runaway wagon – 28 July 2009 79

28. Glenlee – Safeworking breach – 28 October 2009 81

29. Darling Park – Monorail collision – 27 February 2010 83

30. Whittingham – Derailment – 13 March 2010 85

31. Strathfield – Near strike of maintenance staff – 1 April 2010 87

32. Woy Woy – Unsecured container gate – 11 April 2010 90

33. Kogarah – Track worker fatality – 13 April 2010 92

34. Wee Waa – Level crossing collision – 1 September 2010 96

35. Bankstown – Near miss with track workers – 29 October 2010 98

36. Unanderra – Uncontrolled movement – 2 February 2011 100

37. Zig Zag – Collision between a train and a Hi-rail – 1 April 2011 102

38. Enfield yard – Runaway rolling stock – 3 May 2011 105

39. Woy Woy – Level crossing collision – 2 Sep 2011 107

40. Clifton – Broken axle derailment – 23 Nov 2011 109

41. Unanderra – Safeworking incident – 12 Dec 2011 111

42. Gunnedah – SPAD and opposing movement – 7 March 2012 113

43. Nundah – Level crossing collision – 7 May 2012 115

44. Bengalla – Ballast train collision – 18 May 2012 117

45. Summit Tank – Safeworking incident – 17 July 2012 120

46. Boggabri – Coal train derailment – 28 Nov 2012 122

47. Gulgong – Wagon structural failure – 5 Dec 2012 124

48. Rennie – Derailment – 3 January 2013 126

49. Moree – Level crossing collision – 21 May 2013 128

50. East Maitland – Safeworking incident – 27 November 2013 130

51. Moss Vale – Safeworking incident – 21 December 2013 132

Appendix A: Contributing factors framework overview 134

Appendix B: Contributing factors framework analysis 135

Appendix C: OTSI rail investigation reports with keywords 138

Appendix D: Incident notification and classification 142


Contributing Factors in NSW Rail Incidents 2004 – 2013 iii

TABLE OF FIGURES

Figure 1: Reason’s model of organisational accidents 3

Figure 2: OTSI investigations classified using OC-G1 4

Figure 3: Main contributing factors groups 5

Figure 4: Individual/team action findings grouped by person type 6

Figure 5: Technical failure findings grouped by component area 7

Figure 6: Local conditions and organisational factors 8

Figure 7: Knowledge, skills and experience type findings 10

Figure 8: Task demands type findings 11

Figure 9: Personal factors type findings 12

Figure 10: Physical environment type findings 13

Figure 11: Social environment type findings 14

Figure 12: Organisational management type findings 15

Figure 13: Equipment, plant and infrastructure type findings 16

Figure 14: Procedure type findings 17

Figure 15: People management type findings 18

Figure 16: Training and assessment type findings 19


Contributing Factors in NSW Rail Incidents 2004 – 2013 1

Abstract The aim of this report is to record in summary form the results of the classification and

analysis of the findings from Office of Transport Safety Investigations rail safety

investigations.

All the findings from the 51 rail safety investigations undertaken in the 10 year period from

2004 to 2013 were examined. The contributing factors were then identified and coded in

accordance with a Contributing Factors Framework based on Professor James Reason’s

Model of Organisational Accidents. Of the total of 346 findings, 277 (80%) were classified in

the contributing factors group of organisational factors/local conditions. Individual/ team

actions contributed on 49 occasions and technical failures on 20 occasions. The findings

are further classified within each main contributing factors group. The results are presented

in graphical form together with examples from the investigations.

The report contains a brief overview of each investigation accompanied by general

occurrence information. All related findings are tabulated along with their contributing factors

framework details.

No specific recommendations are made in this report. However, rail industry stakeholders

would benefit from using the contributing factors framework as a method to analyse findings

from investigation reports. This would facilitate comparison of contributing factors as a

means to better understand frequently occurring issues and possible industry-wide trends.



Introduction This report records the results from the analysis and classification of the findings from Office

of Transport Safety Investigations (OTSI) rail safety investigations.

The classification system used is the Contributing Factors Framework (CFF), an overview of

which is included in Appendix A. The Rail Safety Regulators Panel published the CFF to

assist interested parties in classifying the key findings of rail safety investigations. The CFF

was developed by a working group comprised of representatives from Australian safety

regulators, the rail industry, and independent rail safety investigation agencies. Work on the

framework began in 2005 and the first version was published in February 2009. OTSI has

applied the framework to its rail investigation findings progressively since its introduction.

The aim of the framework is to:

provide a structured and consistent framework to code the systemic contributors to

incidents and accidents

facilitate the analysis of aggregate data to identify patterns and trends in safety

issues

assist in making informed decisions on safety issues and enhance continual

improvement practices.1

Contributing Factors Framework The CFF is based on the Professor James Reason Model of Organisational Accidents2

which has been widely adopted across the rail industry and other safety critical industries.

This adapted model is illustrated in Figure 1.

This model starts with the organisational factors such as strategic decisions and

organisational processes. The processes are influenced by the corporate culture of the

business. These processes transfer throughout the organisation and give rise to task and

environmental conditions that are likely to lead to violations and errors by individuals/teams

in the workplace, or to technical failures.

1 Rail Safety Regulators Panel (2011): Contributing Factors Framework Manual, Version 2, p.8. 2 Ibid., p.16.



Figure 1: Reason’s model of organisational accidents

The CFF coding process occurs after the formal investigation is concluded. The coding is

then entered into a database for analysis and identification of systemic safety trends. A

summary of the CFF applied to OTSI investigations is included in Appendix B.

The trends that have emerged from OTSI rail safety investigations are evident from the data

presented in the first section of this report. The second section of this report provides a brief

background summary for each investigation along with occurrence details. All related

findings are then tabulated along with the results of the CFF analysis.

A list of OTSI rail safety investigations along with relevant CFF keywords is included in

Appendix C. A full version of each investigation report is available on the OTSI website at

otsi.nsw.gov.au

Occurrence categories Every OTSI rail safety investigation report was classified according to the Occurrence

Classification Guideline (OC-G1) (see Figure 2). Derailment was the most frequent

investigation type. There were 20 derailment investigations, 11 collisions between rail

vehicles, eight safeworking incidents, six level crossing collisions, and three signals passed

at danger (SPADS). Two SPADs involved the driver completely missing the signal, while the

other was a driver misjudgement.

Organisation

Management systems,

decisions & organisational

processes

Local Conditions

Workplace -Task /

Environment

Error and violation

producing conditions

Individual / Teams

Errors & violations

Occurrence

Latent failure pathway

Direct failure

pathway

Social, Political, Regulatory & Economic environment…

Technical failures

Contributing factors

Investigation pathway

Organisation

Management systems,

decisions & organisational

processes

Local Conditions

Workplace -Task /

Environment

Error and violation

producing conditions

Individual / Teams

Errors & violations

Occurrence

Latent failure pathway

Direct failure

pathway

Social, Political, Regulatory & Economic environment…

Technical failures

Contributing factors

Investigation pathwayInvestigation pathway



Figure 2: OTSI investigations classified using OC-G1

The complete list of OC-G1 occurrence categories and related OTSI investigations is

contained in Appendix D. The number of OTSI’s investigations represents only a small

sample of the large number of reported accidents and safety-related rail incidents. The

number and categories of investigations should not be taken in any way to be proportionally

representative of the total of reported incidents.

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15

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Analysis of contributing factors from OTSI rail reports During the period from 2004-2013 there were 345 findings recorded in the 51 OTSI

investigations. There were 49 findings made about individual or team actions, 20 findings

made about technical failures, and 276 findings made about organisational factors or local

conditions (see Figure 3). ‘The evidence from a large number of accident inquiries indicates

that bad events are more often the result of error-prone situations and error-prone activities

than they are of error-prone people.’3

Figure 3: Main contributing factors groups

Most of the findings were classified in the organisational factors/local conditions category.

Not all reports made findings about individual’s actions and only a small proportion of

findings were about technical failures. These groupings of individual/team actions, technical

failures, and organisational factors/local conditions are further analysed in the following

sections of this report.

3 Reason, J. (1997). Managing the risks of organizational accidents, Ashgate, p.129.

Individual / team actions,

49Technical Failures, 20

Organisational Factors/Local conditions, 276



Individual/team actions

The individuals identified in the findings area of the individual/team action area were from the

following groups: infrastructure maintainers, light passenger vehicle drivers, network

controllers, rolling stock maintainers, terminal staff and train crew (see Figure 4). Station

staff, heavy freight vehicle drivers or emergency services staff were not identified in any

report.

Figure 4: Individual/team action findings grouped by person type

Of the train crew identified seven were passenger train drivers, seven were freight train

drivers, two were track machine operators and one was a guard.

The six light passenger vehicle drivers identified in the findings were all car drivers involved

in incidents at level crossings.

Infrastructure maintainers, 14

Light passenger vehicle driver,

6

Network controller, 8

Rollingstock maintainer, 1

Terminal staff, 3

Train crew, 17



Technical failures The technical failure components identified in the findings came from the following groups:

infrastructure, rolling stock, and signalling and communications equipment (see Figure 5).

Figure 5: Technical failure findings grouped by component area

The condition of the track was identified as a contributing factor in all 12 instances of

infrastructure failure. The origin of the failure was maintenance related in the majority of

cases.

Bogies, braking systems, car bodies, and a train detection system were the component

areas found to have contributed to rolling stock failures. A train detection system failure

occurred in the monorail accident where the anti-collision emergency stop system on the

monorail did not function as designed.

The signalling and communication failure resulted from a CCTV camera being sighted such

that its field of vision was partially obscured by a platform structure.

Infrastructure, 12

Rollingstock, 7

Signalling & communication equipment, 1



Local conditions/organisational factors

The analysis of organisational factors/local conditions found that organisational factor

findings were made most often. The 276 findings were split between 102 local conditions

and 174 organisational factors (see Figure 6).

Figure 6: Local conditions and organisational factors

‘Local conditions can be considered conditions present in the local workplace or environment

in which the individual/team action or a technical failure occurs.’4 They are grouped under

the following headings:

knowledge, skills and experience

personal factors

physical environment

social environment

task demands.

‘Organisation factors are those factors in the management system, decision-making at the

senior level and policy settings that guide the activities of the organisation.’5 They can

4 Contributing Factors Framework Manual, Version 2, p.22. 5 Ibid., p.22.

Local Conditions, 102

Organisational factors, 174



sometimes be identified in organisations other than the one directly responsible for the

occurrence.

Organisational factors are grouped as:

organisational management

equipment, plant and infrastructure

people management

procedures

training and assessment

external organisational influences.

These factors may be within the organisation’s internal or external environment.



Local conditions

The most frequently identified local conditions findings were in the knowledge, skills and

experience area. These included persons having trouble with normal operational tasks, lack

of communication skills, inadequate task experience, poor abnormal/ emergency skills and

deficient teamwork skills (see Figure 7).

Figure 7: Knowledge, skills and experience type findings

Examples of knowledge, skills and experience findings can be found in the following

investigations:

An abnormal/emergency skills finding was made in the 2005 Bloomfield opposing

movement investigation. Neither train crew operated the emergency function on the

radio system to report the incident because, having avoided a collision, they did not

consider that they had been involved in an emergency.

In the 2010 Kogarah investigation recordings revealed that voice communications

from train control were informal and not in accordance with network rules and

procedures.

The 2012 Gulgong investigation found that a defective welded joint completed during

a normal operational task was not detected during inspections. This contributed to a

structural failure in a wagon.

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5

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2

4

6

8

10

12

14

16

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The next most common category was in the area of task demands (see Figure 8). The most

significant factor in this area was distraction. Other factors identified were high workload,

being under time pressure and familiarity with the task.

Figure 8: Task demands type findings

Examples of task demand findings can be found in the following investigations:

The 2006 Ariah Park investigation found that the shunter may have been distracted

by the presence of spectators in close proximity as he attempted to couple the tender

and the carriage.

At Singleton in 2007 a high level of task familiarity was found to have lessened the

workers’ appreciation of the risks associated with their task. This accident resulted in

two fatalities when the workers were struck by a train.

A high workload was found to have contributed to the 2009 Glenlee near miss when

a driver returning from a train inspection was almost struck by an oncoming train on

the adjacent track. The workload of network controllers was high prior to and at the

time of the incident.

A near miss at Bankstown in 2010 occurred because a protection officer did not see

workers enter the danger zone as he was distracted by using his mobile phone.

In 2010 at Strathfield a work team was under time pressure to perform a task. They

had insufficient time to complete a full safety assessment and work plan in addition to

all other necessary preparatory tasks. As a consequence, they were nearly struck by

a passing train.

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4

3

1

0

2

4

6

8

10

12

14

Distraction Time pressure High workload Familarity



There were 16 findings made in the area of personal factors. These included problems with

fatigue/alertness, motivation/attitude, preoccupation, stress/anxiety and health (see Figure

9).

Figure 9: Personal factors type findings

Examples of personal factor findings can be found in the following investigations:

The 2005 Lidcombe derailment investigation found that the driver was affected by

fatigue as he had not slept well the night before his shift.

The investigation into the fatalities at Singleton in 2007 found that both workers had

worked seven shifts over the preceding seven days. Consequently, both workers

were probably suffering from a degree of fatigue.

The 2009 Peak Hill derailment investigation found that the co-driver was

incapacitated through illness. Therefore, he was unable to perform his duties of

maintaining a lookout and relaying trackside infrastructure information to the driver.

Similarly, the 2009 Unanderra SPAD and derailment investigation found that the

guard was feeling stressed and unwell which affected his decision-making ability at a

critical time.

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4

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0

1

2

3

4

5

6

7

8

9



The physical environment was found to be a contributing factor on 15 occasions. The

following factors were identified: lighting/visibility, noise, temperature/humidity, and weather

related factors. There was one finding where an unstable surface contributed to the incident

(see Figure 10).

Figure 10: Physical environment type findings

Examples of physical environment findings can be found in the following investigations:

A noise-related finding was made in the 2006 Sandgate investigation into a track

worker injury. The track worker’s ability to hear the approaching excavator would

have been affected by the noise associated with the cutting and welding tasks he

was performing, as well as the operation of trains on the adjacent lines.

An unstable surface contributed to a fatality at Baan Baa in 2006. Stepping onto a

loosely-packed, rough, sloping ballast shoulder from a ballast machine increased the

risk of an accident.

The 2012 Bengalla ballast train collision investigation found that the lights were not

illuminated on a stationary track machine. Because it was a dark night, the pilot on

the propelling train did not see the track machine until just before his train collided

with it.

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1

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3

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6

7

8

9



The social environment was found to be a contributing factor on seven occasions. Norms

and values and peer pressure were the two areas identified (see Figure 11).

Figure 11: Social environment type findings

Examples of social environment findings can be found in the following investigations:

The investigation into a collision on the Zig Zag Railway in 2011 found there was an

accepted practice of qualified workers authorising rail traffic movements without

reference to the train controller. On the day of the incident a guard authorised a hi-rail

movement resulting in it subsequently colliding with a train.

The 2012 Gunnedah SPAD and opposing movement investigation found that the co-

driver was under training, was relatively inexperienced and an authority gradient

existed between him and the driver. This contributed to him not taking more positive

action when the driver did not comply with procedures in stopping the train before the

signal.

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4

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6

Norms and values Peer pressure



Organisation factors

The most frequently identified organisational factor findings were in the organisational

management area (see Figure 12).

Figure 12: Organisational management type findings

Examples of organisational management findings can be found in the following

investigations:

A monitoring, review and validation finding was made in the 2008 Breeza derailment

investigation. The rail was not adequately constrained against the forces on it due to

ineffective anchoring. The task of replacing anchors following track work several

months prior to the derailment had not been completed when the incident occurred.

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10

15

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The investigation into the uncontrolled movement of a train at Unanderra in 2011

found that the modifications made to the brake pipe of a particular class of wagons

did not meet engineering requirements.

The next most common category was in the area of equipment, plant and infrastructure (see

Figure13).

Figure 13: Equipment, plant and infrastructure type findings

Examples of equipment, plant and infrastructure findings can be found in the following

investigations:

The investigation into a railway crossing accident at Nundah in 2012 found the

crossing did not fully meet the requirements of Australian Standards. There was no

visible stop line accompanying the stop sign.

A safeworking incident occurred at Moss Vale in 2013. It was found that there were

no designated locations where train crew could conduct axle bearing inspections

after an axle alert was triggered by a trackside detector.

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In many incidents it was found that problems with procedures contributed to the incident

occurring. There were 31 findings associated with procedures. These included problems with

the accuracy or clarity of procedures, absent procedures, and one instance where the

procedure was not available or accessible (see Figure14).

Figure 14: Procedure type findings

Examples of procedure findings can be found in the following investigations:

Inspection standards for unit train maintenance not emphasising the examination of

the axle barrel contributed to a derailment at Clifton in 2011.

An investigation into a derailment at Rennie in 2013 found there was not a standard

or guideline to assist track managers in responding to unfavourable individual track

geometry measurements.

In 2013 there was a safeworking incident at Unanderra where the investigation found

that the train crew did not have access to procedures to check how protection should

be requested and implemented.

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Accuracy / clarity Absent procedure Availability / accessibility



There were 10 findings associated with people management (see Figure15).

Figure 15: People management type findings

Examples of people management findings can be found in the following investigations:

A train driver involved in an opposing movement at North Strathfield in 2006 had

been rostered for nine consecutive days. The area controller had been rostered for

eight consecutive days. These rostering arrangements were found to have

contributed to the driver missing a signal.

At Whittingham in 2010 the supervisor did not adequately supervise a worker to

ensure the route was correctly set after the points were set and clipped. As a result a

freight train derailed on the points.

A specified welding process which made the weld technically difficult for the welder

during manufacture was found to have contributed to the structural failure of a wagon

at Gulgong in 2012.

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6

Job / task design Rostering /scheduling Supervision Fitness for duty monitoring



There was also a total of 11 findings associated with training and assessment (see

Figure16).

Figure 16: Training and assessment type findings

Examples of training and assessment findings can be found in the following investigations:

At Kogarah in 2010 workers were caught on the track with a train approaching and

no safe place readily accessible. During their induction and worksite protection

training there was insufficient coverage of the emergency safety precautions to be

taken in such circumstances.

An investigation into a safeworking incident at East Maitland in 2013 found that the

on-job training provided to the protection officer was inadequate. Although the on-job

workbook was signed off to confirm that he had demonstrated knowledge in a wide

range of tasks and procedures, the reality was different.

The final category is external organisational influences. It had the least number of findings of

any category. Within this category one finding was made concerning regulatory activities and

one finding was made about industry standards.

These examples of external organisational influence findings can be found in the following

investigations:

The investigation into a derailment at Bethungra in2004 found that the NSW rail

regulator did not have sufficient visibility of the condition of the track and related

infrastructure.

The investigation into the uncontrolled movement of a train at Unanderra in 2011 found that there was no industry standard defining what constituted single and dual pipe wagons. Such a standard would be expected to cover various engineering aspects such as the purpose, application, flow rates and timing in reference to charge rates.

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Initial training Competency assessment

Currency tracking Ongoing training



Investigation report summaries and contributing factors

The following section contains a brief summary of each incident and the findings made for

each investigation. The occurrence details are also provided with information on the number

of injuries and fatalities, the event description and type of operation (passenger, freight or

track maintenance) included in the details is the OC-G1 categorisation.

Occurrence details (Example shown below)

Event description: Passenger train collision with car at level crossing

Type of operation: Passenger

Fatalities 1 Injuries: 4

Occurrence Classification Level crossing occurrence Collision with road vehicle

At crossing with passive warning devices: Stop signs



1. Baan Baa - Level Crossing Collision - 4 May 2004

At 5.10pm a passenger service, carrying 33 passengers and three crew members, collided

with a motor vehicle, with the driver as the sole occupant on the Baranbah Street Level

Crossing at Baan Baa. Baan Baa is located between Boggabri and Narrabri in the Northwest

Plains region of NSW. Following the collision, the leading carriage of the two carriage consist

derailed and came to rest on its right side across the tracks approximately 420 metres

beyond the crossing. The rear carriage remained upright.

As a result of the collision the driver of the car, who

was a local resident, was fatally injured; four train

passengers were hospitalised and a number of

persons, both passengers and train crew, were treated

on site for shock and minor injuries; the car was

destroyed and there was considerable damage to the

train and track. The rail line was closed for three days

to effect repairs.

The investigation established that the accident was a consequence of the car being

positioned within the crossing’s danger zone. The investigation could not establish whether

this was an unintentional or intentional act.

The investigation also established that the respective mechanical conditions of the car and

train did not contribute in any way to the accident. It also established that the train driver

operated the train within specified limits and that he

responded appropriately when it became apparent that a

collision was in prospect.

Whilst emergency services responded efficiently and

effectively to the accident, the evacuation of passengers

and crew from the train was complicated by a number of

the train’s design features. As a consequence of this investigation OTSI made a number of

recommendations to RailCorp, the Australian Rail Track Corporation (ARTC) and the

Independent Transport Safety and Reliability Regulator (ITSRR).



Occurrence details



Fatalities 1 Injuries: 4



Individual actions

Findings Person type Activity type Error/Violation

type

OTSI found that the collision at the level crossing was the

consequence of a failure of the driver of the motor vehicle

to observe NSW traffic rules 121 and 123. OTSI was

unable to determine whether this failure was the

consequence of an unintended act (an error), or an

intended act (a violation).

Light passenger

vehicle driver

Monitoring and

checking

Unknown

Local Condition/Organisational factor

Findings Local

Condition/Organi

sational factor

Keywords Functional area

There were limited defences to warn drivers of motor

vehicles on their approach to the level crossing, or to assist

them to remain clear of the rail line when necessary.

Equipment, plant

& infrastructure

Infrastructure

design

Road

environment

Design features on the Xplorer, under certain

circumstances, inhibit emergency egress.

Equipment, plant

& infrastructure

Functionality Rolling stock

construction

Additional safety equipment is required aboard services

operated by RailCorp.

Equipment, plant

& infrastructure

Availability Rolling stock

construction

Emergency services were inhibited by a lack of specific

knowledge in relation to emergency access points and

power shut-down.

Knowledge, skills

& experience

Emergency

operations

knowledge & skills

Emergency

management

RailCorp’s imposition of blanket speed restrictions

throughout most of regional NSW has reduced the

prospect, and consequences, of collisions at level

crossings.

Organisational

management

Policy On-train

operations



2. Port Botany - Shunting Fatality - 1 July 2004

At 1.50pm on 1 July 2004, a shunter was fatally injured whilst involved in shunting

operations at the Port Botany rail yard. The employee, a qualified train driver, is believed to

have fallen from the decking of a flat top container wagon through a gap in the wagon’s floor

during a shunting movement. Following this fall he was run over by the train’s wheels.

The Driver of the train (T250) involved in the shunting

operation went in search of the shunter, as he had failed

to respond to a planned radio communication. The

shunter was subsequently located across the track by

the driver. There were no eyewitnesses to the accident.

The investigation established that the accident was a

consequence of the shunter being on top of the wagon’s

decking, without the means of a physical restraint, whilst the wagon was in motion. The

design of the wagon featured a smooth skeletal decking which did not incorporate any form

of protection against the risk of falling onto the track.

Based on the information obtained during the investigation

and forensic reports, it was concluded that the shunter

probably lost his footing because of either a jolting

movement, a slip or as a consequence of a momentary

loss of concentration, whilst standing on top of an un-

walled and only partially decked wagon during shunting. It

was found that the company’s risk assessment did not

consider in detail the operational activities of a shunter and the likely risks arising from those

activities. There were no Operator Specific Procedures which covered the company’s

accepted practices for riding on wagon side steps or end steps. Also, the company was

unable to stop the practice of riding on the top of un-walled wagons where they had had prior

knowledge that such a practice had occurred previously within the railway yard environment.



Occurrence details Event description: Shunter killed after falling from flat top container wagon

Type of operation: Freight

Fatalities 1 Injuries: nil

Occurrence Classification Collision Yard collision

With a person not on a level crossing

Individual actions


type

The positioning of the Shunter on top of the wagon’s

decking, without the means of a physical restraint, whilst

the wagon was in motion.

Terminal staff Operating

equipment

Violation


Findings Local

Condition/Organisati

onal factor

Keywords Functional

area

The design of the wagon, which featured a skeletal and

smooth decking and which did not incorporate any form of

protection against the danger of falling onto the track.

Equipment, plant &

infrastructure


construction

The company’s risk assessment and risk management

process did not consider in detail the operational activities

of a shunter and the likely risks arising from those

activities.

Organisational

Management

Risk Management Off-train

operations

The limitations of the company’s approach to training,

competency assessment and supervision, noting the

absence of Operator Specific Procedures that defined

accepted practices for riding on wagon sides and the

supporting training documentation designed to instruct a

shunter in these practices.

Procedures Absent procedure Off-train

operations

The design of side and end steps of some freight wagon

types do not facilitate a safe/ergonomic riding position and

may have encouraged the use of alternate, and unsafe,

riding positions.

Equipment, plant &

infrastructure

Functionality Off-train

operations



3. Bethungra - Derailment - 22 December 2004

At 8.05pm on 22 December 2004 freight service 4VM9, operated by Freight Australia

Limited, derailed whilst descending the grade at Bethungra, on the main south line. 4VM9

consisted of four locomotives and 11 loaded bulk cement wagons and was en route from

Berrima to Melbourne. All 11 wagons from the train and 288 metres of track were severely

damaged as a result of the incident. There were no reported injuries.

The investigation found 4VM9 derailed when it traversed

an area of misaligned and unstable track. The

derailment occurred where the rail had been stressed for

a considerable period of time and that track resurfacing

work 16 days prior to the derailment would have

exacerbated this stress. The initiation of emergency

braking, at a speed 6km/h in excess of the posted speed

limit, when the misalignment first became apparent, would have imparted additional stress to

the track. However, the magnitude of this stress would not have been significant had the

track been stable and properly aligned.

Two of the primary defences designed to prevent such occurrences, track inspections and

track maintenance, failed over time. A third defence of managing an area with known

deficiencies through the imposition of speed limits was not employed.

There were clear indications available to the NSW Rail

Infrastructure Corporation (RIC), and subsequently the

Australian Rail Track Corporation (ARTC), to suggest

track instability in the area where the derailment occurred,

but that these indicators were either unnoticed or not

acted upon. Track inspection records for the previous 12

months implied that there were few problems within the

section in which the derailment occurred. However, inspections of a relatively small area

within the section by the Office of Transport Safety Investigations, revealed that there were

significant defects and that these were not a recent phenomena, suggesting that previous

inspections had been less than thorough.



Occurrence details Event description: A main line derailment of a freight train


Fatalities nil Injuries: nil

Occurrence Classification Derailment On running line

Technical failure

Findings Failed component Failure mechanism Failure origin

4VM9 derailed when it traversed an area of misaligned

and unstable track.

Infrastructure - Track Deformation Maintenance


Findings Local

Condition/Organisa

tional factor


The initiation of emergency braking, at a speed 6km/h in

excess of the posted speed limit, when the misalignment

first became apparent, would have imparted additional

stress to the track. However, the magnitude of this stress

would not have been significant had the track been stable

and properly aligned.

Knowledge, skills

& experience

Abnormal/emergency

operations

knowledge & skills

On-train

operations

Two of the primary defences designed to prevent such

occurrences, track inspections and track maintenance, failed

over time, and a third defence, of managing an area with

known deficiencies through the imposition of speed limits,

was not employed.

Organisational

Management

Risk Management Infrastructure

construction and

maintenance

There were clear indications available to RIC, and

subsequently ARTC, to suggest track instability in the area

where the derailment occurred, but that these indicators

were either unnoticed or not actioned.

Organisational

Management

Risk Management Infrastructure

construction and

maintenance

Track inspection records for the previous 12 months,

compiled by RIC and ARTC, implied that there were few

problems within the section in which the derailment

occurred. However, OTSI’s inspections of a relatively small

area within the section revealed that there were significant

defects and that these were not a recent phenomena,

suggesting that both RIC’s and ARTC’s inspections had

been less than thorough.

Organisational

Management

Monitoring, review

and validation

Infrastructure

construction and

maintenance

The transition of assets, records and systems from RIC to

ARTC was problematic and that ARTC did not enjoy good

visibility of the condition of the asset at the time of handover

of responsibility, or indeed at the time of the derailment.

Organisational

Management

Interface

management

Infrastructure

construction and

maintenance

ITSRR does not have sufficient visibility of the condition of

the track and related infrastructure in NSW and that, whilst it

can and does undertake a range of actions to gain such

visibility, the onus for providing ITSRR with such visibility

should largely rest with those responsible for its operation.

External

organisational

influences

Regulatory

activities

Infrastructure

construction and

maintenance

The derailment occurred where the rail had been stressed

for a considerable period of time and that track resurfacing

work 16 days prior to the derailment would have

exacerbated these stresses.

Organisational

Management

Monitoring, review

and validation

Infrastructure

construction and

maintenance



4. Lapstone/Wauchope - Derailment – 1 & 7 March 2005

On 1 March 2005, at approximately 1:55pm, Pacific National coal service CB76 suffered a

screwed journal after a Packaged Unit Bearing (PUB) failed. As a result of this mechanical

failure, a wagon derailed but remained upright and attached to CB76. The wagon travelled

4.28km in this state and in the process caused significant track damage between Glenbrook

and Lapstone. It also caused ballast to be dislodged from a rail bridge over the Great

Western Highway, shattering the windscreen of a car below. Another incident occurred at

approximately 11:15am, on 7 March 2005, when Pacific National freight service 1WB3 also

suffered a screwed journal when a Packaged Unit Bearing failed. One wagon derailed,

approximately 11km North of Wauchope, but remained upright and attached to 1WB3. As a

consequence, approximately 3km of track and a rail bridge were damaged.

The investigation found that both derailments were

caused by the failure of PUBs. There was nothing to

suggest, in either instance, that the PUBs had been

inadequately maintained or that there were problems

elsewhere on the bogies. Nor were the wagons

overloaded. Both PUBs were virtually destroyed and

there was no conclusive evidence to indicate what

initiated their failure. There were some limited indications to suggest that both bearings

might have been penetrated by moisture or some other foreign material. Pacific National

suspects that in the case of CB76, this may have occurred while the wagon was being

pressure-cleaned. However, this possibility and Pacific National’s premise could not be

confirmed.

Pacific National had appropriate policies in place to

minimise the likelihood of PUBs failing and continued to

refine its policies and practices to further reduce the

related risks. ARTC and RailCorp have plans to expand

and upgrade the range of monitoring and detection

systems throughout the rail network in NSW which would l

contribute to enhancing the safety of rail operations.



Occurrence details Event description: A main line derailment of freight train as a result of a screwed journal




Technical failure

Findings Failed component Failure

mechanism

Failure origin

Failure of packaged unit bearings. Rolling stock - Bogies Fracture Unknown


Findings Local Condition/Organisational

factor


nil nil nil nil



5. Old Burren - Derailment - 6 April 2005

At approximately 5.45pm a fully loaded wheat train operated by Pacific National Limited,

designated as wheat service 5424, derailed on a Class 5 single grain line North West of

Narrabri. As a result of the derailment, which occurred at a location known as Old Burren in

the section of track between Merrywinebone and Burren Junction, six of 37 wheat hopper

wagons came off the rails and were damaged, 87 metres of track was damaged and 17

tonnes of wheat was lost. Neither crew members from the train were physically injured in the

derailment.

The journey from Merrywinebone was uneventful until

5424 exited a curve where the crew recalled noting a

small kick in the rails to their front. The driver was not

concerned about the misalignment; indeed, he indicated

that such occurrences were not uncommon and did not

consider it necessary to adjust the train’s speed of

28km/h, which was below the speed limit of 30km/h.

However, he did maintain observation of the rest of 5424 in his rear vision mirrors.

Both crew members recall that their locomotive wobbled slightly as it passed over the kick.

The driver observed the train ride over the kick and then noticed the leading wagons begin to

rock from side to side, progressively more violently. He immediately shut off the throttle and

applied the emergency brakes. As the train came to a stand, the driver recalls seeing and

feeling some of the wagons kick out sideways off the track before 5424 came to rest.

It was noted that the driver saw the misalignment and had

sufficient time to reduce train speed. However, he elected

not to do so, on the basis of his experience and the fact

that such track conditions were not uncommon to him.

However, it is possible that if the driver had reduced the

train’s speed, the misalignment may have been safely

negotiated. The investigation found 5424 derailed when

misaligned and unstable track spread under load. The condition of the track was not a recent

phenomenon and could be attributed to progressive and un-remediated degradation.

Inspection, defect recording and maintenance systems in the region were less than

sufficiently robust or integrated to provide adequate managerial oversight of the asset and its

condition.



Occurrence details Event description: A main line derailment of freight train




Technical failure


mechanism

Failure origin

The train derailed when a misaligned and unstable

track spread under load.



Findings Local

Condition/Organisation

al factor


The condition of the track was not a recent

phenomenon and could be attributed to progressive

and unremediated degradation.

Organisational

management

Business

planning and

asset/ resource

management

Infrastructure

construction and

maintenance

Inspection, defect recording and maintenance

systems in the region were less than sufficiently

robust or integrated to provide adequate managerial

oversight of the asset and its condition.

Organisational

management

Monitoring,

review and

validation

Infrastructure

construction and

maintenance

There is continued utilisation of Class 5 lines that do

not meet the required standards under the provisions

of a waiver system that was introduced by RIC,

embraced by ARTC, but which was never

countenanced by the ITSRR and which expired on 1

October 2004.

Organisational

management

Risk/change

management

Infrastructure

construction and

maintenance

Adherence to track engineering standards appears to

have assumed less significance and risk management

appears to have been increasingly devolved to a local

level. Such practises might be acceptable were they

informed by a detailed understanding of track

conditions and deliberate decision-making.

Organisational

management

Risk/change

management

Infrastructure

construction and

maintenance



6. Grawlin Plains - Level Crossing Collision - 31 May 2005

At approximately 3.00pm a single locomotive operated by the Australian Railway Group

collided with a Toyota Landcruiser towing a trailer on a level crossing at Grawlin Plains,

approximately 10 km South of Forbes in the Central West Region of NSW.

The driver of the Landcruiser, a local farmer, was

fatally injured in the collision and his vehicle was

destroyed. The locomotive remained on the track and

came to a stand approximately 350m past the point of

impact. The locomotive suffered minor damage to the

front headstock region and various side-mounted

components. The track infrastructure was not damaged

but debris was scattered over 350m of the track. While there were no injuries to the crew of

the locomotive, both members were treated for shock.

The major safety issues identified in this report relate to

the actions of the driver of the motor vehicle; the

immediate response of the Locomotive’s crew; passive

level crossing safety; train communications and

emergency response. The investigation established that

the collision was caused by the failure of the driver of the

Landcruiser to commence braking in sufficient time for

him to stop and give way to the Locomotive, as was required by Australian Road Rule 121.

The speed at which the driver of the Landcruiser approached the level crossing was not

consistent with a prior intention to stop at the crossing. The driver’s chances of survival were

further diminished because he was not wearing a seat belt at the time of the accident and

that the seat belt he should have been wearing was defective.

Other findings were that the road signage on the approaches to, and at, the level crossing

did not conform to the minimum requirements prescribed by Australian Standard

1742.7:1993, Manual of Uniform Traffic Control Devices, Part 7: Railway Crossings. Also

road users approaching the level crossing from the East had their visibility of trains

approaching from the South obstructed by the presence of trees, vegetation and a wheat

silo.



Occurrence details






Individual actions


type

The collision was caused by the failure of the driver of the

Landcruiser to commence braking in sufficient time for him

to stop and give way to the Locomotive, as was required

by Australian Road Rule 121.

Light passenger

vehicle driver

Monitoring and

checking

Unknown


Findings Local

Condition/Organis

ational factor


There were limited defences to warn drivers of motor

vehicles on their approach to the level crossing, or to assist

them to remain clear of the rail line when necessary.

Equipment, plant

& infrastructure

Signage Road

environment

Design features on the Xplorer, under certain

circumstances, inhibit emergency egress.

Equipment, plant &

infrastructure


construction

Additional safety equipment is required aboard services

operated by RailCorp.

Equipment, plant

& infrastructure


construction

Emergency Services were inhibited by a lack of specific

knowledge in relation to emergency access points and

power shut-down.

Knowledge, skills &

experience

Emergency

operations

knowledge & skills

Emergency

management

RailCorp’s imposition of blanket speed restrictions

throughout most of regional NSW has reduced the

prospect, and consequences, of collisions at level

crossings.

Organisational

management

Policy On-train

operations



7. Bloomfield- Opposing movement - 20 August 2005

At approximately 11.27am two Pacific National Limited coal trains, designated DS184 and

DS233 respectively, were routed into the same section of track from opposing directions.

The opposing movement occurred when DS233 exited one of four sets of parallel lines at

Thornton in the Hunter Valley Region of NSW, under controlled signalling arrangements, and

entered the single line track leading into the Bloomfield Colliery. As it approached the

Thornton staff hut where it was required to stop and where its crew was required to

communicate with the Train Controller, DS233 was confronted by DS184 which was awaiting

a final clearance to depart the Colliery. The driver of DS233 was able to bring his train to a

stand approximately 64 metres from DS184 and all but one service was able to be diverted

around DS233, the rear of which remained on one of the main lines. There was no damage

or injuries as a result of the incident.

The opposing movement occurred when the Train

Controller at the Broadmeadow Hunter Train Control

Centre (HTCC) authorised the movement of DS233

into the Bloomfield Colliery Branch Line, having

overlooked the fact that DS184 was awaiting a

clearance to exit the same track. This oversight was

caused by the fact that the Broadmeadow HTCC Train

Controller was pre-occupied with the requirement to

reschedule train movements elsewhere, due to a points failure at Whittingham,

approximately 50km North West of Thornton. In addition, because DS184 was not standing

on circuited track, neither the Broadmeadow HTCC Train Controller nor the Area Controller

at Maitland Signal Box had the benefit of having the train’s position illuminated on their track

indication panels.

Operations on the Bloomfield Colliery line were unusual in

that it was the only location on the network where a single

line Staff and Ticket section leads into and out of a

balloon loop. The investigation established that the

opposing movement would not have occurred had the

driver of DS184 communicated with the train controller

and advised him that he could not move as scheduled

because he did not have a signal to proceed. However, he was not obliged to do so; delayed

departures from the Bloomfield Colliery line were not unusual and drivers were not always

given an explanation for the delays or a revised departure time.



Occurrence details

Event description: Opposing movement by two freight trains



Occurrence Classification Safeworking rule/procedure

breach

Token based system rule procedure breach

Individual actions – Network Controller

Findings Person type Activity type Error/Violation type

The opposing movement occurred when the Train

Controller at the Broadmeadow Hunter Train Control

Centre (HTCC) authorised the movement of DS233 into

the Bloomfield Colliery Branch Line, having overlooked the

fact that DS184 was awaiting a clearance to exit the same

track.

Network

controller

Monitoring and

checking

Error


Findings Local

Condition/Organis

ational factor


This oversight was caused by the fact that the

Broadmeadow HTCC Train Controller was pre-occupied

with the requirement to reschedule train movements

elsewhere, due to a points failure at Whittingham,

approximately 50kms North West of Thornton.

Task Demands High workload Off-train operations

In addition, because DS184 was not standing on circuited

track, neither the Broadmeadow HTCC Train Controller nor

the Area Controller at Maitland Signal Box (MSB) had the

benefit of having the train’s position illuminated on their

track indication panels.

Equipment, plant &

infrastructure

Absent equipment,

plant &

infrastructure

Off-train operations

Operations on the Bloomfield Colliery line are unusual in

that it is the only location on the network where a single

line Staff and Ticket section leads into and out of a balloon

loop. The frequency of train movements on the line is also

irregular.

Knowledge, skills

& experience

Abnormal/

emergency

operations

knowledge & skills


These factors increased the potential for error and were

compounded by the fact that DS184 and DS233 were

operating at a point where two different systems of

safeworking each with its own procedures, intersected.

Procedures Accuracy/clarity Off-train

operations

Having lost visibility of DS184 after it left Thornton staff hut,

there were no additional procedures or prompts that might

have reminded the Area Controller at MSB that the train

was still on the Bloomfield Colliery line.

Procedures Absent procedure Off-train

operations

ARTC’s Network Rules and Procedures is the capstone

reference for train operations in territory controlled by

ARTC. These rules are supplemented by Local Appendix

Unit 217 (LAU 217) and General Order 8-2001 which

contain local and specific orders for safeworking at

Thornton. However, there were subtle differences between

these safeworking procedures which, in conjunction with

the uniqueness of the track layout at Thornton and the

Knowledge, skills &

experience

Task experience Off-train

operations



relative infrequency of operations there, resulted in

different levels of understanding between some Drivers,

Area Controllers and Train Controllers in relation to their

obligations to communicate in certain circumstances.

The communications between all of the involved parties

did not conform to the requirements contained in ARTC’s

Network Rules and Procedures.

Knowledge, skills &

experience


operations

Individual actions – Train Crew


The opposing movement would not have occurred had the

Driver of DS184 communicated with the Train Controller

(HTCC) and advised him that he could not move as

scheduled because he did not have a signal to proceed.

Train Crew Communicating Error


Findings Local

Condition/Organi

sational factor


However, he was not obliged to do so; delayed departures

from the Bloomfield Colliery line are not unusual and

Drivers are not always given an explanation for the delays

or a revised departure time. Over time, and in the absence

of clear instructions in relation to the requirement to

communicate in such circumstances, some Drivers have

become conditioned to waiting for a proceed signal.

Procedures Accuracy/clarity Off-train

operations

Neither train crew operated the emergency function on the

Countrynet radio system to report the incident because,

having avoided a collision, they did not consider that they

had been involved in an emergency. However, part of

DS233 was still on the main line and an opportunity to

divert a following train was lost. Subsequently, however, all

other following trains were effectively diverted.

Knowledge, skills

& experience

Abnormal/

emergency

operations

knowledge &

skills

On-train

operations

The communications between all of the involved parties

did not conform to the requirements contained in ARTC’s

Network Rules and Procedures.

Knowledge, skills

& experience

Task experience On-train

operations



8. Steel sleepers – Systemic report -2005

When the OTSI was established in 2004 it took over an investigation into a derailment at

Rocky Ponds in November 2002. This derailment had been caused by track misalignment.

One of the recommendations of the report was for OTSI to conduct a supplementary

investigation into the introduction and performance of steel sleepers in the NSW Rail

Network The systemic investigation found that in 1996 the decision was made to install steel

sleepers on the Main South line in a random installation pattern as a part of the Partial Re-

Sleepering program. This decision was made jointly at senior management level in the NSW

railway organisations of Rail Access Corporation (RAC) and Rail Services Australia (RSA).

The decision to continue with their installation was made against the advice of the

Engineering Standards Group and in contradiction of the manufacturer’s recommendation.

The Engineering Standards and Manufacturer’s advice

recommended that a heavier sleeper section be used

together with a different installation process. There was

no corporate standard in place covering the installation

within either organisation. There was also no track

stiffness design verification conducted to provide an

assurance that random steel sleepers would be

compatible when interspersed with timber sleepers. A standards waiver was not issued

before installation took place on Class 1 Main line track.

The decision to introduce steel sleepers on Class 1 Main line track revolved around two key

issues: the impending timber sleeper supply problem and the cost benefits to be gained from

the use of steel sleepers. The forecast supply problem with timber sleepers initiated a

number of studies into the alternatives regarding sleeper type and installation pattern. These

studies identified savings associated with the use of steel sleepers and decisions were made

based on these savings. The investigation found the creation of RAC and RSA in 1996 made

for an environment where changes to the infrastructure

could be carried out under processes that differed from

the previously vertically integrated State Rail. Changes to

business processes could be made more readily in the

newly formed organisations, especially where there had

been major organisational changes and loss of

personnel.



Occurrence details Event description: A systemic investigation into the installation of steel sleepers in NSW. When the OTSI was

established in 2004 it took over an investigation into a derailment at Rocky Ponds in November

2002. This derailment had been caused by track misalignment. One of the recommendations of

the report was for: ’The Office of Transport Safety Investigation to conduct a supplementary

investigation into the introduction and performance of steel sleepers in the NSW Rail Network.

This investigation would seek to identify the basis on which steel sleepers where introduced into

the network and whether their introduction has increased the likelihood of track structure failures

to any significant extent.’

Type of operation: Track maintenance



Technical failure


mechanism

Failure origin

The installation of steel sleepers on Class 1 main line in

1996 (Main West) and later in 1997 (Main South)

contravened the sleeper standard at that time.

Infrastructure - Track Other Installation/co

mmissioning


Findings Local


onal factor


No immediate standards waivers were obtained to allow

installation of steel sleepers on Class 1 Main lines. A waiver

to the standard allowing for the change was ultimately

obtained some 18 months following the introduction.

Organisational

management

Risk/change

management

Infrastructure

construction and

maintenance

Installation procedure and pattern recommendations gained

from steel sleeper trials on the Main West Class 1 and Class

2 lines were not followed in the installation on the Main

South.

Organisational

management

Risk/change

management

Infrastructure

construction and

maintenance

No prior engineering trials were conducted on Class 1 Main

lines covering the modified installation process and patterns

employed on the Main South Class 1 line.

Organisational

management

Risk/change

management

Infrastructure

construction and

maintenance

Financial provision for the tamping of steel sleepers as they

were installed on the Class 1 Main South was inadequate in

the planning and the implementation stages.

Organisational

management

Business planning

& asset/ resource

management

Infrastructure

construction and

maintenance

The RAC Asset Management approach at the time of

installation was to proceed with the installation unless there

was engineering proof that steel sleepers were unsafe.

Organisational

management

Policy Infrastructure

construction and

maintenance

Controls over the identification of which timber sleepers

were to be removed were inadequate in the initial stages of

changeover.

Organisational

management

Information

management

Infrastructure

construction and

maintenance

The filling and compaction of steel sleeper ballast pods was

not consistently achieved due to the problems associated

with the revised installation process required by the

Maintainer.

Organisational

management

Contractor/

interface

management

Infrastructure

construction and

maintenance

The inherent difficulties of identifying substandard

installation immediately following the installation process

meant that a measurement of quality could not be easily

associated with the installation.

Organisational

management

Contractor/

interface

management

Infrastructure

construction and

maintenance



9. Conoble- Derailment - 16 October 2005

At approximately 7:54am a Pacific National (PN) freight train, designated 7SP5, derailed one

unladen flat wagon in the vicinity of the township of Conoble in the Western Region of NSW.

After travelling a further 34.8km the wagon re-railed itself in the vicinity of the township of

Ivanhoe. The train driver was not aware of what had happened, but stopped the train some

133km later because he did not feel that it was as responsive as it should be. He found that

a brake pipe isolating cock, located between the 30th and 31st wagon, was in the up

(closed) position and that there was extensive damage to the rear wheel-set of the 30th

wagon in the consist.

The derailment of the rear wheel set of the rear bogies

of wagon RQKY 02034E was due to excessive lateral

movement of the bogie, known as hunting. The

constant contact side bearer components of the bogie

should have countered the tendency to hunt but they

had been fitted with incorrect resilient blocks when the

wagon underwent a major service less than four

months prior to the derailment. The fitting of the incorrect type of resilient blocks, RB 35

instead of RB 27, was attributable to human error. Three factors contributed to the error: the

maintenance crew were fitting RB 35 type blocks to other types of wagons during the

previous week; both types of blocks were the same colour and shape; and block storage

arrangements at the maintenance facility were inadequate for effective stock management.

The investigation found no evidence of train handling or

track condition having contributed to the derailment.

However, PN had been critical of the standard of the track

and its effect on ride quality between Parkes and Broken

Hill for some years, though the results of testing

conducted before and after the derailment have proven

inconclusive and remained contested between PN and

ARTC. The problem could be attributed to a system that focuses on measuring a variety of

parameters related to track geometry rather than the impact the combined effect of those

parameters might have on ride quality.



Occurrence details Event description: A main line derailment of freight train.




Technical failure


mechanism

Failure origin

The derailment of the rear wheel set of the rear bogies of

wagon RQKY 02034E occurred because the wagon was

‘hunting’. This was the result of the inability of the rear

bogie components to prevent or control excessive lateral

movement of the bogie.

Rolling stock- Bogie Wear Installation/

commissioning


Findings Local


onal factor


The wagon’s Constant Contact Side Bearer’s were fitted

with incorrect resilient blocks when it underwent a major

service less than four months prior to the derailment. The

blocks wore very quickly to a state where they were not

providing effective dampening of the forces acting on the

wagon.

Equipment, plant &

infrastructure


construction and

maintenance

The fitting of the incorrect type of blocks, RB 35 instead of

RB 27, was attributable to human error. Three factors

contributed to the error: the maintenance crew were fitting

RB 35 type blocks to other types of wagons during the

previous week; both types of blocks are the same colour

and shape; and block storage arrangements at the facility

were inadequate for effective stock management.

Equipment, plant &

infrastructure


construction and

maintenance

PN’s train marshalling requirements were ambiguous

especially in their guidance to marshall lightly loaded

wagons to the rear, where possible. 7SP5 left the terminal

where its consist was formed with four empty wagons

which were very close to the front of the consist. Wagon

RQKY 02034E was arguably towards the rear but could

have been positioned closer to the rear in Sydney.

Whether or not the positioning of the wagon contributed to

the derailment cannot be determined but, at least, there is

scope for more definitive guidance on train marshalling.

Procedures Clarity Off-train

operation



10. Lidcombe - Derailment – 4 November 2005

At approximately 12:07am 4BM7, a Brisbane to Melbourne freight service, passed Signal ST

419GL at Stop without authority whilst traversing the Lidcombe Goods Loop and derailed at

a set of catch-points identified as No.717. The catch-points were deliberately positioned

beyond Signal ST 419GL to derail any train that passed the signal at Stop without authority,

to mitigate the risk of collision with trains on the nearby main line.

4BM7 consisted of two locomotives and 34 container

wagons and was operated by Interail Australia Pty Ltd,

a subsidiary of Queensland Rail. The leading

locomotive derailed all wheels before becoming

embedded in the ballast and resting against a small

safety wall on top of an eight metre-high embankment.

The second locomotive derailed all wheels on the

leading bogie but remained upright. There were no injuries resulting from the derailment.

The derailment occurred when the driver of 4BM7 failed to

respond to a Stop indication at Signal ST 419GL and ran

through a set of catch-points which performed as they

were designed to, by deliberately derailing the train to

prevent both unauthorised entry onto the main line and

the inherent hazard that such unauthorised entry would

pose to authorised main line traffic.

Other findings were that the driver had only been at the controls of 4BM7 for approximately

10 minutes and was still adjusting to the train’s handling. In addition, he had not slept well

following his previous shift. These factors, and the prospect of proceeding on holidays the

next day, may also have affected the driver’s attentiveness. No.717 catch-points functioned

as intended. However, the placement of the catch-points did not conform to RailCorp’s

design standards.



Occurrence details

Event description: SPAD and derailment of freight train.




Individual actions


The derailment occurred when the driver of 4BM7 failed to

respond to a Stop indication at Signal ST 419GL and ran

through a set of catch-points which performed as they

were designed to, by deliberately derailing the train to

prevent both unauthorised entry onto the main line and the

inherent hazard that such unauthorised entry would pose

to authorised main line traffic.

Train crew Monitoring and

checking

Error


Findings Local

Condition/Organis

ational factor


Notwithstanding an indication from the preceding Signal

ST 422S, which indicated that he should proceed with

caution, the driver admitted to being complacent during his

approach to Signal ST 419GL because it was his

expectation that the Signal would be displaying a proceed,

or ‘calling on’, indication. This expectation was based on

his previous experiences at the Signal where he claims he

had never previously been required to stop.

Personal factors Motivation/

attitude

On-train operations

A large peppercorn tree on the Western side of the track

restricted the driver’s visibility until he was approximately

93 metres from Signal ST 419GL. However, had the driver

maintained proper control of 4BM7 in accordance with the

previous signal indication, he would have had sufficient

time and distance, albeit with a small margin for error, to

bring 4BM7 to a stand prior to Signal ST 419GL.

Physical

environment

Visibility Infrastructure,

construction and

maintenance

Knowledge, skills &

experience

Normal

operations

knowledge &

skills

The driver had only been at the controls of 4BM7 for

approximately 10 minutes and was still adjusting to the

train’s handling. In addition, he had not slept well following

his previous shift. These factors, and the prospect of

proceeding on holidays the next day, may also have

affected the driver’s attentiveness.

Personal factors Fatigue/

alertness

On-train operations

RailCorp has a maintenance program to check on matters

that might impact on the operation or visibility of signals,

but this program failed to detect what was an obvious and

long-standing obstruction, caused by a large peppercorn

tree on the Western side of the track, 93 metres from

Signal ST 419GL.

Organisational

management

Information

management

Infrastructure,

construction and

maintenance



11. Ariah Park – Shunting fatality – 15 April 2006

A heritage passenger steam train operated by Lachlan

Valley Railway Society Cooperative Ltd was

participating in an event to celebrate the centenary of

the opening of the rail line between Temora and Ariah.

The train consisted of a 32 Class steam locomotive,

No. 3237, its tender and five passenger carriages. For

the journey from Temora to Ariah Park, it was designated SS83 and configured with the

tender of the locomotive leading. It arrived at Ariah Park at 10:30am with approximately 160

passengers who disembarked at the platform and moved on foot to the site of a

commemorative ceremony adjacent to the Coolamon Street level crossing. The locomotive

and tender were detached from the carriages and moved

around the rail loop to take up a position near the level

crossing for the ceremony.

On completion of the ceremony at about 11:40am, the

locomotive and tender had to be reversed towards the

Ariah Park platform to be re-coupled with the carriages for

the return journey to Temora as heritage service SS84. The train’s Guard directed this

reversing movement with hand signals and was responsible for connecting the couplings

between the locomotive’s tender and the leading passenger carriage.

To engage the hook and link of the coupling mechanism, the Guard stepped into the gap

between the tender and the carriage on two occasions; initially to align the coupling link and

subsequently to place the carriage’s coupling link over the tender’s coupling hook. At

approximately 11:52am, as the Guard attempted to effect the coupling manoeuvre, he was

crushed between the tender and the carriage. The Guard received immediate emergency

treatment at the site of the incident and was then transported by ambulance to Temora

Hospital where he died shortly afterward from the injuries he had sustained.



Occurrence details

Event description: A shunter was killed when he was crushed between carriages.



Occurrence Classification Collision Running line collision


Individual actions


type

The accident occurred when the Guard placed himself in

an unsafe position between a moving tender and a

stationary carriage in order to manually couple the two

pieces of rolling stock.

Train crew Operating

equipment

Error


Findings Local


onal factor


The Guard had worked 18 shifts over the preceding 20

days and had been involved in preparation of the train well

into the evening before, and in the early morning on the

day of, the accident. It is likely, therefore, that the Guard

was affected by fatigue.

Personal factors Fatigue/

alertness

Off-train

operations

He may also have been distracted by the presence of

spectators in very close proximity to him as he attempted

to couple the tender and the carriage.

Task demands Distraction Off-train

operations

The Guard was an experienced rail safety worker but his

primary experience lay in signalling, and LVRS could not

provide evidence to show that he had formally qualified as

a shunter or that he had the competence to carry out

manual coupling tasks.

Organisational

management

Risk/ change

management

Off-train

operations

When the Guard stepped between the tender and the first

carriage, he lost contact with the Driver of the locomotive

because he did not employ another crew member to

repeat his hand signals to the Driver, as was required by

Lachlan Valley Operating Procedure (LVOP) 16.

Knowledge, skills

and experience

Normal

operations

knowledge and

skills

Off-train

operations

LVRS did not anticipate and manage a range of risks that

were associated with their operations on the day of the

accident, and their wider operations more generally.

Organisational

management

Risk/ change

management

Off-train

operations

LVRS was failing to employ its SMS and as such, was in

breach of the terms of its accreditation.

Organisational

management

Monitoring,

review and

validation

Off-train

operations

Video footage taken immediately prior to the incident

showed the Guard and Chairman of LVRS riding on a

ladder on the end of the locomotive’s tender which

contravened a prohibition notice, 02346/1 – 04/001105,

issued by ITSRR on 7 July 2004.

Organisational

management

Competence of

senior

personnel

Off-train

operations



Documentation provided by LVRS confirmed that the

Driver was fully qualified to operate SS84 but similar

records could not be produced to substantiate the

qualifications of the remainder of the crew.

Organisational

management

Information

management

On-train

operations

The certificates of competency issued to the Fireman,

Supernumerary Fireman and LVRS’s Trainer/Assessor

had expired.

Training and

assessment

Competency

assessment

On-train

operations

The Supernumerary Fireman should have been required to

submit to an updated health assessment before returning

to crew duties following a serious injury, but this

requirement had not been complied with.

People management Fitness for duty

monitoring

On-train

operations

LVRS had established procedures for propelling, shunting

and coupling operations, including LVOP 10 (Propelling

Movements) and LVOP 16 (Screw Couplings & Transition

Links). However, its operating procedures had not been

amended to reflect the requirements of a prohibition notice,

issued by ITSRR in July 2004, in relation to riding on

moving . Nor had LVOPs been amended to reflect

requirements identified during successive audits by the

Regulator.

Organisational

management

Monitoring,

review and

validation

Off-train

operations

The decision to operate SS84 with a carriage that did not

have buffers and to attach it to the locomotive’s tender,

had risks that were not appreciated on the day. It was also

inconsistent with LVOP 16 which required crews to

“Ensure that vehicles with buffers are only coupled to other

vehicles fitted with buffers or diaphragms”.

Organisational

management

Risk/ change

management

Off-train

operations

LVRS did not have a proper understanding of its risks and

did not have an effective risk management framework in

place.

Organisational

management

Risk/ change

management

On-train

operations

ARTC’s policy on secondary employment “External

Employment (Policy Number HR06-004)” and the rostering

processes which underpin its management of fatigue,

warrant internal review.

Organisational

management

Policy Off-train

operations



12. Baan Baa – Ballast wagon fatality – 22 May 2006

At approximately 9:00am a track worker employed by the Rail Infrastructure Corporation and

seconded to the Australian Rail Track Corporation was fatally injured while participating in

ballasting operations approximately 3km South of Baan Baa. The ballast train (5M23) was

crewed by two Southern & Silverton Railway Pty Ltd drivers and consisted of three

locomotives and 22 ballast wagons, with a plough van at the rear.

The fatally injured worker had

been one of a team of three track

workers who were controlling the

distribution of ballast. A fourth

worker operated the plough at the

rear of the train, reducing the

height of the ballast where

necessary so that it was no higher than the rails. A fifth worker supervised the operation from

the leading locomotive, while a sixth drove a support vehicle along the fire trail beside the

track.

In order to maintain continuity of ballast distribution, the

three track workers each rode at the front or rear of a

loaded wagon to operate the ballast hopper door controls,

alighting when the ballast in that wagon was depleted,

and re-joining the train at a loaded wagon by means of

the steps providing access to the walkway below the

hopper door controls. The ballasting operation

commenced at approximately 7:54am and was underway when at about 9:00am one of the

three ballast wagon operators saw a colleague lying on the ballast shoulder. He alerted the

rest of the crew and when they attended to the worker lying on the ballast, he was found to

have a major head injury and to be deceased.

The track worker died as a result of severe head injuries that were sustained by falling onto

the ballast shoulder and being struck by a ballast hopper side door of a passing wagon. No-

one witnessed the track worker’s fall so it could not be positively determined whether he fell

while getting off a moving ballast wagon, or while moving beside the track.



Occurrence details

Event description: A ballast worker was killed when he fell onto the ballast.





Individual actions


The track worker died as a result of severe head injuries that

were sustained by falling onto the ballast shoulder and being

struck by a ballast hopper side door of a passing wagon.

Infrastructure

maintainer

Operating

equipment

Error


Findings Local

Condition/Organis

ational factor


Stepping down from a moving rail vehicle is inherently

dangerous and the danger is increased when stepping onto

a loosely-packed, rough, sloping ballast shoulder and these

were the prevailing conditions at the scene of the accident.

Physical

environment

Other –

unstable

surface

Infrastructure

construction and

maintenance

At the time of the accident the ballast train was moving at a

speed averaging between 9 and 10 km/h, significantly faster

than the 4 to 6 km/h at which ballast is usually laid and this

would have heightened the risks associated with movement

onto and off the ballast wagons and movement on the

ballast.

Task demands Time pressure Infrastructure

construction and

maintenance

The track workers sought to slow the train down but the

radio that was normally available to them had been

reallocated due to failure of the radio used by the plough

operator. This meant that their request could not be

communicated directly to, and therefore acted upon

immediately by, the driver.

Equipment, plant

and infrastructure

Absent

equipment

Infrastructure

construction and

maintenance

Both the Work Method Statement and the Pre-Work Brief

identified the dangers associated with the operation and

classified the related risk as being “medium” in nature. The

documents failed to identify any means other than the

exercise of care, to reduce the risk. In this regard the activity

planning was deficient.

Procedures Accuracy/

adequacy

Infrastructure

construction and

maintenance

The work plan specified a significantly greater amount of

work than could be performed in the available time. As a

consequence, the track workers were placed under pressure

and therefore exposed to increased risk.


adequacy

Infrastructure

construction and

maintenance

The work plan contained no contingency provisions to be

implemented in the event that communications equipment

became unserviceable and there was no hand-held or other

radio as a back-up to ensure continuity of radio

communication in the event of an equipment malfunction.

Procedures Absent

procedure

Infrastructure

construction and

maintenance



13. Town Hall Tunnel - Self harm fatality - 30 August 2006

At approximately 4:25pm on Wednesday 30 August 2006, a 43 year old woman was struck

and killed by CityRail passenger service 10-F in an underground section of the Eastern

Suburbs Railway (ESR) between Town Hall and Central Railway Stations, approximately

238 metres North of Platform 25 at Central. The woman’s entrance into the tunnel was

unauthorised and evidence acquired after the incident indicates that she was intent on

committing suicide.

The Police and Emergency Services were notified and

upon entering the tunnel system were escorted to the

scene of the incident where they found the deceased

woman beneath the third carriage of the train. A

decision was made to evacuate the passengers

through the front of the train utilising the emergency

door in the train driver’s cab. It was initially estimated

that up to 1000 passengers were evacuated from the

train and escorted through the tunnel and onto Platform 25 at Central Station. During the

course of the evacuation, Ambulance officers were called to attend to a passenger who

suffered an anxiety attack.

The evacuation was completed at approximately 5:40pm

and the train was moved at 6:51pm, after which Police

completed their examination of the scene. The

investigation revealed that the woman entered the tunnel

via stairs leading from the platform to the track surface at

the Northern end of Platform 25 at Central Station. The

defences against unauthorised entry into the tunnel

system from Platform 25 consisted of signage at the tunnel portals, which was clearly visible,

indicating that public access to the tunnel system was prohibited, and a CCTV network to

monitor public movement on the platform. However, the CCTV camera best placed to

capture movement in the tunnel had its field of vision obscured by a platform structure.



Occurrence details Event description: A passenger died after being struck by a train.



Occurrence Classification Suspected suicide Struck by train

Technical failure


mechanism

Failure origin

The CCTV network is limited as a defence against

unauthorised entry into the tunnel system from

Platform 25 because the camera best placed to

capture movement into the tunnel had its field of vision

obscured by a platform structure.

Signalling and

Communications item:

Control interface

equipment

Other Installation/com

missioning



14. North Strathfield – Opposing movement – 2 September 2006

At approximately 1:08am an empty CityRail service 67-R passed Signal ST 164 at stop

without authority on the Down Relief line at North Strathfield and continued onto the single,

bi-directional Goods line between North Strathfield and Homebush, as the points were set

for this route. At the same time, Pacific National’s freight service 5YN2 was travelling on the

same Goods line between Flemington and Homebush, but in the opposite direction. 67-R

and 5YN2 were proceeding towards each other on the same line.

The Area Controller at Strathfield Signal Box witnessed

the evolving opposing movement on his indication

board and attempted to contact the Drivers of 67-R and

5YN2 by radio to direct them to stop their trains

immediately. The Driver of 5YN2 responded by

stopping his train as directed. However, the Area

Controller was unable to establish radio contact with

the Driver of 67-R because the Driver had entered the wrong train designation, or run

number, when he logged into the radio network. In the meantime, a number of other Area

Controllers stood on the balcony of the Strathfield Signal Box and tried to attract the

attention of the Driver of 67-R in an attempt to warn him of

the impending danger. In the face of what was an

imminent and significant emergency, other members in

the Strathfield Signal Box reacted quickly by making radio

calls to support the Area Controller and attempting to

warn the Driver of 67-R by using flags and hand lamps.

The Driver was unaware of these attempts to contact him

but eventually realised that he was on the wrong line and bought his train to a stand adjacent

to the Strathfield Signal Box and some 194 metres from the stationary 5YN2.

The opposing movement was a consequence of an error by the Driver of 67-R who either did

not see, or did not respond to, Signal ST 164 and passed the signal when it was at stop. As

a result, 67-R deviated from the intended route and proceeded onto on the same track as,

and travelling towards, 5YN2.



Occurrence details

Event description: There was an opposing movement between a passenger train 67-R and freight train 5YN2

when 67-R passed signal ST164 at stop.



Occurrence Classification Signal Passed at Danger Completely missed while running

Individual actions


The Driver of 67-R who either did not see, or did not

respond to, Signal ST 164 and passed the signal when it

was at stop. As a result, 67-R deviated from the intended

route and proceeded onto on the same track as, and

travelling towards, 5YN2.


checking

Error

Other Area Controllers stated that they would have set the

route in such a way that would have required the Driver to

have waited longer at Signal ST 168R but then given him a

clear run through Signal ST 164 and on to Strathfield.

Such a setting would also have provided an increased

safety margin.

Network controller Preparation

and planning

Error


Findings Local

Condition/Organis

ational factor


Signal ST 164 is sited in a manner and location that meets

the required technical parameters; as such it should have

been readily apparent. However, as a ‘ground dwarf

signal’, it is lower than other signals in the immediate area

and may have been overlooked by the Driver in favour of

two Main Line signals in advance of it which were showing

proceed indications.

Equipment, plant

and infrastructure

Infrastructure

design

Infrastructure

construction and

maintenance

The Driver of 67-R had worked for nine consecutive days

and was due to proceed on rest days at the end of their

shift. There was an increased likelihood of him making an

error.

People

management

Rostering/

scheduling

On-train operations

The Area Controller had worked for eight consecutive days

and was due to proceed on rest days at the end of his

shift. There was an increased likelihood of him making an

error.

People

management

Rostering/

scheduling


There was no record within RailCorp of Signal ST 164

having previously been passed at danger. Even so, Signal

ST 164 is not fitted with any form of mechanical protection,

such as a train stop or catch points, to mitigate the

consequences of a SPAD.

Equipment, plant

and infrastructure

Absent

equipment,

plant &

infrastructure

Infrastructure

construction and

maintenance



15. Thirroul – SPAD and derailment – 11 September 2006

At 5:32am the leading car on CityRail’s passenger service 312A operated by RailCorp

derailed at catchpoints in the vicinity of No.3 Platform at Thirroul after failing to stop at Signal

WG 568D. On approach to the signal the train did not respond to normal braking techniques

forcing the driver to apply his emergency brakes approximately 20 metres prior to the signal.

The train consisted of an eight-car Tangara set and

was carrying approximately 30 passengers who were

safely disembarked under the direction of the guard.

There were no injuries and only minor damage to the

train and track. The prevailing weather conditions were

wet and blustery. Speed, signalling anomalies, driver

fatigue and wheel and rail defects were able to be

readily excluded as contributory factors. Importantly, brake failure was eliminated at the

beginning of the investigation as a result of on-site testing undertaken by RailCorp

engineers. The investigation then focussed on track conditions and the braking process.

Severe weather conditions prevailing at the time were

found to be responsible for the formation of an emulsion

consisting of rust, moisture and salt building up on the rail

which had not been used for some 58 hours. This resulted

in a particularly slippery rail surface and consequent

reduced braking effectiveness. Historically, there had

been a number of similar situations of Tangaras

encountering stopping difficulties in wet and inclement

conditions at Thirroul and in the wider South Coast region. Further, having disc brakes, the

Tangara contributed less to rail head conditioning during normal operation than did trains

with brake shoes that help to remove contamination from the wheel tread.

In this instance, braking effectiveness was reduced to such a degree that significantly

greater stopping distances were needed than was usual. This should have been apparent to

the driver from an experience of minor wheel slip under similar conditions earlier in the trip.

However, insufficient allowance was made for the obvious reduction in braking effectiveness.



Occurrence details

Event description: The leading car on CityRail’s passenger service derailed at catch-points at Thirroul after

failing to stop at Signal WG 568D.




Individual actions


The derailment occurred because passenger service 312A

proceeded past Signal WG 568D, which was at Stop, and

ran through a set of catch-points which performed in the

manner for which they were designed. The Driver sought

to comply with the signal by bringing his train to a stand but

it failed to respond because an emulsion formed by rust,

moisture and salt on top of the rails impeded the transfer of

braking effort.


equipment

Error


Findings Local

Condition/Organis

ational factor


Actuation of the WSP module earlier in the trip was

followed by a more cautious braking technique by the

Driver for a short period, but this same degree of caution

was not in evidence on the approach to Thirroul.

Knowledge, skills

and experience

Abnormal/

emergency

operations

knowledge and

skills

On-train operations

The braking performance of all trains is downgraded by

wet conditions and this has contributed to a number of

SPADs, and instances of overshooting platforms and

colliding at dead-ends. A disproportionate number of these

have been on the South Coast, especially at Thirroul. It is

probable that this is due to the particularly slippery rail

conditions resulting from the moist, salty environment on

rails that may carry no traffic for extended periods.

Physical

environment

Weather-

related factors

On-train operations

The No. 3 Platform had not been used for 58 hours prior to

the derailment. If this had been in excess of 72 hours the

track may have been conditioned using a train operating

specifically for the purpose. However, the severity of the

weather conditions would have promoted oxidation of the

rail at a faster rate than normal. Tangaras are fitted with

disc brakes which make them less effective in conditioning

rail in the course of normal operation than trains fitted with

treaded brakes, and as a consequence the rearward

carriages would have had little benefit from conditioning by

the leading carriages.

Equipment plant

and infrastructure

Functionality On-train operations



16. Nyngan – Derailment – 1 October 2006

At 5:46am the trailing locomotive and 14 wagons within Pacific National Limited’s ore

container service 4835 derailed four kilometres South-East of a locality known as Miowera,

on a Class 3 freight line, between Nevertire and Nyngan in the Central West region of NSW.

These rail vehicles and 22 containers suffered varying degrees of damage. Fortunately,

there were no injuries.

4835 departed Nevertire at 5:15am for Nyngan. The

crew recalled the journey from Nevertire towards

Nyngan as being uneventful until shortly after passing

the 604 kilometre post when they felt the train jerk and

shudder. The Driver then observed, in the rear view

mirror on his side of the locomotive’s cabin, dust

emanating from underneath the train and noticed that

the brake air pressure gauge was indicating a loss of brake pipe pressure. His view to the

rear was then obscured by a large dust cloud. These signs typically indicate that some

portion of a train has derailed and the Driver therefore applied the train’s emergency brakes.

The Assistant Driver, who was seated on the opposite

side of the cabin, also recalled the jerk and watching the

second and third wagon disappear from sight in his mirror

before the dust also obscured his view

Event recordings captured on the two Hasler tapes

removed from 4835 indicated that the train had been

travelling at 78km/h at the time of the incident. This speed was under the posted speed limit

of 80km/h for the immediate area. The recordings also showed that 4835 had been operated

in accordance with ARTC’s Network Rules and Procedures and within posted track speed

limits up until the loss of brake pipe pressure at 5:46am, after which it came to a stand.

4835 derailed because the track over which it was travelling was in a poorly maintained

condition. The derailment at 604.120km occurred when a poorly-supported rail joint snapped

under the pressure of the weight of 4835’s approach. When this joint snapped, the exposed

rail end was struck by the wheels of 4835’s leading locomotive. Approximately 6m of rail

subsequently shattered and as a consequence, the trailing locomotive and 14 wagons

derailed.



Occurrence details

Event description: A freight train derailment on a running line.




Technical failure


mechanism

Failure origin

4835 derailed because the track over which it was

travelling was in a poorly maintained condition. The

derailment at 604.120km occurred when a poorly-

supported rail joint snapped under the pressure of the

weight of 4835’s approach. When this joint snapped, the

exposed rail end was struck by the wheels of 4835’s

leading locomotive. Approximately 6m of rail subsequently

shattered and as a consequence, the trailing locomotive

and 14 wagons derailed. The rail-end became exposed

when the fishplates that had been used to join two lengths

of rail broke. Metallurgical testing established that this

breakage was associated with fatigue fractures that had

developed in the fishplates over time because of

inadequate support underneath the rail joint.

Infrastructure -

Track

Fracture Maintenance


Findings Local

Condition/Organis

ational factor


The limitations in the condition of the track were readily

apparent but were not detected in successive track

inspections. This meant that ARTC lacked visibility of

issues that should have informed its maintenance and

track management priorities.

Organisational

management

Monitoring,

review &

validation

Infrastructure

construction and

maintenance

ARTC has established standards, processes and an

‘‘Exceedent Control System” to identify and manage the

risks associated with track defects and/or failures.

However, these standards and processes were not

properly applied within the Nevertire-Nyngan rail section

and as a consequence ARTC lacked visibility of, and did

not act to address, defects that should have been readily

apparent.

Organisational

management

Risk/

change

management

Infrastructure

construction and

maintenance



17. Sandgate – Track work injury – 7 November 2006

At approximately 1:10pm a 24 year-old male track worker was preparing to weld a newly-laid

section of rail in an area where new track was being commissioned when he was struck by a

reversing Hi-rail excavator operated on behalf of John Holland Rail. The track worker was

severely injured, requiring hospitalisation and emergency surgery.

The welder and the excavator driver were engaged in

separate tasks associated with the construction of an

additional flyover to provide improved rail traffic flow at

Sandgate near Newcastle NSW. The excavator

operator was filling the shoulders of newly-laid track

with ballast and the welder was one of a crew of four

engaged in cutting the rail in preparation for welding

track panels together.

The welding crew completed three welds without incident and were working on their fourth

when the excavator approached. Although the welding crew was aware that an excavator

was operating in the general area, they were unaware of

its close proximity to them. The operator of the excavator

was being assisted by a spotter but neither saw the

welding crew and only became aware of its presence

when other workers nearby shouted to alert them to the

fact that the excavator had struck one of the welders.

One of the excavator’s wheels subsequently ran over the welder’s left arm forcing it into a

25mm gap which the welder had cut in preparation for joining the rail. Although his arm was

severely crushed in the process, had this gap not existed, the welder’s arm would most likely

have been severed.



Occurrence details

Event description: A track worker was injured when he was struck by a reversing excavator.


Fatalities nil Injuries: 1



Individual actions


The accident occurred because the welder and excavator

operator were oblivious to each other’s presence on the

track.

Infrastructure

maintainer

Operating

equipment

Error


Findings Local

Condition/Organi

sational factor


The welder’s ability to see the approaching excavator was

further restricted by the safety goggles he was required to

wear, which limit peripheral vision.

Physical

environment

Visibility Infrastructure

construction and

maintenance

The welder’s ability to hear the approaching excavator

would have been affected by the noise associated with the

cutting and welding tasks he was performing, and the

operation of trains on the adjacent lines.

Physical

environment

Noise Infrastructure

construction and

maintenance

The nature of the task in which the excavator operator was

engaged required him to focus in the opposite direction to

that which the excavator was travelling this rendered the

excavator’s rear vision mirror ineffective.

Physical

environment

Visibility Infrastructure

construction and

maintenance

The excavator operator was being assisted by a ‘spotter’

but the spotter’s attention was focussed on protecting rail

traffic on an adjacent track, not on workers around the

excavator.

Task demands Distraction Infrastructure

construction and

maintenance

The excavator was fitted with a warning beacon but it was

ineffective because it was inoperable.

Equipment, plant

& infrastructure

Functionality Infrastructure

construction and

maintenance

The risks associated with the day’s tasking had been

identified but the controls that had been specified to

mitigate them were imprecise and therefore inadequate.

Organisational

management

Risk/ change

management

Infrastructure

construction and

maintenance

WorkCover NSW’s Code of Practice for Moving Plant on

Construction Sites, 2004 identifies that where heavy

machinery cannot be separated, particular controls need to

be in place. Had such defences been in place, the

excavator and welders would not have been permitted to

operate in close proximity to each other.

Organisational

management

Monitoring,

review &

validation

Infrastructure

construction and

maintenance

The excavator operator was late for work and

consequently did not attend the safety briefing. However,

even if he had, the safety controls that were identified

during the briefing were imprecise and therefore

inadequate.

Organisational

management

Monitoring,

review &

validation

Infrastructure

construction and

maintenance



18. Leeton – Derailment – 11 January 2007

At 5:30pm ten container wagons on Pacific National’s freight service 5CM3 derailed

approximately 3km North West of Leeton in the Riverina region of NSW. The train consisted

of three locomotives and 27 container wagons conveying 69 shipping containers, and was

en route from Griffith to Melbourne.

The derailment occurred on a straight section of track

as the train was slowing in preparation for a temporary

speed restriction just beyond the Griffith Road level

crossing. The 17th and 19th to 27th wagons derailed

and the train came to rest blocking the level crossing.

Police, Roads and Traffic Authority and Leeton Shire

Council personnel attended and directed road traffic to

an alternative crossing. Fortunately, the crew was not injured and there were no other

persons involved in the derailment.

The ten derailed wagons, three shipping containers on one of the wagons which overturned,

220m of track and the road surface at the level crossing sustained varying degrees of

damage. The NSW Rural Fire Service responded to a

small grass fire caused by the derailment.

The investigation found that the derailment was caused

by a lateral misalignment of the track at 615.987km. The

two main track-related factors contributing to the lateral

misalignment were found to be excessive compressive

forces in the rail, and failure of the track structure to contain the compressive forces. In

addition, it was found that, although the Australian Rail Track Corporation (ARTC) had

appropriate processes in place to monitor and measure the condition of the track, errors and

omissions in the records meant that an accurate depiction of the track condition was not

being recorded. This was particularly the case in regard to the annual welded track stability

analysis (WTSA) which did not detect any problems warranting other than routine

programmed maintenance. As the primary tool for detecting the potential for misalignments,

the WTSA had some limitations in that there were some conditions which it did not analyse.



Occurrence details

Event description: A freight train derailed due to a track misalignment.



Occurrence Classification Derailment On Running line

Technical failure


mechanism

Failure origin

The derailment of PN freight service 5CM3 was caused by

a misalignment in the track at 615.987km as it was being

traversed by the train. The misalignment was of such

magnitude that travelling below the allowed speed could

not negotiate the reverse curves with a radius of

approximately 60m resulting from the misalignment.

Infrastructure -

Track

Deformation Maintenance


Findings Local

Condition/Organis

ational factor


The investigation could not determine the specific cause of

the misalignment. However, it was most likely due to

structural weaknesses in the track that were not detected

during programmed track condition monitoring and that

may have been contributed to by mistakes made in the

welding process during the conversion of the track from

JWR to CWR.

Organisational

management

Risk/Change

management

Infrastructure

construction and

maintenance

The track structure lacked the structural rigidity to constrain

the forces acting on it, particularly the buckling forces

arising from the very hot prevailing conditions. Specifically:

• a disproportionate number of loose fastenings in the

predominately timber sleepers transferred the buckling

forces to the intermittently placed steel sleepers; and

• the steel sleepers did not contain a sufficient quantity of

compact ballast to provide the critical mass essential to

resist lateral movement.

Organisational

management

Risk/Change

management

Infrastructure

construction and

maintenance

Although ARTC had appropriate processes in place to

monitor and measure the condition of the track, errors and

omissions in the records meant that a true and accurate

indication of the situation was not being represented. This

was particularly the case with regard to the WTSA

completed on the basis of data collected in 2006 which did

not detect any problems warranting other than routine

programmed maintenance.

Knowledge, skills

and experience

Normal

operations

knowledge and

skills

Infrastructure

construction and

maintenance

The welding returns recording the welding work on the line,

including a portion of track within 100m of the derailment,

were not filled out in the manner intended and were not

signed-off appropriately. As a consequence, it remains

impossible to determine whether or not the track was

correctly adjusted in the welding process.

Organisational

management

Monitoring,

review &

validation

Infrastructure

construction and

maintenance



ARTC has an established maintenance and defects

management system to identify and manage the risks

associated with track defects and failures which rely on

accurate measurement and recording by maintenance

staff and sub-contractors. However, the accuracy of some

assessments is being affected through reliance on

inaccurate or incomplete information on inspection sheets

and unverified records of track maintenance undertaken

apparently without adequate supervision, monitoring or

auditing.

Organisational

management

Monitoring,

review &

validation

Infrastructure

construction and

maintenance

Despite a specific recommendation made in a previous

OTSI Investigation Report, no specific standards or

instructions have been produced to cover the ongoing

inspection of ballast levels or compaction in steel sleeper

pods.

Procedures Absent

procedures

Infrastructure

construction and

maintenance

The use of the hi-rail (visual) inspections to detect track

abnormalities was largely ineffective as it was not expected

that the high speed “heat patrol” would detect the deficient

track conditions that led to the eventual misalignment. The

emptiness of the steel sleeper pods and the lack of

evidence of proper adjustment should have been detected

by earlier walking inspections but were not.

Task demands Time pressure Infrastructure

construction and

maintenance

The extent of trackwork in the vicinity of the derailment

location (and level crossing) and the length of time it might

have affected the line could have been well in excess of

what is catered for in the WTSA. It may be prudent,

therefore, to give such a combination of circumstances

special consideration in the WTSA process.


clarity

Infrastructure

construction and

maintenance



19. Euabalong West – Derailment – 14 January 2007

At 2:53pm a Pacific National Super-Freighter service 6BA6 derailed at high speed in the

Euabalong West – Matakana section.

6BA6 consisted of two NR class locomotives and 26

container wagons conveying 63 containers and was en

route from Brisbane to Adelaide when it derailed

approximately 4kms West of Euabalong West, in

Central Western NSW. The 15th and subsequent

wagons derailed resulting in substantial damage to the

track, wagons and their cargo. Fortunately, the crew

were not injured and there were no other persons involved in the derailment.

A hazardous materials (Hazmat) team from the NSW Fire Brigade responded to the site

because hazardous materials spilled from several containers following the derailment.

The investigation found that instability and misalignment

of the track structure at 623.452kms caused the 15th and

subsequent wagons of 6BA6 to derail. The instability of

the track was attributable to a lack of structural rigidity

resulting from non-conformance with ARTC Engineering

Standards. There was no evidence to indicate that the

way in which 6BA6 was marshalled, loaded or handled contributed to its derailment.

ARTC had technical standards which, if applied correctly, should have identified a variety of

track-related defects and their potential impact. However, because the related inspection,

maintenance and documentation requirements were not undertaken effectively, those

responsible for analysing the condition of the track and determining maintenance priorities

worked with information that was erroneous in some instances and incomplete in others. As

a consequence, they did not comprehend the extent to which the track in the area in which

the derailment occurred had become compromised.



Occurrence details

Event description: A freight train derailed due to track instability.




Technical failure

Findings Failed component Failure mechanism Failure origin

Instability and misalignment of the track structure at

623.452kms caused the 15th and subsequent wagons of

6BA6 to derail.


The instability of the track was attributable to a lack of

structural rigidity resulting from non-conformance with

ARTC Engineering Standards as evidenced by the

following:

a. poor condition of timber sleepers,

b. ineffective timber sleeper fastenings,

c. poor rail anchorages,

d. inconsistent ballast depth and compaction,

e. non-conforming placement pattern of the steel sleepers,

f. minor additions of rail in the welding processes.



Findings Local


onal factor


Despite predicted high air temperatures on the day, no

additional track patrols, as required by ARTC Standard

TMP 17, were scheduled.

Organisational

management

Monitoring, review

& validation

Infrastructure

construction and

maintenance

Although ARTC has established standards, track

maintenance records indicated the following:

a. that track maintenance staff were entering little or

incomplete information on inspection sheets despite its

maintenance system being reliant on such information to

accurately monitor the state of the track;

b. accuracy was not maintained during rail welding

processes, and c. the WTSAs conducted in 2005 and 2006

were flawed due to the lack of accurate information

regarding the state of the track.


attitude

Infrastructure

construction and

maintenance

Despite a specific recommendation being made in the

OTSI “Steel Sleeper Introduction on NSW Class 1 Mainline

Track” that “field inspection guidance be provided”, there

were no specific standards or instructions for the ongoing

inspection of ballast levels or compaction in steel sleeper

pods.

Procedures Absent procedures Infrastructure

construction and

maintenance

The ARTC internal audit and compliance program was

deficient as it did not include any audits which visually

inspected or sampled the condition of the main line in the

Orange to Broken Hill Corridor.

Organisational

management

Monitoring, review

& validation

Infrastructure

construction and

maintenance



20. Connemarra – Derailment – 8 February 2007

At approximately 3:00pm 16 wagons of Pacific National’s empty grain service 9529 derailed

in the rail section between Binnaway and Werris Creek at a locality known as Connemarra in

North Western NSW. The train parted during the derailment when four derailed wagons

concertinaed across the track. The other derailed wagons remained in a generally upright

position.

The train consisted of four locomotives and 47 empty

grain wagons, and was travelling from Nowra to Werris

Creek via Dubbo with the intention of then proceeding

to load grain at silos located between Gunnedah and

Moree. The incident resulted in damage to 845 metres

of track, and varying degrees of damage to 16 grain

wagons. Fortunately no-one was injured.

In its investigation of the incident, OTSI found that the train was being operated at a speed

permitted for its type and for the track speed limit in force at the time. The drivers were not

aware of any problems with the track, and there were no visible signs of

track misalignment as they approached the derailment point.

The drivers were sensitive to the effect of high temperatures on safe

operating speed and, due to the hot conditions, had enquired whether a

temporary speed restriction, known as a WOLO, had been implemented

for the sections they were to enter. As the temperature was

approximately 1°C below that at which a WOLO restriction would have been imposed, no

such restriction was in place. OTSI investigators found that the track had misaligned due to

stresses caused by the elevated temperature and the movement of the train, as the train

passed over an unstable section of curved track.



Occurrence details





Technical failure Findings Failed component Failure

mechanism

Failure origin

The derailment occurred because the track on which the

train was operating misaligned beneath the train.


Local Condition/Organisational factor Findings Local


onal factor


The condition of the track was such that it was unable to resist

the combination of thermal stresses due to the heat of the

day, and the dynamic loading due to the passage of the train.

Physical environment Temperature/

humidity

Infrastructure

construction and

maintenance

Had the track been in sound condition, it would have been

capable of maintaining its alignment as the train passed.

However, its ability to do so was compromised by poor

sleeper distribution and alignment, and ineffective rail

fastening.

Knowledge, skills

and experience

Normal

operations

knowledge and

skills

Infrastructure

construction and

maintenance

Although the track had been subject to all inspections required

by ARTC’s maintenance standards in the year prior to the

derailment and the specified maintenance and monitoring was

being performed, the track was found to have the following

faults: the distribution of timber and steel sleepers was

irregular, sleeper spacing was uneven with frequent examples

of skewed sleepers, many dog spikes were ineffective, there

were examples of out-of-place and missing anchors, and

there were a number of Category 3 rail twists and rails out of

level.

Knowledge, skills

and experience

Normal

operations

knowledge and

skills

Infrastructure

construction and

maintenance

Despite the fact that ARTC specifically states that the ability of

a train to operate at the posted speed over a track with

Category 3 exceedents depends on the condition of the , thus

transferring the decision on safe operating speed to the train

operator, the operator is not informed of the existence of

these faults.

Organisational

management

Communication

and consultation

process

Infrastructure

construction and

maintenance

Had the air temperature been one degree Celsius higher, a

WOLO would have been declared and the train would have

been limited to a speed of 50km/h rather than the posted

speed of 75km/h. It is inappropriate that no speed restriction

at all was deemed to be necessary.

Procedures Absent

procedures

Infrastructure

construction and

maintenance

On the evidence of this derailment and others that have

occurred under similar conditions, ARTC’s track inspection

and maintenance strategies are not fully effective in

preventing track misalignments and derailments during

periods of high temperature.

Organisational

management

Monitoring,

review &

validation

Infrastructure

construction and

maintenance



21. Singleton – Track worker fatalities – 16 July 2007

At approximately 5:48am a signal electrician and his assistant were struck and fatally injured

by Pacific National’s coal service HV161 at No.56A points approximately 445m South of

Singleton railway station. The two rail maintenance workers had been called-out to attend to

the points which had malfunctioned earlier in the morning.

OTSI’s analysis of recorded conversations between the

Electrician and the Network Controller in charge of train

movements through Singleton, together with signal

records, revealed that the two rail maintenance

workers were working under a method of worksite

protection known as NAR (No Authority Required).

Under this arrangement, one of them was required to

keep a lookout for approaching trains at all times.

At 5:44:09am, the Driver of Pacific National’s South-bound coal service HV388 observed

two workers on an adjacent line near the No.56 points and sounded the horn to alert them to

his train’s presence. The Driver indicated that he was

slowing his train at the time, in anticipation of having to

stop at a signal ahead, and that one of the two workers

acknowledged HV388’s presence. At 5:46:22am, the

Driver of PN’s Northbound coal service HV161

extinguished his train’s headlight after seeing HV388

ahead, as he was obliged to do under ARTC’s Network

Rules. HV388 continued to slow but the signal indications ahead of HV161 were such that its

Driver was able to continue to operate his train at its maximum permitted speed of 80km/h

and at 5:47:22am the two trains commenced to pass each other. Approximately 39 seconds

later, and while the two trains were still in the process of passing each other, the Driver of

HV161 was confronted with what appeared to be two workers in the danger zone

immediately in front of his train. In what he described as being an instant later, HV161 struck

and fatally injured the two rail maintenance workers.



Occurrence details

Event description: Two rail maintenance workers were struck by a freight train and killed.





Individual actions


The two rail maintenance workers were working under a

method of worksite protection known as NAR and this

required that one of them kept a lookout at all times. In the

instant before HV161 struck the two rail maintenance

workers, the Driver saw one of them crouching or kneeling

at the No.56A points while the other was standing with his

back towards the train and appeared to be pointing a torch

onto the track. Since neither of the workers was keeping a

lookout at this time, neither of them saw the approaching

HV161 and did not appreciate the need to move to a safe

place.

Infrastructure

maintainer

Monitoring and

checking

Error


Findings Local

Condition/Organi

sational factor


The NAR method of worksite protection employed does

not oblige those who employ it to communicate their

intentions to others. In this instance, the Electrician did

advise the Network Controller of his intentions but the

Network Controller was not obliged to, and did not, inform

the Drivers of HV161 and HV388 that there were

maintenance workers on the track near Singleton station.

While the Driver of HV388 ultimately saw the two

maintenance workers, the Driver of HV161 had no

forewarning of their presence and by the time he saw

them, he did not have time to warn them of his train’s

presence.


adequacy

Infrastructure

construction and

maintenance

Visual and audible cues that might have alerted the two

workers to HV161’s approach were diminished because

HV161 was operating with its headlight extinguished and

the noise generated by the passing of HV388 on an

adjacent line masked the sound of HV161’s approach.

Physical

environment

Lighting/visibility Infrastructure

construction and

maintenance Physical

environment

Noise

The two rail maintenance workers had worked within the

danger zone at night on many occasions and the

Electrician was very familiar with the location in which he

and his colleague were working. It is possible that these

high levels of familiarity lessened the workers’ appreciation

of the risks associated with their task.

Task demands Other- familiarity Infrastructure

construction and

maintenance



The Electrician was rostered on-call to respond to events

in Whittingham-Muswellbrook-Dartbrook-Gulgong area on

the morning of 16 July 2007. However, the Electrician’s

Assistant was not on-call and would therefore not have

anticipated being called-out in the early hours of the

morning. In addition, both workers had worked seven shifts

over the preceding seven days. It is therefore probable that

both workers were suffering from a degree of fatigue and

that this may also have affected their appreciation of the

risks associated with their task.

Personal factors Fatigue/alertness Infrastructure

construction and

maintenance

ARTC Network Rule ANWT 300 (Planning Work in the Rail

Corridor) specifies that all work within the rail corridor must

be preceded by a safety assessment by a qualified

Protection Officer and that the protection arrangements

that are to be in force while the work is undertaken must be

recorded. Both of the rail maintenance workers were

qualified Protection Officers but it is clear from recorded

conversations that the Electrician was acting in this

capacity at the time of the accident. However, OTSI could

not find any record of the protection arrangements and

therefore had no way of determining whether the work was

preceded by a safety assessment.

Procedures Absent

procedures

Infrastructure

construction and

maintenance

ARTC’s Network Rule ANGE 204 (Network

Communications), and a related Network Procedure,

ANPR 721 (Spoken and Written Communication), requires

a structured approach to the transmission and receipt of

information and obliges those who are communicating to

reach a complete and shared understanding of those

matters under discussion. The Network Controller and the

Electrician conversed on three occasions during the

morning of 16 July 2007 but their communication did not

conform to ARTC’s requirements. While their manner of

communication did not contribute directly to the

circumstances that led to the accident, had the Electrician

and the Network Controller observed the required

communication protocols and communicated in a more

structured way, aspects such as the proximity of HV161

and HV388 and the instructions to clear signals would

have to have been repeated by the Electrician and

Network Controller respectively and greater significance

might have been attached to both of these elements of

safety critical information.

Knowledge,

skills and

experience

Communication

skills

Infrastructure

construction and

maintenance



22. Breeza – Derailment – 8 January 2008

At approximately 4:33pm Pacific National Limited coal service BO552 derailed in the vicinity

of Breeza approximately 16km North West of Werris Creek in NSW. BO552 consisted of two

locomotives and 42 loaded coal wagons. The train was a regular coal service which had

been loaded earlier that day at Boggabri and was en route to Port Waratah. The train crew

reported that 19 wagons had derailed, commencing at the 10th wagon in the consist and

leaving the remaining 14 on the track. The crew were uninjured and able to inform and

update response teams of the situation.

The derailment coincided with a number of track

misalignments which were occurring around the same

time in other sections of the line. Just minutes prior to

the derailment the driver of a passenger train reported

the effects of several minor misalignments some 25km

and 36km along the track to the North West. The

derailment of BO552 was determined to be a

consequence of a misalignment caused by the effect of hot weather on a poorly maintained

section of track. The weather conditions on the day were described by the crew as very hot,

with the nearest monitoring stations at Tamworth and Gunnedah recording temperatures of

between 36°C and 37°C.

A partial re-sleepering program was completed in the previous September but a number of

anchors were not refitted to timber sleepers. A rail adjustment was completed five and a half

weeks prior to the derailment in response to an analysis

which showed considerable stability loss in the vicinity

through creep. The extent of the compensating

adjustment appears to have been much less than

indicated as necessary by creep measurements. Thus,

the heat related stresses on the day of the derailment

were in addition to residual stresses, due to insufficient

rail adjustment, which were inadequately restrained due to ineffective track stability.

In late 2008, the entire track between Gunnedah and Werris Creek was re-sleepered with

concrete sleepers, which upon follow-up inspection in January 2009 appeared to have

remedied the problems which were present in the section at the time of the derailment.



Occurrence details





Technical failure


mechanism

Failure origin

The derailment was caused by a misalignment in the track

as it was traversed by the train. The misalignment was due

to the inability of the track infrastructure to constrain the

compressive stresses in the rails resulting from long term

uncontrolled rail creep.



Findings Local


onal factor


The rail was not adequately constrained against the

forces on it due to ineffective anchoring. Replacement of

anchors following track work several months prior to the

derailment was not completed.

Organisational

management

Monitoring,

review &

validation

Infrastructure

construction and

maintenance

Rail adjustment to address identified excessive rail

creep carried out five and a half weeks prior was

unsatisfactory in that less than a third of the excess steel

determined by measurement as part of a WTSA was

removed from a point within 80m of the site of the

derailment.

Organisational

management

Monitoring,

review &

validation

Infrastructure

construction and

maintenance

The additional compressive stresses on the rails due to

hot conditions could not be constrained due to the

inadequacy of the anchoring of the track.

Equipment, plant and

infrastructure


construction and

maintenance

Network Control was alerted to track buckles in the

vicinity by an earlier passenger service and, although it

was only minutes prior to the derailment, there is no

evidence that a warning had been or was about to be

broadcast to other rail traffic.

Knowledge, skills

and experience

Communication

skills

Infrastructure

construction and

maintenance

The maintenance regime in place for the detection and

rectification of substandard track conditions allowed for

the poor condition of the track to exist despite regular

inspections.

Organisational

management

Monitoring,

review &

validation

Infrastructure

construction and

maintenance



23. Homebush – SPAD and Derailment – 7 January 2009

At 4:43pm at Homebush, a CityRail eight-car Tangara passenger service passed Signal

ST265L at stop without authority (SPAD) and derailed on the catch-points. No injuries

resulted directly from the derailment or subsequent detrainment of passengers. A minor

injury was reported by a young man using crutches who sustained a suspected sprained

wrist while climbing the stairs to exit the platform adjacent to the derailed train.

The CityRail train, designated as 37-K, consisted of an

eight-car Tangara Electric Multiple Unit train and was

carrying an unknown number of passengers. It was

proceeding Westbound at Homebush Station where it

was scheduled to stop. As the Driver was travelling

alongside Homebush Platform he misinterpreted which

signal applied to his line and accelerated with the

intention of proceeding through to the next station.

As the train passed the end of the platform its brakes were activated by the train stop. To

prevent the train from continuing onto the adjacent line and potentially colliding with another

train, a set of catch-points were positioned to derail the

train into a safe area. As a result of the catch-points

performing their intended function, the leading car of 37-K

derailed all wheels and the leading bogie of the second

car also derailed, while the remaining six cars remained

on the track. 37-K came to a stand 41 metres past the

catch-points with the leading three cars and part of the fourth car beyond the platform and

the remaining four cars adjacent to the platform.

The investigation found that the SPAD and subsequent derailment was a consequence of an

error by the Driver who misinterpreted which signal applied to his line. The Driver was

relatively inexperienced and it is probable that his driving and situational awareness were

adversely affected by fatigue brought on by insufficient quality rest and sleep. It was also

found that the position of the two signals, ST265L and S261S, increased the probability of a

driver misinterpreting which signal applied to the line.



Occurrence details

Event description: A passenger train passed a signal at stop and derailed on the catch-points.




Individual actions


type

The derailment was the result of the standard operation

of catch-points in response to Signal ST265L being

passed at danger by service 37-K. The driver of 37-K

responded in error to Signal ST261S on an adjacent line

which displayed a proceed indication instead of Signal

ST265L which governed his line and was at stop.

Train Crew Monitoring and

checking

Error


Findings Local


onal factor

Keywords Functional

area

The Driver was relatively inexperienced which may have

led to a misinterpretation of which signal applied to his

track.

Knowledge, skills

and experience


operations

It is likely that the Driver was not sufficiently rested to

enable him to effectively perform his duties.

Personal factors Fatigue/alertness On-train

operations

Signal ST265L is sited in a manner and location that

meets the required technical parameters. Yet the

position of the two signals, ST265L and ST261S,

increased the probability of a driver misinterpreting

which signal applied to which line.


infrastructure

Infrastructure

design

Infrastructure

construction

and

maintenance

The train stop and catch-points associated with Signal

ST 265L operated correctly but their location in the track

layout still resulted in the derailed 37-K stopping foul of

the Down Suburban line.


infrastructure

Infrastructure

design

Infrastructure

construction

and

maintenance



24. Unanderra – SPAD and Derailment – 24 January 2009

At approximately 2:35am CityRail four-car Tangara passenger service K496 departed from

Unanderra Station towards Signal WG1010 which was at stop. A loud noise from a

passenger disturbance in the vestibule behind the Driver momentarily distracted him and, as

a result, he allowed the train to pass Signal WG1010 at stop without authority (SPAD).

The train then encountered the two safety defences

associated with Signal WG 1010. The first, a train stop,

automatically triggered the application of the train’s

emergency brakes as it passed the signal thus

reducing its speed and so mitigating the consequences

of the SPAD. The second defence, catch-points,

derailed the train into a safe area away from the

adjacent line and so a potential collision with an opposing freight service, which was

approaching on the Down Illawarra line, was prevented. The leading two cars of K496

derailed all wheels and the leading bogie of the third car also derailed, while the remaining

car remained on the track.

No injuries were sustained by the crew or passengers. The damage caused by the

derailment was limited to the bogies and bodywork of the two front passenger cars and to

the infrastructure associated with the catch-points.

The investigation found that the SPAD and

subsequent derailment was a consequence of the

Driver’s inattentiveness resulting in his not responding

to the stop signal which applied to his line. The

Driver’s error can be attributed to one or, most likely,

a combination of the following: the distraction of the passenger disturbance behind him, a

loss of situational awareness due to fatigue brought on by insufficient quality rest and sleep,

and the Guard not working from his assigned position. This was the fifth recorded SPAD at

Unanderra since 2003. A SPAD in 2003 was investigated by OTSI resulting in a

recommendation that a human factors review be undertaken in relation to signals and the

predictive information they convey. The recommendation was subsequently not

implemented.



Occurrence details

Event description: A passenger train passed a signal at stop and derailed on the catch-points.




Individual actions


type

Service K496 passed Signal WG1010 when it was

showing a stop indication (SPAD). It then derailed on the

catch-points which were set open in accordance with the

Signal’s stop indication. The SPAD of Signal WG1010 was

the consequence of human error on the part of the train

Driver.

Train Crew Monitoring and

checking

Error


Findings Local


onal factor

Keywords Functional

area

Contrary to procedural requirements, but on the grounds of

feeling stressed and unwell, the Guard was riding in the

driver’s cab with the Driver’s approval. This meant that he

took his cue to proceed from Signal WG1016, the next

signal in advance from the platform, instead of the Guard’s

Indicator which was linked to Signal WG1010.

Personal factors Stress/anxiety On-train

operations

Although the Driver of K496 was qualified for the route, it

was likely that he was subconsciously expecting the route

beyond the Unanderra platform to be set for the train to

continue past Signal WG1010 as it had been in his

experience on all previous occasions. He departed the

platform on the Guard’s bell indication, passed Signal

WG1016, but then did not respond to Signal WG1010,

which was at stop, until the associated train stop had

triggered the application of the train’s emergency brakes.

Personal factors Preoccupation On-train

operations

Signal WG1010 may also have been obscured for part of

the time due to the position of the driver’s blind and

trackside infrastructure.

Equipment, plant

and infrastructure

Infrastructure

design

On-train

operations

It is likely that fatigue played a part in the Driver losing

concentration and situational awareness. He was not

sufficiently rested to enable him to effectively perform his

duties due to a lack of quality sleep, lingering effects of the

flu and sub-optimal sleep environment because of hot

weather.

Personal factors Fatigue/alertness On-train

operations

Immediately prior to the derailment he had allowed himself

to be distracted by a noisy passenger disturbance behind

his cab. The Guard was likewise distracted.

Task demands Distractions On-train

operations



Neither the Guard nor Driver are recorded as having

received formal instruction related to self-assessing fitness

for work in their induction training but they would have at

least undergone awareness sessions subsequently.

However, the current RailCorp training information and

Fatigue Management Policy contain little detail on how to

optimise the sleep environment or how to objectively

assess one’s own fitness for duty.

Training and

assessment

Ongoing training On-train

operations

This is the fifth recorded SPAD at Unanderra since 2003.

The 2003 SPAD was investigated by OTSI resulting in a

recommendation that a human factors review be

undertaken in relation to signals and the predictive

information they convey. The recommendation was

subsequently not implemented. In February 2009, in

response to the incident subject of this investigation, a

“Human Factors SPAD Hazard Checklist” was used to

conduct a sighting test for Signal WG1010 which revealed

five infrastructure issues that could have an impact on

driver performance.

Organisational

management

Risk/change

management

On-train

operations



25. Peak Hill – Derailment – 8 February 2009

At approximately 5:23pm El Zorro grain service 8996 derailed nine grain wagons

approximately 7km North of Peak Hill in the Western region of NSW. The train consisted of

four locomotives and 38 loaded grain wagons. The train was en route from Nyngan to Port

Kembla at the time of the derailment. There were no injuries to the crew but there was

extensive damage to 370m of track infrastructure and the nine wagons.

The investigation determined that the derailment was

caused by the train travelling at excessive speed. At

the point of derailment, the train was travelling at

63km/h through an area on which a 40km/h speed limit

had been imposed. The speed restriction had been

imposed due to the condition of the track and had been

appropriately promulgated. However, the relevant

documentation applicable to the locations of all speed restrictions had been left in the last

trailing locomotive of the consist following a prior run-around movement at Narromine.

Initially the Driver had slowed to 23km/h for the speed restriction, but then prematurely

accelerated believing he had cleared the restricted section and that the clearance sign,

which would signify the end of the restriction, was

missing. The Driver allowed the train to exceed the

speed restriction for some 8.5km up to the point of

derailment. The speedometer on the locomotive was

not working and the driver had been relying on his

experience to judge the speed of the train. The Co-

Driver was not in a position to undertake his normal

duties to assist the Driver as he had been indisposed due to illness throughout the journey.

There was a slight misalignment near the derailment site. But, more significantly, the train

had just traversed a small wooden underbridge where the train was felt to sway to one side.

This was found to be due to gaps between the bridge girders and their supports.

At the time of the derailment, a program of upgrading the section of track was underway

involving re-sleepering and ballast renewal. This program had been in progress at various

locations in the area where the derailment occurred for the past two years. Nevertheless,

there was an inherent weakness in the structural integrity and rigidity of the track where the

derailment occurred.



Occurrence details





Technical failure


mechanism

Failure origin

The track could not constrain the forces on it at the point of

derailment as it was in a less than optimum condition.

Infrastructure -

Track


Individual actions Findings Person type Activity type Error/Violation

type

The derailment of nine wagons of grain service 8996 at

Kilometrage 505.400 was caused by excessive speed in

that the train was travelling at 23km/h above the speed

assessed as safe for the condition of the track in that

section.

Train Crew Operating

equipment

Error

The overloading of wagons by up to 9.15% placed

additional stress on the track.

Terminal staff Monitoring and

checking

Unknown


Findings Local

Condition/Organis

ational factor


Although correctly promulgated and signposted speed

restrictions were in place, the driver increased speed some

13km before the end of a speed limited section, believing

the Clearance Sign to be missing.


attitude

On-train

operations

On departing Narromine, the driver relied on his

experience to estimate the speed of the train because the

speedometer of locomotive EL54 was not working.

Continuing to operate the train without the benefit of a

speedometer was contrary to Network Rule ANTR 410

which required him to re-marshal at the “first suitable

location” of which there were three between Narromine

and the derailment site.

Equipment, plant

and infrastructure

Functionality On-train

operations

The driver did not utilise the digital speedometer in the

diagnostic information display panel at the rear of the cabin

to check the train’s speed.


attitude

On-train

operations

During the “run-around” manoeuvre at Narromine, the

speed restriction notice applicable at the time, and issued

to the train, was not transferred to EL54 by the co-driver

when the lead locomotives changed over.

Knowledge, skills

and experience

Teamwork skills On-train

operations



The co-driver was incapacitated through illness and unable

to perform his duties in relation to maintaining a lookout

and relaying trackside infrastructure information to the

driver.

Personal factors Health-related

condition

On-train

operations

The track could not constrain the forces due to: deflection

in a wooden underbridge which allowed excessive vertical

movement causing the train to sway when passing over it;

a slight misalignment at the point of derailment;

weaknesses in the track anchorage because of loose

fastenings; poor ballast condition, and inadequate tamping

associated with an incomplete steel sleeper replacement

program.

Organisational

management

Contractor/

interface

management

Infrastructure

construction and

maintenance

To a lesser extent the effects of very hot weather over a

protracted period placed additional stress on the track.

Physical

environment

Temperature/

Humidity

Infrastructure

construction and

maintenance



26. Goobang – SPAD and collision – 10 May 2009

On the morning of Sunday 10 May 2009, Track Australia was transferring two track

machines from Dubbo to Cootamundra via Parkes on behalf of the Australian Rail Track

Corporation (ARTC). The machines were operating in convoy with a ballast regulator leading

and a tamping machine following. Both track machines were crewed by personnel from

Track Australia and the convoy was running as train number 8M71.

At approximately 10:00am the ballast regulator closed

on signal GJ144 on the approach to Goobang Junction

near Parkes. Signal GJ144 was displaying a stop

indication. While trying to stop his machine at the

signal, the ballast regulator operator checked through

the rear window of the machine and assessed that the

trailing tamping machine was not going to stop in time

to avoid a collision. He then made the decision to speed up and pass the signal at stop

(SPAD). However, the tamping machine collided with the ballast regulator approximately

20m prior to the signal. The tamping machine stopped short of the signal but the ballast

regulator came to a stand approximately 60m beyond the signal. No crew members were

injured and both machines suffered only superficial damage.

The investigation revealed that the collective knowledge and experience of the crew

members on the route being travelled was confined to that gained travelling in the opposite

direction as passengers on the machines a week earlier.

This lack of route knowledge was determined to be a

major contributing factor to the incident. The ballast

regulator operator was relying on location signs as his

primary navigational aid. Despite being qualified in signal

recognition, he did not respond to a landmark sign 869m

prior to the signal, and did not react to the signal until he was approximately 40m from it

although its presence was clearly visible for well in excess of that distance

Since there were no voice recorders on the track machines, there remains uncertainty as to

why a radio warning about signal GJ144, claimed to have been sent by the ballast regulator

operator, was not received by the tamping machine crew.



Occurrence details

Event description: Two track machines collided with each other.




Between trains

Individual actions


type

The operator of the lead track machine of 8M71 made a

conscious decision to pass signal GJ144 when it was at

stop. He did so in the belief that this would serve to avoid a

rear-end collision involving his ballast regulator and the

following tamping machine. However, the separation

between the machines was not sufficient to avoid a minor

collision as the ballast regulator accelerated away.

Train Crew Operating

equipment

Error


Findings Local


al factor


The route knowledge of the crew members was limited to

travelling the route in the opposite direction as passengers

on the machines a week earlier. Not having a pilot driver or

being in possession of any documentation that would

assist their navigation, they relied on location signs. The

crews did not respond to a landmark sign well in advance

of the signal though it should have triggered the same

response as a location sign.

Knowledge, skills

and experience


operations

The ballast regulator operator’s signal recognition skills

were inadequate for the task on which he was required to

exercise them.

Knowledge, skills

and experience

Normal

operations

knowledge and

skills

On-train

operations

The PO was distracted at the time of passing the landmark

sign, the significance of which he would have been

expected to recognise.


operations

The Pre-Work Brief form which recorded the hazards and

safety controls, did not address any specific risks

associated with travelling in convoy or through relatively

unknown territory.

Procedures Accuracy/clarity On-train

operations

The tamping machine crew denied receiving a warning via

radio claimed to have been sent by the ballast regulator

operator when he realised he was about to SPAD. It is also

noted that non-discreet UHF radio channels were relied

upon for communications between machines despite GRN

radios being available.

Equipment, plant

and infrastructure


operations

The separation between the machines was less than that

required to be safe at the speed at which the tamping

machine was travelling.

Knowledge, skills

and experience

Normal

operations

knowledge and

skills

On-train

operations



27. Temora – Runaway wagon – 28 July 2009

At approximately 3:05am empty grain wagon CQGY 540S, owned by Chicago Freight Car

Leasing Australia (CFCLA) and leased by El Zorro Transport (EZT), ran away from the

Temora Wheat Sub-Terminal during a shunting operation to detach it from a train. The

wagon was being detached for stowage and subsequent transfer to Junee for scheduled

maintenance requirements and because of defects identified during a previous safety

inspection.

The wagon ran for a total of 7.8 kilometres before

coming to a stand near the locality of Sproules Lagoon.

During this time, it demolished a temporary buffer stop,

struck an uncommissioned derailer and damaged a set

of points, all of which were associated with an

Australian Rail Track Corporation (ARTC) track

infrastructure rationalisation program. The wagon

traversed seven level crossings on the main line recording an average speed of 44.5km/h

between the active level crossings at Junee Road and Victoria Street in Temora.

Fortunately, there were no persons injured or vehicles struck during the runaway.

The investigation found that, while the crew followed correct procedure when detaching the

wagon, it ran away because the handbrake was not fully applied due to the brake chain

becoming jammed behind the guide bracket of the gear

assembly. The chain jammed because of the ineffective design

of the guide bracket installed to cater for the horizontal mounting

of the AAR IP93-type geared handbrake wheel assembly.

Despite the damage from chains jamming being regularly

repaired by maintainers, the problem was not communicated to

the wagon owner or operators. There was also excessive travel

within the handbrake system attributable to lack of adjustment during maintenance.

The only defence in place against a runaway on to the main line was a temporary buffer stop

which proved to be insufficiently robust to stop the wagon. It was constructed using a light

duty standard in the absence of any available heavy duty standard that would have been

appropriate to the situation at Temora.



Occurrence details

Event description: Freight wagon runaway.



Occurrence Classification Runaway

Technical failure


mechanism

Failure origin

The wagon ran away because the handbrake was not fully

applied due to the chain becoming jammed behind the

guide bracket of the gear assembly.

Rolling stock – Braking

system

Mechanical

discontinuity

Design


Findings Local


al factor

Keywords Functional

area

The poor design of the guide bracket installed to cater for

the horizontal mounting of the AAR IP93-type geared

handbrake wheel assembly permitted the chain to become

jammed in the gear drive mechanism. This meant the

handbrake was not fully applied when the wagon was

detached even though it appeared to be.


infrastructure

Functionality Off-train

operations

There was excessive travel within the handbrake system

caused by the lack of adjustment during maintenance.

Knowledge, skills and

experience

Normal

operations

knowledge and

skills

Off-train

operations

The temporary buffer stop fitted at 486.950kms was

insufficiently robust to stop the runaway wagon. The buffer

stop was installed using ARTC’s Engineering Standard

TDS 16 even though this is only meant to serve “light duty”

applications. Additionally, the clamping arrangement used

was not in accordance with TDS 16, thereby further

weakening the structure.


infrastructure


construction

and

maintenance

No additional defences, such as a portable derailer, were

placed on the line to mitigate against runaway rail vehicles

and protect the integrity of the network once the No. 1

Siding was connected to the main line.


infrastructure

Absent

equipment,

plant and

infrastructure

Infrastructure

construction

and

maintenance



28. Glenlee – Safeworking breach – 28 October 2009

At 1:44pm Pacific National (PN) freight train 3BM4 almost struck the Co-driver of another PN

freight train, 2XW4, who was returning to his locomotive after conducting an axle bearing

inspection. The Co-driver believed there would be no trains running on the adjacent ‘Down

Main’ line after communicating with a Network Controller at the Network Control Centre

South at Junee (NCCS).

The Network Controller had earlier made a request to

the Co-driver of 2XW4 that the train be stopped so an

inspection could be carried out on one of the train’s

axle bearings in response to a hot box detector alert

received at NCCS. From the brief communication with

the Network Controller, the Co-driver thought that both

the Up Main line and the Down Main line had blocking

facilities applied. However, he did not confirm that the Down Main line was safe to access

before conducting the on-track inspection as required under Network Rules.

Having found nothing wrong from the inspection, the Co-driver was returning to his

locomotive along the ‘Down Main’ line when he received a radio call from the Driver warning

of an approaching train. At the same time, the Co-driver

sensed the approaching train from “humming” on the track

and moved quickly to a safe place between the ‘Up Main’

and ‘Down Main’ line.

The incident occurred at the operational interface between Australian Rail Track Corporation

(ARTC) and RailCorp territory. At the location 2XW4 came to a stand, the signals to the rear

on the Up Main line are controlled by ARTC and the signals on the adjacent Down Main line

are operated by RailCorp under ARTC’s control. The Network Controller was a trainee

undertaking on-job training. This was the first occasion on which he had had to request a

train driver stop and undertake an axle bearing inspection in response to a hot box detector

alert. Procedures to deal with hot box detector alerts were not covered in his off-job training

and, at the critical time, his supervising Network Controller was distracted by a personal

telephone call. Additionally, there were no specific procedures for the application of blocking

facilities at operational interfaces.



Occurrence details

Event description: Safeworking breach lead to near miss of a person conducting a track inspection.

Type of operation: Off-train operations


Occurrence Classification Safeworking breach Other procedure/rule breach

Individual actions


type

The reason 3BM4 entered the section and almost struck the

Co-driver of 2XW4 was that no blocking facility was

requested to be placed on the Down Main line to prevent a

train from entering into that section.

Train Crew Communicating Error

Network

controller

Communicating Error


Findings Local

Condition/Organi

sational factor


Contrary to Network Rules, the Co-driver of 2XW4 did not

confirm that the Down Main line was safe to access, either

by calling the Campbelltown Signal Box or confirming the

protection arrangements with the Network Controller at

Junee before he exited the train. The Co-driver made the

assumption that the protection arrangements put in place

provided protection from traffic in both directions.

Knowledge, skills

and experience


operations

The Network Controller was a trainee undertaking on-job

training under supervision. This was the first occasion on

which he had had to request a train driver to stop and

undertake an axle bearing inspection in response to a hot

box detector alert.

Procedures to deal with hot box detector alerts were not

covered in his off-job training. Additionally, he was not

familiar with the area around the operational interface.

Knowledge, skills

and experience


operations

Training and

assessment

Initial training Off-train

operations

The supervising Network Controller was distracted by an

incoming personal telephone call at this operationally critical

time so, in effect, the trainee was acting unsupervised.

Task demands Distractions Off-train

operations

The communication between the Network Controller and the

Co-driver was poor. It was brief and lacking detail, in

particular, there was no feedback or clarification about the

protection arrangements which needed to be applied to the

‘Down Main’ line if the axle bearing inspection was to take

place.

Knowledge, skills

and experience

Communications

skills

Off-train

operations

The workload of both the trainee and supervising Network

Controllers was high prior to and at the time of the incident.

They had worked continuously since beginning their shift at

7:00am and had received a high number of calls mainly

associated with train delay problems throughout the

morning. Neither had any scheduled rest or meal breaks

during the shift and there were no allocated personnel in the

Control Centre to act as reliefs for meal breaks or in the

case of a need to take unscheduled breaks.

Task demands High workload Off-train

operations



29. Darling Park – Monorail collision – 27 February 2010

At about 4:00pm a Veolia Transport Sydney Metro monorail (Monorail 1) carrying 15

passengers collided with the rear of a stationary monorail (Monorail 4) at Darling Park

Station, Darling Harbour, Sydney. Monorail 4 had 45 passengers on board and was

experiencing door problems which caused it to stand at the Darling Park Station for longer

than normal. It had just completed loading passengers and the doors on five carriages were

still in the open position when it was hit from behind by Monorail 1 which at the time of

impact was estimated to be travelling at 6m/s (22km/h). Four passengers from Monorail 1

sustained minor injuries and three were transported to hospital for treatment. No one on

Monorail 4 was injured.

Each monorail was fitted with an Anti-Collision

Emergency Stop (ACES) system which was interfaced

to the main Programmable Logic Controller (PLC). This

control system acted as a backup when the monorail

was being operated in manual mode. An alarm was

activated inside the driver’s cab when it detected

another monorail 150m ahead and a different alarm

and the emergency brakes were activated when the separation closed to 100m. On this

occasion the alarms and emergency brakes activated correctly but did not stop the monorail

before it struck the stationary monorail in Darling Park Station.

The investigation established that Monorail 1 was travelling above the speed profile as it

approached the station and that the Driver did not react quickly enough to brake the

monorail when the first of two alarms sounded, warning

him of the presence of another monorail 150m ahead.

The Driver had about five seconds after the first alarm

sounded during which time he should have applied the

brakes before the emergency brakes activated. In this five

second interval, the Driver received a two-way radio call

from Train Control warning him of the stationary monorail ahead. It is likely that this call

distracted him sufficiently to degrade his braking reaction time. The speed profile for the

section of track where the alarm activated was 8.5m/s and testing showed that the most

likely scenario was that Monorail 1 was travelling at around 9.5m/s in that section.



Occurrence details

Event description: Collision by one monorail train into the rear of a stationary monorail train

Type of operation: On-train operations


Occurrence Classification Collision Running line

Between trains

Individual actions


type

The investigation established that Monorail 1 was travelling

above the speed profile at the time of the collision and that

the Driver did not react quickly enough to brake the

monorail when the first of two alarms sounded, warning

him of the presence of another monorail 150m ahead.

Train Crew

Monitoring and

Checking

Error

Technical failure


mechanism

Failure origin

The Anti-Collision Emergency Stop (ACES) system on

Monorail 1 should have prevented the collision but it did

not do so. While the ACES system activated the

emergency brakes, they did not stop the monorail before it

entered Darling Park Station because the design of the

braking system and the ACES distance settings made no

allowance for monorails being driven above the speed

profile of 8.5m/s.

Rolling stock-

Train Detection

System

Software/

firmware

anomaly

Design


Findings Local

Condition/Organis

ational factor


The Driver of Monorail 1 was likely to have been distracted

at a critical time on approach to Darling Park Station by

one or more events, including a conversation with the

Relief Driver at the time the first proximity alarm activated,

and by a radio call from the Controller before the second

proximity alarm.


operations

The view to Darling Park Station was obscured by tree

foliage which prevented the driver from having a clear view

to the station entrance, and the stationary Monorail 4

therein, until he was 40m from it.

Physical

environment

Lighting/

visibility

On-train

operations

The design of the braking system and the ACES distance

settings made no allowance for monorails being driven

above the speed profile of 8.5m/s.

Equipment, plant

and infrastructure


operations



30. Whittingham – Derailment – 13 March 2010

At approximately 9:48am Pacific National empty grain service 2531, travelling from Berrima

Junction to Werris Creek, derailed as it traversed No.203 points at Whittingham, near

Singleton in the Hunter Valley Region of NSW. At the time, an altered method of

Safeworking was being used to control train movements through Whittingham because of

civil and signal renewal works associated with the Maitland to Whittingham Third Track

Project. This method, CAN Block Working, required the points at Whittingham to be operated

manually.

The events leading to the derailment commenced at

8:10am when a team, consisting of a daywork

supervisor and two qualified workers, was directed by

Network Control to manually set 203 points in the

normal position for a proposed main line train

movement. The turnout was made up of three

elements: facing points, a swingnose and a catch point.

When setting 203 points, the qualified workers did not start from the furthermost end as

required by ARTC Network Procedure ANPR 743 Manually Operating Handthrow Electric

Points. This resulted in the swingnose being left set in the reverse position. Further, despite

it being a requirement in the procedure, the qualified workers did not check the route after

setting the points despite having sufficient time to do so. Consequently, service 2531 struck

the swingnose which had been left set in the wrong position and derailed. It was travelling at

55km/h at the time.

Both locomotives and the eight leading wagons were severely damaged, as well as 110

metres of track including 203 points and various items of signalling equipment.

Approximately 6,000 litres of diesel fuel was also spilt.

The driver received a bruised shoulder and was

transported to Singleton Base Hospital. The assistant

driver attended hospital later as a precautionary measure.

The investigation found that the derailment was the result

of a lack of process and validation by the qualified

workers when setting and clipping the points.



Occurrence details

Event description: A freight train derailed when a set of points were incorrectly set.




Individual actions


type

The derailment of 2531 was a consequence of 203B

swingnose being left set in the reverse position when 203

points were set and clipped for the passage of the train.

This resulted in the wheels on the down rail of the Down

Main line being directed towards the inner (gauge) side of

the up rail of the Up Branch line and off the rail head.

Infrastructure

maintainer

Monitoring and

checking

Error


Findings Local


onal factor


Despite sufficient time being available, neither the qualified

workers nor the Supervisor ensured the route was

correctly set for 2531 after the points were set and clipped,

and before giving an assurance to Network Control to that

effect, in accordance with Network Procedure ANPR 743.

People management Supervision Infrastructure ,

construction and

maintenance

Despite being in possession of competency certification for

Engineering Hand Signallers Level 2, evidence suggests

the qualified workers were not adequately assessed, if at

all, in the competency of manually operating handthrown

electric points before being recertified.

Training and

assessment

Competency

assessment

Infrastructure ,

construction and

maintenance

The risk assessment conducted for the Singleton

Extension Yard Limits and CAN Block Working was

detailed and well documented. However, the controls for

which the Hunter 8 Alliance was responsible were not fully

implemented by its Rail Safety Manager or recorded on the

Worksite Protection Plan and Pre-work Briefing forms by

the Protection Officer. As a result, the supervisors were not

fully informed about the controls that had been determined

as applicable to the assessed risks at their Whittingham

site.

Organisational

management

Information

management

Infrastructure ,

construction and

maintenance

There were no formal or effective contractual

arrangements entered into covering the workers engaged

by the Hunter 8 Alliance to implement the CAN Block

Working, other than a verbal agreement to honour fee for

service invoices.

Organisational

management

Contractor/

interface

management

Infrastructure ,

construction and

maintenance

No adequate verification was made of the competencies or

the currency of the qualifications of engaged workers prior

to their commencing work.

Training and

assessment

Currency

tracking

Infrastructure ,

construction and

maintenance



31. Strathfield – Near strike of maintenance staff – 1 April 2010

Shortly after 5:00am the Driver of N804 CityRail Gosford to Sydney Terminal interurban

service reported to the Area Controller at Strathfield Signal Control Centre that his train had

nearly struck four members of a signal maintenance team working at 538A points on

approach to Platform 1 at Strathfield Station. The Team had been called by the Area

Controller to attend 538A points which had failed.

The Team arrived at the site shortly after 4:50am

where the Protection Officer determined they could

inspect the points using Network Rule NWT 310 No

Authority Required (NAR) as the method of worksite

protection. Although NAR requires at least one

member of the Team to maintain a lookout to warn of

approaching rail traffic, no member of the Team was

formally nominated as the lookout. The task was assumed by a member of the Team who

became the least involved in the maintenance work at the points. NAR does not require any

warning be given to train crews of the presence of rail safety workers on or near the track.

As N804 approached 538A points, the Driver saw the four workers standing in the middle of

the track with their backs to the train. He immediately applied the emergency brake and

sounded the horn. At this point, the train was within 50m

of the points and had decelerated to 39km/h. In response

to the horn blast, the workers moved very quickly in a

disorganised fashion to clear off the track. Expecting it

was likely the train would strike one or more of the

workers, the Driver ducked underneath the dashboard

and waited for the train to come to a stand, which it did at

the points. Here, the Driver recognised the workers as signal maintenance crew and abused

them for their actions. He then reported the incident to the Area Controller at Strathfield.

The near strike was the direct result of the signal maintenance team workers choosing to

remain in the danger zone after the initial warning of the approaching train. Subsequently,

none of them became alert to the presence of the train until its horn was sounded by the

Driver.



Occurrence details

Event description: Near strike of maintenance staff.



Occurrence Classification Safeworking rule or

procedure breach

Track work procedure breach

Individual actions


type

The near strike occurred when the signal maintenance

team, working under the NAR method of worksite

protection, did not clear the danger zone as soon as the

positioned warning light was automatically extinguished by

the approach of train N804. At the time the warning light

extinguished, the train was 29 seconds (at track speed)

from their location.

Infrastructure

maintainer

Monitoring and

checking

Violation


Findings Local

Condition/Organis

ational factor


Despite the warning of the train approaching, the Team

engaged in “at risk behaviour” by remaining on track and

instructing the Lookout to warn them when he saw the

train. Contrary to Network Procedures, the Lookout did not

continue to perform his role and the Team did not clear the

track until the Driver of N804 noticed them and blew his

horn.

Social

environment

Peer pressure Infrastructure ,

construction and

maintenance

The Team was on track approximately 15 minutes after

call-out which indicated that they had insufficient time to

complete a full safety assessment and work plan in

addition to all other necessary preparatory tasks. This is

also indicated by the lack of detail on the Worksite

Protection Plan and Pre-work Briefing forms prepared for

the task. Although other higher and safer forms of worksite

protection or train diversions were available, it appears

NAR was chosen by the Protection Officer as the worksite

protection method as it was the most expedient and least

time consuming method to implement.

Task demands Time pressure Infrastructure ,

construction and

maintenance

Of the methods available, NAR provides the least amount

of protection and relies entirely on the lookout’s vigilance,

notwithstanding the fact that in this case he had the

assistance of the warning light. It is reasonable to expect

that a thorough, conscientious safety assessment at the

site should have led to a decision to implement a higher

form of worksite protection and, importantly, one which

would have provided for separation of trains and workers,

as well as informing train crews of the presence of workers

on and about the track.

Organisational

management

Risk/change

management

Infrastructure ,

construction and

maintenance



Reinstatement of the Protection Officer and Lookout to full

safeworking duties was not in accordance with the

Network Rules and Network Procedures Certification

Standard. The decisions made to reinstate them on the

day of the incident appear to have been based on

operational imperatives rather than safety requirements.

People

management

Job/task design Infrastructure ,

construction and

maintenance

NAR has been the subject of scrutiny over a number of

years but near strikes continue to occur within worksites

using it as the method of protection. The 2005 RailCorp

Worksite Protection Project recommended some changes

to the management and conduct of NAR but not all of its

recommendations have yet been implemented.

Organisational

management

Risk/change

management

Infrastructure ,

construction and

maintenance

There had been serviceability problems with the 538A

points over the 10 months since their replacement but the

routine maintenance system had not provided timely

detection and rectification of these problems. Points failure

attributed to lubrication wash away indicates a possible

underlying problem or combination of problems with the

lubricant being used, its application or the points

themselves.

Equipment, Plant

and infrastructure

Functionality Infrastructure ,

construction and

maintenance

Communications between the Protection Officer and Area

Controller were conversational and informal rather than

operationally formal according to prevailing communication

protocols.

Knowledge skills

and experience

Communication

skills

Infrastructure ,

construction and

maintenance

Management supervision of worksite protection through

on-site monitoring of work-on-track activity and auditing of

worksite planning and briefing documentation does not

appear to be as regular and rigorous as it ought to be.

Such activity is a legislative requirement and the need for it

has been highlighted on several occasions including in

RailCorp’s Worksite Protection Project and by the

Regulator.

Organisational

management

Risk/change

management

Infrastructure ,

construction and

maintenance

The unilateral issue of Standard Operating Instruction’s by

both ARTC and RailCorp to amend the network rules,

procedures and operating instructions associated with

NAR was not in accordance with the provisions of Part 5 of

the Rail Safety (General) Regulation 2008.

Organisational

management

Risk/change

management

Infrastructure ,

construction and

maintenance



32. Woy Woy – Unsecured container gate – 11 April 2010

At approximately 11:45am Pacific National freight service 7MB4 was travelling through Woy

Woy Station when an unsecured gate on container BSCF215 became detached after hitting

the fencing at the Sydney end of Platform 1 and then striking another fence on the end of

Platform 2. The gate skidded across the platform for approximately 20 metres before

smashing a seating bay glass windbreak panel and coming to rest on the platform. The

dislodged gate narrowly missed striking members of the public waiting on the platform but,

despite a number of people being showered with broken glass, only one person suffered

minor injuries.

The investigation found that the second gate (of four)

on the right side of container BSCF215 detached from

the collapsible container as it struck the platform

fencing because its locking pins had dislodged from

their retaining lugs and it was not adequately restrained

from swinging laterally out of gauge. Two transport

agencies were involved in transporting the container

from where it was loaded to the Melbourne Freight Terminal (MFT) where it was transferred

onto a railway wagon. At no stage was it identified that the side gates of the container were

not secured in accordance with the performance standards recommended in the National

Transport Commission’s Load Restraint Guide – Second Edition 2004.

Subsequently, a pre-departure train examination did not detect that the gates on the

container were not secured in accordance with Pacific National’s Freight Loading Manual.

Checking on the integrity of the loading after departure

relied on a series of roll-by inspections which have

inherent limitations on their effectiveness. However, a

swinging gate was detected and rectified as a result of

one of the roll-by inspections en route but further roll-by

inspections did not detect either the loss of two other gates or anomalies with the securing of

the gates until after the incident. Pacific National’s own investigation into the incident

identified the relevant hazards and proposed 16 wide-ranging safety actions to be taken to

prevent the recurrence of similar incidents, and assigned responsibility and time frames for

implementation.



Occurrence details

Event description: An unsecured container gate strikes infrastructure of a train station.



Occurrence Classification Collision Running line

With infrastructure

Technical failure


mechanism

Failure origin

The second gate on the right side of container BSCF 215

detached from the container as it struck platform fencing

on Woy Woy Station because its locking pins had

dislodged from their retaining lugs and it was not

adequately restrained from swinging laterally out of gauge.

Rolling stock – Car

body

Mechanical

discontinuity

Operation


Findings Local


al factor


Between the time of loading of the container in Reppers

Transport yard at Stawell on 26 March and departure of

the train from MFT on 10 April, the loaded container

passed through the hands of several road and rail freight

agencies. At no stage was it identified that the side gates

of the container were not secured in accordance with the

requirements of the Load Restraint Guide and PN’s Freight

Loading Manual.

Knowledge, skills

and experience

Normal

operations

knowledge

and skills


Following clearance by train examiners at MFT, checking

on the integrity of the loading relied on a series of roll-by

inspections which have inherent limitations on their

effectiveness.

Knowledge, skills

and experience

Normal

operations

knowledge

and skills




33. Kogarah – Track worker fatality – 13 April 2010

At approximately 1:08am a CityRail inter-urban passenger service C488, en route from

Kiama to Central Station, struck and fatally injured a track worker at Kogarah Station as he

attempted to get clear of the track by climbing up on to Platform 1. The worker was part of a

team employed by Swetha International Pty Ltd which was contracted by RailCorp to remove

rubbish from tracks. The other four members of the team scattered from the path of the train

and avoided injury.

The Protection Officer for the team obtained approval

to use Controlled Signal Blocking (CSB) as the method

of work site protection at Kogarah. However, a number

of safety critical requirements of Network Rules and

Procedures were omitted in the process of

implementing the CSB. In particular, checks and cross-

checks between the Area Controller and the Protection

Officer were not completed on the two key CSB safety measures, that is, ensuring the

section was clear of all rail traffic and that the required blocking facilities had been applied on

the protecting signal/s. The Area Controller had not applied blocking facilities when he told

the Protection Officer that the blocks were on and the Protection Officer did not seek

confirmation that CSB had been fully implemented before commencing work.

The investigation found that the track worker was struck because the Area Controller did not

identify that the train was already in the section approaching Kogarah and past the

protecting signals before he applied blocking facilities. When the Area

Controller became aware of the situation, he asked the Station’s

Customer Service Attendant to initiate a warning over the Station’s

public address system, rather than using the more expedient means of

the MetroNet Train Radio system to bring trains to an emergency stop.

The Area Controller had only just returned from a lengthy period of

leave, most of which was sick leave. Although he returned to full duties without restrictions,

there was sufficient evidence from the circumstances which had necessitated the sick leave,

together with his previous medical history, to indicate that it would have been prudent to

have required clearance through a triggered health assessment before allowing him to

resume full duties, in accordance with the National Standard for Health Assessment of Rail

Safety Workers.



Occurrence details

Event description: Track worker killed after being struck by passenger train.




With person not on a level crossing

Individual actions


type

The track worker was struck and fatally injured because the

Area Controller did not identify that passenger service C488

had departed Hurstville and was in the section heading

towards Kogarah. When he authorised Controlled Signal

Blocking (CSB) for the protection of the rubbish removal

worksite alongside Platform 1 at Kogarah Station, C488 had

already passed protecting signal SM 914 and the driver had

not been informed of the presence of workers on the track at

Kogarah. In particular, checks and cross-checks were not

completed to ensure the section was clear of rail traffic and

the required blocking facilities had been applied.

Network controller Monitoring and

checking

Error

Instead of using the MetroNet Train Radio system available

to immediately alert trains that workers were on or about the

track, the Area Controller telephoned the Customer Service

Attendant at Kogarah Station and asked for an

announcement to be made over the Station public address

system to alert the track workers to the danger of the

oncoming train. This process took up valuable seconds and

resulted in insufficient time for the track workers to

comprehend the situation and then react to the warning.

The Area Controller had not applied blocking facilities when

he told the Protection Officer blocks were on.

Network controller Communicating Violation

Although the Protection Officer’s intentions and plan for the

worksite protection were sound, his planning, briefing and

documenting procedures lacked rigour in that they were not

fully completed and were conducted off site, en route to the

team’s initial work location at Beverly Hills.

Infrastructure

maintainer

Preparation and

planning

Violation

The Protection Officer did not seek confirmation that CSB

had been fully implemented as he assumed there would be

no more rail traffic and that the Area Controller knew what to

do as he had implemented CSB for him twice a little earlier

that evening without incident.

Infrastructure

maintainer

Communicating Violation


Findings Local

Condition/Organi

sational factor


Initially, the four workers cleaning the track attempted to

climb onto Platform 1 as there were no safe places for them

along the Platform. Three of the workers abandoned that

Training and

assessment

Initial training Infrastructure ,

construction and



course of action and moved to the adjacent (live) track.

Evidence indicated that during induction and worksite

protection training, there was insufficient coverage of the

emergency safety precautions to be taken by workers if they

are caught on the track with a train approaching and no safe

place readily accessible.

maintenance

Although the Area Controller was experienced and held the

necessary current competencies, he had only recently

returned from a lengthy period of mainly sick leave

associated with health issues that had been ongoing

intermittently for some years. Even though he had returned

to work unrestricted, he had concerns about his fitness for

duty which had been shared with his Manager while on

leave. He considered calling in sick on the night of the

incident but was concerned about the ramifications of taking

more sick leave. There were sufficient ‘triggers’ in the Area

Controller’s circumstances to indicate that a new health

assessment should have been conducted to determine his

ability to perform his job safely, prior to returning to full

duties.

Organisational

management

Information

management

Off-train

operations

It is likely that the combined effects of a lengthy period of

irregular shifts, reduced sleep, working during the circadian

low and pre-existing health issues adversely affected the

Area Controller’s work performance.

Personal factors Fatigue/alertness Off-train

operations

Staff working in the Sydenham Signal Complex were not

provided with permanent full-time supervision, with

management generally only in location from 5:00am to

1:00pm on weekdays, depending on operational

imperatives, although network operations superintendents

could be called in on an as required basis. There were

conflicting reports as to whether immediate support or

supervision was available to the Area Controller or other

staff after the incident.

People

management

Supervision Off-train

operations

Accounting for attendance was voluntary for staff and the

taking of breaks during shifts occurred on an ad hoc basis.

Despite clear and repeated promulgation of policy, it is

apparent that personal electronic equipment was being used

for non-work related purposes by staff while on duty.

Task demands Distraction Off-train

operations

Although the MetroNet Train Radio provided the ability to

broadcast an emergency ‘STOP’ message, as well as a

direct call to the train, the Area Controller was not confident

in using it or in its capabilities. Nonetheless, RailCorp

considers that the training of Area Controllers in MetroNet

functionality is adequate and frequent enough. However, a

number of area controllers asserted they had never

undertaken a ‘Stop ALL Stop’ drill. Training drills in such a

seldom-required emergency procedure should be conducted

regularly so as to maintain the highest level of competency.

Training and

assessment

Ongoing training Off-train

operations

The recorded voice communications were informal and

conversational and not in accordance with Network Rules

and Procedures, particularly in relation to the handling of

safety critical information. This was despite RailCorp

publishing information bulletins emphasising the importance

to safety of effective communications and the ITSR targeting

communication protocols in its audit and inspection

Knowledge, skills

and experience

Communication

skills

Off-train

operations



programs.

RailCorp had been conducting regular compliance audits of

recorded communications but these were not random, there

being a tendency for them to be done on the same day in a

particular time frame during a non-peak period and did not

specifically target communications between area controllers

and protection officers. Few non-compliances were identified

and, as they were classified as minor, they were actioned

informally and no record of the action kept.

Organisational

management

Monitoring,

review and

validation

Off-train

operations

Immediately after the incident, RailCorp made a subtle

change to the CSB Rule and Procedure using an

emergency change provision in the Rail Safety (General)

Regulation 2008. It was found that there was not a universal

knowledge of the change within RailCorp and that

understanding of the original rule varied among those

charged with applying it.

Organisational

management

Information

management

Off-train

operations

A warning light system, which relies on a lookout

maintaining active observation, was in place at Kogarah due

to restricted sighting on the track approach from the South. It

was not utilised as the Protection Officer considered CSB

had been successfully implemented and that any possible

threat was assessed as coming from the opposite direction

(albeit on the adjacent track). Additionally, there were no

backup mechanisms to alert persons in the vicinity that the

lights had in fact extinguished. However, while the purpose

of warning lights is included in the Network Rules and

Procedures, they do not reinforce the requirements for

workers to act when warning lights extinguish. Warning

lights are not shown on older diagrams and network maps.

Procedures Accuracy/Clarity Off-train

operations

The procedures used to place signals back to stop in

emergencies were not current or clearly understood by

users. Further, recent system hardware and software

modifications were not clearly delineated to or understood

by users. For example, the Area Controller was unaware

that the Signal Emergency Control Button on the adjacent

panel had the ability to set automatic signals on his panel to

Stop between Hurstville and Kogarah.

Procedures Accuracy/Clarity Off-train

operations



34. Wee Waa – Level crossing collision – 1 September 2010

At approximately 7:40am two Pacific National locomotives, operating as train D551, struck a

road motor vehicle (RMV) on a private level crossing located in the Narrabri West to Wee

Waa section approximately four kilometres east of the township of Wee Waa. As a result, the

driver of the RMV, a 32 year old resident from Wee Waa, suffered fatal injuries. No crew

members of D551 were injured but they were treated for shock.

The crew stated that D551 was travelling at the

maximum permitted track speed of 80km/h on

approach to the level crossing, and this was verified in

the analysis of the event recorder tape from the leading

locomotive. At a point approximately 400m prior to the

crossing, they sounded the train whistle (horn) in

accordance with ARTC Network Rule ANTR 408 Using

Train Whistles. At a point approximately 100 metres from the crossing the Driver again

sounded the whistle observing that, at this time, the crossing was clear. However, almost

immediately after, the Assistant Driver observed a white RMV appear ‘travelling from right to

left at moderate speed’ and alerted the Driver. The Driver immediately made an emergency

brake application. They then felt and heard the locomotive strike the RMV. D551 came to a

stand some 632m beyond the crossing.

D551 impacted the RMV on the passenger side in the area of the rear pillar of the cabin and

tray section. The RMV was then propelled in an arc-like trajectory from the crossing and

spun approximately 180°. It came to rest on the parallel

access road at a point some 32m from the crossing and

14.4m from the track.

The primary cause of the collision was the driver of the

RMV not stopping and giving way to the approaching train

as is required by Australian Road Rules 121 and 123.

OTSI was not able to establish why the driver of the RMV failed to stop.



Occurrence details






Individual actions


The collision was caused by the failure of the driver of the

Road Motor Vehicle to stop and give way to the

Locomotive, as was required by Australian Road Rule 121

and 123.

Light passenger

vehicle driver

Monitoring and

checking

Error



35. Bankstown – Near miss with track workers – 29 October 2010

At 12:55am the driver of an empty CityRail train travelling through Bankstown towards

Sydenham reported having sounded the train’s whistle and applied emergency braking due

to the presence of rail workers on the track ahead. The train stopped approximately 60

metres away from the workers, who by then had moved to a safe place beside the track.

The four workers, under the supervision of a Protection

Officer, were removing litter from the rail corridor.

Controlled Signal Blocking had been determined as the

appropriate method of worksite protection to be

employed at Bankstown.

After finishing work on the Down track beside Platform

2, the workers crossed to a safe place at the end of the platform and adjacent to the Up track

where a train was standing at Platform 1. While they

waited for this train to depart, the Protection Officer, who

had been delayed by the need to photograph the

condition of the Down track after cleaning, caught up with

his team. When the train departed, the four workers

moved onto the track and commenced litter removal, in

the belief that their Protection Officer had arranged the

planned worksite protection.

Meanwhile, the Protection Officer, walking along the platform near his team of workers, was

having difficulty contacting the Area Controller at Sydenham by mobile phone to arrange for

the protection on the Down track to be lifted and for protection to be provided on the Up

track. While the workers were on the track and the Protection Officer was seeking mobile

phone connection, the CityRail train approached the Station in the Up direction. On seeing

the workers on the track in front of him, the driver sounded the train’s whistle and

immediately applied emergency braking, stopping short of the workers’ location. On hearing

the whistle the workers moved quickly to the nominated Safe Place, while simultaneously the

Protection Officer turned to warn the workers.

The near miss occurred because, when the track workers commenced work on a live section

of track without any form of worksite protection, their Protection Officer did not ensure their

immediate movement to a Safe Place.



Occurrence details

Event description: Near miss with track workers.



Occurrence Classification Safeworking rule or

procedure breach

Track work procedure/rule breach

Individual actions Findings Person type Activity type Error/Violation type

The near miss occurred because when the track workers

commenced work on a live section of track without any

form of worksite protection.

Infrastructure

maintainers

Communicating Error

The Protection Officer did not ensure their immediate

movement to a Safe Place.

Infrastructure

maintainers

Monitoring and

checking

Error


Condition/Organi

sational factor


The Protection Officer was distracted by the need to

communicate with the Area Controller to fulfil the CSB

protection that had been provided for the then completed

work on the Down track, and by the need to take “before

and after” photographs of the corridor as part of the Station

Corridor Cleaning contract. As a consequence he did not

fulfil his primary task which was to provide a safe working

environment for his team.

Task demand Distraction Infrastructure ,

construction and

maintenance

The Protection Officer’s attempts to contact the Area

Controller to fulfil CSB arrangements on the Down track

and to arrange for CSB on the Up track were delayed by

his inability to find a location with an adequate mobile

phone service.

Equipment, plant

and infrastructure

Reliability Infrastructure ,

construction and

maintenance

The track workers proceeded onto the track to commence

work without first checking whether protection had been

established.

Task demands Time pressure Infrastructure ,

construction and

maintenance

The manner of spoken communication between the

Protection Officer and the track workers lacked precision

and clarity, resulting in misinterpretation.

Knowledge skills

and experience

Communication

skills

Infrastructure ,

construction and

maintenance

The Protection Officer’s discussion of protection methods

with the Area Controller was ambiguous, leaving the Area

Controller to understand that work on the Up track at

Bankstown was to be performed under NAR.

Knowledge skills

and experience

Communication

skills

Infrastructure ,

construction and

maintenance

The preparation of Worksite Protection Plans and conduct

of Pre-work Briefings using forms partly copied from earlier

jobs and finalised on the way to the worksite provided the

benefits of time saving and consistency. However, this can

make it easy to overlook unanticipated issues specific to a

worksite at a particular time, and can also result in a lack of

precision with no clear understanding by team members as

to the specific measures to be used.

Procedures Clarity Infrastructure ,

construction and

maintenance



36. Unanderra – Uncontrolled movement – 2 February 2011

At approximately 6.38am a loaded El Zorro Transport Pty Ltd grain service 3996, en route

from West Wyalong to Port Kembla, passed signal WG 1014 at danger before coming to a

stand 527 metres beyond the signal which is located on the Northern side of Unanderra

Station. The driver had not been able to control the speed of the train towards the end of its

descent of the steeply sloping Illawarra Mountain. No injuries resulted from the incident and

there was no damage occasioned to any or infrastructure.

The investigation found that the train became

uncontrolled during its descent because the manner in

which it was driven did not provide for effective braking.

Initial braking effort was too light, but then was

progressively increased until a full brake application

was achieved using the brake valve handle-off position

rather than the full service or emergency position. At a

critical point in the sequence of events, braking became unbalanced when the dynamic

brake was disengaged and then re-engaged. In addition, on a number of occasions

throughout the journey, the train was allowed to travel well in excess of the designated

speed of 25 km/h for single pipe trains as well as the posted speed of 30 km/h.

Although it did not contribute directly to the uncontrolled movement, there was a difference

between the type of braking system actually fitted to the train and the system that was listed

in the Train Operating Conditions (TOC) manuals. The

WGBY class of wagon making up the consist of the train

was fitted with a dual pipe braking system. However, this

was not documented or recognised as such during the

certifying process on their introduction into service or

during subsequent operations. Consequently, they were

listed in the RailCorp and Australian Rail Track Corporation (ARTC) Train Operating

Conditions (TOC) manuals as ‘single pipe’ wagons.



Occurrence details

Event description: Uncontrolled movement.



Occurrence Classification Signal passed at danger Completely missed by driver


El Zorro grain service 3996 became uncontrolled during its

descent of the Illawarra Mountain because the train was not

managed in accordance with good practice. The result was a

loss of the necessary braking effort to be able to maintain full

control of the movement.


equipment

Error


Condition/Organi

sational factor


Up to the time of the incident, El Zorro had no documented

policies or procedures for the control of trains descending the

Illawarra Mountain. Instead, drivers were instructed to use the

network manager’s TOC manuals.

Procedures Absent

procedures

On train operations

Despite being issued with TOC waivers from both RailCorp

and ARTC which classified the WGBY wagons as single pipe

wagons, El Zorro operated the grain train services under dual

pipe conditions from the time of introduction of the wagons into

service. This anomaly was not identified by either RailCorp or

ARTC.

Organisational

management

Monitoring,

review and

validation

On train operations

The co-driver was unable to establish contact with the

Wollongong Signal Box to alert the signaller to the

uncontrolled movement until after the train came to a stand.

He chose to use a mobile telephone in preference to the

CountryNet radio emergency function.

Equipment, plant

and infrastructure

Functionality On train operations

ARTC’s TOC manual had not been updated since 2004 and

there were 592 waivers awaiting insertion in the manual.

Some information in the Local Appendix Units was also not

current.

Organisational

management

Information

management

Rolling stock

construction and

maintenance

The modification to the WGBY wagon involving the addition of

a connection from the main reservoir pipe to the wagon’s

auxiliary reservoir was not subjected to feed or flow rate tests

and does not meet RailCorp’s or ARTC’s engineering

requirements.

Organisational

management

Risk/ change

management

Rolling stock

construction and

maintenance

The modification to the WGBY wagon involving the addition of

a connection from the main reservoir pipe to the wagon’s

auxiliary reservoir was not subjected to feed or flow rate tests

and does not meet RailCorp’s or ARTC’s engineering

requirements.

Organisational

management

Risk/ change

management

Rolling stock

construction and

maintenance

Currently in Australia, there is no standard defining what

constitutes single and dual pipe wagons, including the various

engineering aspects such as the purpose, application, flow

rates and timing in reference to charge rates.

External

organisational

influences

Industry

standards or

guidance

Rolling stock

construction and

maintenance



37. Zig Zag – Collision between a train and a Hi-rail – 1 April 2011

At 1:30pm a Zig Zag Railway maintenance vehicle (the Hi-Rail), collided with a two-car Rail

Motor on the No 1 Viaduct, Top Road, between Clarence and Top Points stations. The Hi-

Rail, with a Driver and Passenger on board, was freewheeling down the hill in reverse in the

section from Clarence towards Top Points. The Rail Motor, operated by a Driver, was

travelling without passengers in the opposite direction from Top Points.

The Rail Motor Driver saw the approaching vehicle and

applied the brakes. However, the two persons onboard

the Hi-Rail, facing the opposite direction, did not see

the Rail Motor before the collision. The force of the

collision compacted the body of the Hi-Rail such that

neither cab door would open. The two occupants of the

Hi-Rail were injured in the collision and were assisted

out of the Hi-Rail and onto the Rail Motor by the Rail Motor Driver who was uninjured. The

force of the collision caused a minor misalignment of the track.

The investigation established that the collision resulted from the Driver of the Rail Motor and

the Driver of the Hi-Rail not being aware that they were travelling towards each other on the

same track in the Top Points-Clarence section. This lack

of situational awareness resulted from procedural errors.

The Rail Motor Driver departed Top Points without

communicating his intention to his Guard or the Hi-Rail

crew, and the Rail Motor Guard exceeded his authority by

authorising the Hi-Rail to leave a worksite and proceed to

Top Points.

A number of other factors were found to have contributed to the collision, particularly a lack

of radio communications and operational safeworking errors. Other safety issues identified

during the investigation included delayed notification of the accident; poor maintenance of

Train Register Books; passengers travelling in the Rail Motor driver’s cab; Rail Motor

Driver’s fatigue; and excess speed of the Hi-Rail.



Occurrence details

Event description: Collision between passenger train and hi-rail vehicle.

Type of operation: Passenger and track maintenance



Between trains

Individual actions


type

The collision occurred because the Driver of the Rail Motor

and the Driver of the Hi-Rail were unaware that they were

travelling towards each other on the same track in the same

section and, in the case of the Rail Motor Driver, when he

saw the approaching Hi-Rail, was unable to take any

emergency action which would have been effective in

preventing the Hi-Rail from colliding with the Rail Motor.

Train crew Operating equipment Error

The Driver of the Hi-Rail was unable to take any emergency

action to prevent the collision because he was travelling

backwards down the track and neither he nor his Passenger

was maintaining an effective lookout.


The Rail Motor Guard exceeded his authority by authorising

the Hi-Rail to leave the RTA worksite and proceed to Top

Points.



Findings Local

Condition/Organi

sational factor

Keywords Functional

area

The Rail Motor Driver departed Top Points without

communicating his intention to his Guard or the Hi-Rail

crew.

Knowledge,

skills and

experience

Communication skills On train

operations

The Hi-Rail was travelling above the posted speed

restriction of 10km/h on the No.1 Viaduct.

Knowledge,

skills and

experience

Normal operations

knowledge & skills

On train

operations

The Rail Motor Driver’s performance may have been

degraded by fatigue.

Personal factors Fatigue/alertness On train

operations

The Rail Motor Driver left Top Points without any radio

communication at his end of the Rail Motor and no other

means of communicating with other staff. Consequently,

he did not hear the Hi-Rail Driver request and get approval

from the Guard to travel to Top Points.

Equipment, plant

& infrastructure

Absent equipment,

plant & infrastructure

On train

operations

Both the Driver and Guard of the Rail Motor had made an

error on a previous trip when they failed to check they had

the Staff when they departed Top Points.

Knowledge,

skills and

experience

Teamwork skills On train

operations

The Rail Motor Driver, acting in his capacity as Operations

Manager, authorised both the Rail Motor and Hi-Rail to

depart Clarence with the Staff unsecured at the other end

of the section.

Knowledge,

skills and

experience

Normal operations

knowledge & skills

On train

operations



The management of operations was concentrated in the

hands of one person on the day of the collision. The Rail

Motor Driver was also acting as the Train Controller as well

as holding the position of Operations Manager.

Organisational

management

Competence of

senior personnel

On train

operations

There was an accepted practice of qualified workers

authorising rail traffic movements without reference to the

train controller.

Social

environment

Norms and values On train

operations

It was accepted practice for both Staffs being kept in the

Lithgow end of the Rail Motor. This increased the

probability that the required check, that the correct Staff

was at hand, was not done if the Rail Motor was driven

from the Clarence end.

Social

environment

Norms and values On train

operations

The procedure relating to the collection of Staffs from

Signal Boxes was ambiguous.

Procedures Accuracy/clarity On train

operations

The Rail Motor Driver allowed two passengers to ride in

the front cab on a journey from Top Points to Clarence.

This may have distracted him and, to a lesser extent, the

Guard from checking if they had the Staff before departing.

Task demands Distraction On train

operations

There was no rule about passengers travelling in the cab

of the Rail Motor.

Procedures Absent procedures On train

operations



38. Enfield yard – Runaway rolling stock – 3 May 2011

At approximately 12:45pm a Pacific National Terminal Operator was changing brake blocks

on a rake of 28 loaded aggregate wagons stabled in North Road No.1 in Enfield Yard. When

he released the air pressure in the braking system on a wagon in the centre of the rake in

order to change a brake block, the remaining brakes applied to the rake did not hold the rake

on the prevailing grade and it began to run away.

The Terminal Operator’s attempt to stop the rake by

applying hand brakes on two wagons as they passed

was not successful. The rake ran away through the

yard and entered South Road No.1 colliding with

another stabled rake consisting of 15 empty fuel tanker

wagons and three flat bed wagons (located at the

opposite end). The combined rakes continued, with two

of the tankers derailing and slewing across the track, carrying away two shunting signals and

an overhead wiring portal stanchion. The two rakes came to rest approximately 460 metres

from the point of collision with the derailed tankers foul of the Up and Down Main lines. The

rake of aggregate wagons ran away for a total of 1085 metres.

The investigation established that too few handbrakes had been applied to the rake in order

to hold it on the prevailing grade. Pacific National’s maintenance regime and training of

terminal operators was not adequate for the effective

maintenance of brakes on rolling stock that did not have

slack adjusters. Also, Pacific National did not comply with

the Safety Interface Plan and Management Agreement

with RailCorp in regard to controlling the risk of runaways.

Further, Pacific National did not comply with its own

procedures for risk assessments to test the efficacy of its

minimum requirement for handbrake application at Enfield Yard. The investigation identified

a number of safety issues for improvement including Pacific National’s non-conformance

with its own procedures for undertaking risk assessments, and gaps in training and

procedures in relation to brake maintenance.



Occurrence details

Event description: Runaway .



Occurrence Classification Derailment Running line collision

Individual actions


type

The immediate cause of the incident was that, during

maintenance activities, the air brakes were released on

wagon NPZH35652C and the rake ran away due to the

rake’s remaining brakes being insufficient to hold it stationary

on the prevailing grade.

Terminal staff Operating

equipment

Error


Findings Local


onal factor

Keywords Functional

area

Pacific National did not comply with the requirements of

the Safety Interface Plan with RailCorp; viz., it did not

comply with the requirements to “ensure that is not left

unattended unless appropriately stabled and protected in

accordance with RailCorp Network Rules and

Procedures”.

Organisational

management

Communication

and consultation

process

Off train

operations

Pacific National did not comply with the requirements of

the Management Plan with RailCorp which specified that

the requirements of the TOC Manual were to be met. The

TOC Manual specified that nine wagons should have had

handbrakes applied on this train.

Organisational

management

Communication

and consultation

process

Off train

operations

Pacific National had not carried out any risk assessments

to test the efficacy of its minimum requirement for

handbrake application at Enfield Yard as required by its

own procedures and the Safety Interface Plan.

Organisational

management

Risk

management

Off train

operations

There were no procedures specific to the maintenance

activity of changing brake blocks especially on wagons that

were not fitted with slack adjusters.

Procedures Absent procedures Off train

operations

No training been provided to Terminal Operators in regard

to the adjustment of brakes on without slack adjusters.

Training and

assessment

Initial training Off train

operations



39. Woy Woy – Level crossing collision – 2 Sep 2011

At approximately 6.17pm CityRail’s Sydney to Wyong interurban passenger service 289G,

carrying approximately 200 passengers, struck a stationary, unoccupied road motor vehicle

(RMV) on the Down Main line at the Rawson Road level crossing at Woy Woy on the Central

Coast of NSW. The RMV had become stuck on the line after its driver became disoriented

and turned onto the line from the crossing while trying to locate a street running parallel to

the line.

The driver of the RMV had been unable to move the

RMV after it became stuck despite the assistance of a

number of passers-by who saw him attempting to move

it off the line. However, shortly after they commenced

attempting to assist the driver, the automatic protection

equipment at the level crossing activated, indicating an

approaching train. The driver, and those assisting,

immediately moved off the tracks out of the path of trains.

The driver of 289G was unable to stop before striking the RMV which, after impact, became

wedged underneath the train and was pushed for approximately 300 metres along the track

but without derailing the train.

While no persons were reported injured in the incident, a

number of safety issues were identified during the course

of the investigation. These included: an inadequate

obstruction deflection system on passenger used on

interurban routes to prevent larger obstructions from

becoming wedged underneath and potentially derailing the train; information overload from

signage at the crossing; the lack of road markings inside the rail corridor defining the

roadway; and the lack of emergency contact information provided at level crossings.



Occurrence details

Event description: Passenger train collision with car at level crossing.




Occurrence category At crossing with active warning devices

Individual actions


type

The collision occurred as a result of the driver of the RMV

becoming disoriented at Rawson Road level crossing, driving

his vehicle onto the railway line and then not being able to

remove the vehicle from the line to a safe location.

Light passenger

vehicle driver

Monitoring and

checking

Error


Findings Local


onal factor

Keywords Functional

area

The number and variety of signage positioned in the

vicinity of the crossing created information overload.

Task demands High workload Road

environment

There were no road markings providing a clear delineation

of the roadway inside the rail corridor at the crossing.

Equipment, plant

and infrastructure

Signage Road

environment

OSCAR EMU sets incorporate lifeguards to clear small

obstacles or debris from the path of the train wheels,

designed in accordance with Section 16 of (British)

RailTrack Railway Group Standard GM/RT 2100.

However, neither the OSCAR sets nor other EMU

passenger operating on interurban routes incorporate

additional protection to deflect more substantial obstacles

such as provided for in Section 12 of the Standard.

Equipment, plant

and infrastructure

Absent

equipment

Rolling stock

construction

and

maintenance



40. Clifton – Broken axle derailment – 23 Nov 2011

At approximately 11.56pm a Pacific National coal service MC92 derailed eight wagons at

Clifton. MC92, a 45-wagon train with single locomotives at its front and rear, was fully loaded

with coal and was travelling South from the Metropolitan Colliery at Helensburgh to Inner

Harbour at Port Kembla where it was to be unloaded. The leading locomotive had just

passed Clifton level crossing when an emergency application of the train’s brakes occurred

automatically and it came to a stand. The rear of the train was still inside the Coalcliff tunnel.

The Driver on the leading locomotive notified the

RailCorp Signal Complex at Wollongong that his train

was stopped. He then sent his Co-driver back to

inspect the train and locate whatever had caused the

brakes to apply automatically. The Co-driver found that

the train had derailed North of the level crossing and

used his two-way radio to alert the Driver. At 12.08am

the Driver notified the RailCorp Signal Complex at Wollongong that the train had derailed.

The investigation revealed that the barrel of the No.3 axle of the eighth position wagon had

broken and parted, causing both wheels to derail. As a result, seven wagons following this

wagon derailed. The two locomotives and all other

wagons remained on the track. Although there were no

injuries as a result of the derailment, approximately 470

metres of damaged track needed to be replaced.

The investigation established that the break in the axle

was attributable to the propagation of metal fatigue at the

site of the fracture. The fatigue fracture was initiated some time prior to the final complete

failure of the axle at the derailment site but, due to damage sustained in the derailment, the

initiator of the fracture could not be determined.



Occurrence details

Event description: Freight train derailment due to broken axle on wagon.



Occurrence Classification Derailment On a running line

Technical failure


mechanism

Failure origin

The derailment of MC92 was a consequence of the barrel of

the No. 3 axle of the eighth wagon breaking. This breakage

caused the wheelset to derail which subsequently resulted in

eight wagons fully or partially derailing. The axle broke due

to the initiation and propagation of metal fatigue at the site of

the fracture. The fatigue fracture was initiated some time

prior to the final complete failure of the axle at the derailment

site but, due to consequential damage around the axle

circumference, a determination could not be made about the

initiator for this fatigue failure.

Rolling stock- Bogies Fracture Unknown


Findings Local


onal factor


The axle, which was about 50% fractured at the time of the

incident, finally failed while being subjected to normal

cyclic loading.

Equipment, plant

and infrastructure


construction and

maintenance

The current inspection standards for Unit Train

Maintenance do not emphasise the examination of the axle

barrel.


adequacy

Rolling stock

construction and

maintenance

The two or three year interval (depending on kilometres

travelled) between the non-destructive testing of axles may

exceed the time taken from the initiation of a stress raiser

to the ultimate failure of an axle.


adequacy

Rolling stock

construction and

maintenance

The train crew on the trailing locomotive were inside the

cab of their locomotive which was stationary inside the

Coalcliff Tunnel, with no effective means of

communication. The Coalcliff Tunnel is a known black spot

for communications.

Equipment, plant

and infrastructure

Absent

equipment

Rolling stock

construction and

maintenance

There is potential for wagons to be overloaded as there is

no measurement of the weight of the wagons at the

loading terminal, or along the track, until the unloading

facility at Inner Harbour Port Kembla.


adequacy

Freight handling

The shutdown button and the control/engine switches in

the trailing locomotive of MC92 were ineffective in shutting

down the engine following the derailment.

Equipment, plant

and infrastructure

Control input

devices design

Rolling stock

construction and

maintenance



41. Unanderra – Safeworking incident – 12 Dec 2011

At about 12:45am a Pacific National freight train 3930 was stationary at Unanderra Station

when the driver was contacted by the area controller in the Wollongong Signalling Complex

with a request to inspect the condition of one of his wagons. To carry out this inspection, the

driver requested Controlled Signal Blocking (CSB) so that he could access the danger zone

of the track adjacent to his train. The intended effect of the CSB was to exclude rail traffic

from the portion of track in which he would be working. The area controller granted the

request and the driver left the cab of his locomotive and climbed down onto the track.

While he was in the danger zone, the driver was

notified by his co-driver that no CSB protection was in

place and he subsequently observed the lights of an

approaching train. Although he could not determine on

which track this train was proceeding, he prudently

moved to the closest safe place between two wagons

of his train. As it transpired, the approaching train was

travelling on the track on the opposite side of the platform to PN 3930 and posed no actual

threat to the driver’s safety.

The investigation identified a lack of adherence to communications protocols and the specific

procedures, including information exchange protocols, contained in RailCorp’s CSB Rules

and Procedures that were in force at the time. Protecting

train crew using CSB was identified as a task seldom

undertaken by either the area controller or the train driver.

The Report highlights the extent to which ineffective

communications continue to constitute one of the

significant contributing factors in the causation of

safeworking incidents reported to OTSI. Additionally, differences in the rules and procedures

applied by the various network owners within NSW continue to exist.



Occurrence details

Event description: Safeworking breach with driver on track.



Occurrence Classification Safeworking Rule or

procedure breach


Individual actions


type

The investigation established that the incident occurred

because the communications protocols and the specific

procedures, including information exchange protocols,

contained in RailCorp’s CSB Rules and Procedures that

were in force at the time, were not adhered to.

Network controller Monitoring and

checking

Error


Findings Local

Condition/Organis

ational factor


Verbal communication did not conform to the requirements

of RailCorp Network Rule NGE204 Network

communication, Network Procedure NPR721 Spoken and

written communication or the requirements of the CSB

(now ASB) rules and procedures.

Knowledge, skills

and experience

Communication

skills

Off-train

operation

Evidence suggests that the AC may have relied on an

earlier learned routine to provide practical protection to the

driver trainer on the Down Illawarra Main line which did not

conform to the letter of the prevailing Network Rules and

Procedures. He was unable to clarify what ‘protection’ had

been requested by the train crew, and which he had

authorised, when challenged by the train controller.

Knowledge, skills

and experience

Normal

operations

knowledge and

skills

Off-train

operation

The AC’s knowledge of the CSB rules and procedures was

incomplete, and he lacked familiarity with applying it,

particularly in relation to the infrequently performed task of

protecting train crews.

Knowledge, skills

and experience

Normal

operations

knowledge and

skills

Off-train

operation

The train crew did not have access to reference

documents to check how CSB (an infrequent task for them

also) should be requested and implemented. Additionally,

they did not have access to the worksite protection plan

form (NRF 015A).

Procedures Availability/

accessibility

Off-train

operation

Pacific National was unaware that their train crews were

required to use Form NRF 015A (or NRF 015B for lookout

working) and had therefore taken no steps to provide the

forms, or training in their use, to train crews.

Organisational

management

Information

management

Off-train

operation

The AC conferred with the 2nd person about the safety

arrangements without reference to the driver trainer who

was the Protection Officer.

Knowledge, skills

and experience

Communication

skills

Off-train

operation

This lack of consultation was exacerbated by the fact that

the driver trainer’s handheld WB radio was unserviceable

when he was outside the locomotive’s cab.

Equipment, plant

and infrastructure

Absent

equipment

Off-train

operation



42. Gunnedah – SPAD and opposing movement – 7 March 2012

At 10.27pm a Pacific National grain train 5424N passed signal GH26 on the outskirts of

Gunnedah while it was showing a red Stop indication. The second person alerted the driver

to the incident and the driver responded by applying the brakes. The train then trailed

through a set of points before coming to a stand. Concurrently, Pacific National coal train

WH191 was proceeding in the opposite direction from a passing loop onto the single Main

line and so was on a collision course. On becoming aware of 5424N coming towards him,

the driver of WH191 immediately brought his train to a stand. The trains stopped 715 m

apart with 5424N 870 m beyond signal GH26. The crew of 5424N did not detect the

presence of WH191 until after both had stopped.

The network controller attempted to make an

emergency broadcast call over the CountryNet radio

when he became aware of 5424N passing signal

GH26. However, the call failed primarily due to the

network controller’s lack of understanding of the radio

system’s characteristic delay when placing this type of

call. The Australian Rail Track Corporation

subsequently produced an information and instructional document on the subject and

distributed it to its network controllers.

The investigation focused on the actions of the train crews before and during the incident

and the communications failures immediately after it. Also considered was the design and

layout of the signalling infrastructure and crew fitness for

duty.

The reason the driver of 5424N did not respond to the

signal indication is likely to have been his misreading of

two consecutive stop signals as a single signal causing

him to misinterpret where he should stop.



Occurrence details

Event description: SPAD and opposing movement by two freight trains



Occurrence Classification Signal Passed at Danger Completely missed by driver


The SPAD and opposing movement resulted from train

5424N being driven through signal GH26 at Stop without

authority then proceeding to trail through 55A points. This

brought the train into a conflicting movement with train

WH191 approaching with authority from the opposite

direction on the single line.


checking

Error

On becoming aware of the SPAD, the Network Controller

did not attempt to contact 5424N directly via CountryNet,

instead first trying to contact WH191 then making a

‘broadcast call’, neither of which was successful.

Network

controller

Communicating Error


Condition/Organi

sational factor


When viewed from a distance, signal GH22 appears directly

above signal GH26. The main head and marker lights of

each signal merge to appear to be one light. This produces

the effect that signals GH26 and GH22 look like one signal

(main head and marker) as two red lights can be observed

one almost above the other, even though they are two

separate signals 2.1 km apart. The driver is likely to have

observed the two signals as being one and formed the

opinion that the signal was GH22 where, from past

experience, he might expect to have to stop.

Physical

environment

Lighting/

visibility

On-train operation

It is likely that the visual distortion was caused by the design

of the signal lights that now use LED technology which, in

low ambient light, make the smaller marker light appear to

be of similar size and intensity to the larger main head. The

two separate signals appeared to the driver to be one and,

despite the calls from the second person, influenced the

driver’s mental model of where he was authorised to

proceed.

Equipment, plant

and

infrastructure

Infrastructure

design

On-train operation

The second person was under training and was relatively

inexperienced; an authority gradient existed between him

and the driver. This contributed to the second person not

taking more positive action when the driver of 5424N did not

comply with PN’s procedure requiring him to reduce speed

to 15 km/h 200 m from the signal and stop 50 m before it.

Social

environment

Peer pressure On-train operation

Defence against human error at the site relied entirely on the

crew of 5424N observing and obeying the indication of

colour light signals. Installation of an automatic train

management system on the network will provide additional

defences in the future.

Equipment, plant

and

infrastructure

Absent plant On-train operation



43. Nundah – Level crossing collision – 7 May 2012

At 9.11am on Friday 4 May 2012 an unladen coal train travelling north-west on the Main

North line collided with a utility on a railway crossing on Middle Falbrook Road, Glennies

Creek, at a rail location known as Nundah. The driver of the utility was fatally injured in the

collision.

The train, operated by QR National Limited, was less

than 100 metres from the crossing and travelling at 71

km/h when the crew saw the utility approaching the

crossing from their right at a moderate speed and then

continuing onto the crossing without appearing to slow.

The train struck the left side door of the utility, dragging

the vehicle for 70 metres and finally stopping under emergency braking about 400 metres

past the point of impact, with the utility on the right hand side of the train on the adjacent

track. A laden Pacific National coal train travelling in the opposite direction had been

standing for some minutes with its headlight extinguished approximately 800 metres from the

crossing on the adjacent track, and its crew immediately secured their train and hurried up

the track to lend assistance.

The railway crossing was passively protected by stop signs and associated roadside signs

and road markings, except for a stop line on the road immediately before the crossing. The

driver’s vision of trains approaching from the south-east

was limited by the presence of a work compound to his

left. However, the stop sign before the crossing was

visible for a distance of at least 85 metres.

The reason the utility was driven onto the crossing without

stopping is unknown. However, it is possible that the driver was distracted by the busy visual

environment as he approached the crossing and that the driver’s view of the train

approaching from his left was compromised by the presence of the work compound and

fences in his line of sight.



Occurrence details

Event description: Level crossing collision between road motor vehicle and freight train.



Occurrence Classification Level crossing occurrence: Collision with road vehicle


Individual actions


The driver of the utility drove past the stop sign without

stopping and continued onto the crossing into the path of

the approaching train which was unable to stop in time to

avoid collision.

Light passenger

vehicle driver

Monitoring and

checking

Unknown


Findings Local

Condition/Organi

sational factor


The driver was distracted by the number of signs and other

roadside furniture, by the presence of the Upper Hunter

Valley Alliance compound and by the poor condition of the

road, and paid insufficient attention to the relatively

inconspicuous crossing.

Task demands

Distractions

Road environment

The driver’s view of the approaching train was obscured by

the presence of the compound fencing.

Physical

environment

Lighting/visibility Road environment

The railway crossing did not fully meet the requirements of

Australian Standard 1742.7—2007 as there was no visible

stop line accompanying the stop sign. Furthermore, the

position of the stop sign, although meeting the

requirements of the standard, was such that, if used as the

only guide for the correct stopping position, afforded the

driver an obstructed view to the left.

Equipment, plant

and

infrastructure

Signage Road environment



44. Bengalla – Ballast train collision – 18 May 2012

At approximately 5.15am the leading wagon of Australian Rail Track Corporation (ARTC)

ballast train 6M21 was derailed after colliding with an unmanned ballast regulating machine

within a worksite in the Bengalla to Mangoola section on the Ulan line. The regulator was

stationary, having run out of fuel. Four workers who were riding on the train underwent

precautionary examination at Muswellbrook Hospital and were treated for minor bruising.

Although the regulator was pushed approximately 50 metres by the train, the rolling stock

suffered comparatively minor damage.

At the time of the collision the train was being propelled

under the direction of a Pilot standing on the rear

platform of the leading wagon. The Pilot had been

made aware of the disabled regulator by the qualified

worker acting in the capacity of Protection Officer of a

resurfacing team responsible for it. However, he had

not been given, nor had he sought, details of the machine’s exact location and believed it

was standing approximately three kilometres beyond the intended drop point for the ballast.

The Pilot did not see the regulator until just before the train collided with it.

The collision of ballast train 6M21 with the disabled ballast regulating machine, and the

subsequent derailment of the leading wagon, was found to be attributable to ineffective

communication between safety critical staff about the

location of the disabled ballast regulator.

Overreliance was placed on the direction lights on the

regulator to indicate its stationary presence and provide

sufficient warning of an obstruction on the track, but these

lights were reported to not be illuminated when the ballast

train was approaching. Also contributing to the incident was the fact that no warning devices

were placed on the track in accordance with ARTC’s Network Rule ANTR 416 Disabled

Trains when the regulator ran out of fuel.

The investigation also found shortfalls in a number of supervisory, management and

protection practices employed by the work groups.



Occurrence details

Event description: Collision between two ballast trains.




Between trains

Individual actions


The collision of ballast train 6M21 with the disabled ballast

regulating machine, and the subsequent derailment of the

leading wagon, is attributable to ineffective communication

between safety critical staff about the location of the

disabled ballast regulator.

Infrastructure

maintainers

Communicating Error

No protection was placed on the track in accordance with

ARTC Network Rule ANTR 416 Disabled Trains when the

regulator ran out of fuel.

Infrastructure

maintainers

Preparation and

planning

Error


Findings Local

Condition/Organi

sational factor


Overreliance was placed on the direction lights on the

regulator to indicate its stationary presence and provide

sufficient warning of an obstruction on the track, and these

lights were reported not to be illuminated when the ballast

train was approaching.

Physical

environment

Lighting/visibility On-train operations

Despite being informed that the regulator had run out of

fuel, the Traffic Officer/PO and the PO did not consider the

vehicle to be disabled in accordance with the definition

contained within the Glossary of the ARTC Network Rules

and Procedures. In the absence of any controlling rules or

procedures for disabled vehicles in worksites, adequate

vehicle separation and protection was not provided.

Further, there was an understanding by the Traffic

Officer/PO that, because the regulator had run out of fuel

within a worksite, it did not require protection in

accordance with ARTC Network Rules ANTR 400 and

ANTR 416.

Procedures Absent

procedure

Infrastructure

construction and

maintenance

The LS Rail Worksite Supervisor did not consider the risks

and consequences of the regulator becoming disabled in

the section away from fuel access points despite being

informed that it was low on fuel at the commencement of

the shift.

People

management

Job/task design Infrastructure

construction and

maintenance

The Traffic Officer/PO and the PO did not review or

undertake another risk assessment despite the changes in

risk when the regulator became disabled.

People

management


construction and

maintenance

The PO did not review or undertake another risk

assessment when the plough van was removed from the

ballast train.

People

management


construction and

maintenance



The track tamper and regulator were effectively operating

as a worksite within a worksite. However, this was not

recorded on any worksite documentation; nor were the LS

Rail team signing onto the pre-work briefing forms at the

main site office.

Social

environment

Norms and

values

Infrastructure

construction and

maintenance

The Pilot did not direct the movement of the train in

accordance with ARTC Network Rule ANTR 424 and

SWMS TRA-027. Further, he was unaware of the speed

requirements in SWMS TRA-027 because he had not

been trained in ARTC’s Ballast Train Unloading

Awareness Training package and a copy of the SWMS

was not available on site.

Training and

assessment

Initial training Infrastructure

construction and

maintenance

No instructions or procedures had been developed for

lengthy propelling movements.

Procedures Absent

procedures

Infrastructure

construction and

maintenance

Environmental conditions and inadequate personal

protective equipment influenced the position taken by the

Pilot when directing the train.

Physical

environment

Weather-related

factors

Infrastructure

construction and

maintenance

Communications used at the worksite were not clear and

concise and, particularly post-incident, did not comply with

ARTC Network Rule ANGE 204, Network Procedure

ANPR 721 and the ARTC Incident Management Manual

TA44.

Knowledge,

skills and

experience

Communication

skills

Infrastructure

construction and

maintenance

The LS Rail pre-work briefing forms were photocopies

which were not uniquely numbered and did not follow

document control procedures. There was no reference to

any SWMSs on the forms and there were no hazards or

controls identified for disabled rail vehicles inside the

worksite. Further, the hazards and controls that were listed

were the same for both day and night shifts.

Procedures Clarity Infrastructure

construction and

maintenance

The pre-work briefing form compiled by the Protection

Officer at the main site office was deficient as it made no

reference to any SWMSs; nor were any of these

documents available at the worksite. Further, the hazards

of disabled rail vehicles, partially or unevenly loaded

wagons, propelling movement speeds between worksites

and communications failure between the Pilot and

locomotive crew were not identified and recorded on the

form; nor was the fact that another worksite was effectively

operating within the worksite.

Procedures Clarity Infrastructure

construction and

maintenance

The regulator was not carrying any emergency equipment

as listed in Section 9 of the TOC Manual and there was no

designated secure storage space on the vehicle.

Equipment, plant

and

infrastructure

Absent

equipment

On-train operations

The wagon upon which the ballasting team was riding was

not fitted with an emergency valve to apply the brakes on

the train. Because of this, the Pilot had to alert the

locomotive crew by radio to stop the train when the

regulator came into view.

Equipment, plant

and

infrastructure

Absent

equipment

On-train operations

There were no apparent defects on the lighting system of

the regulator. However, at least two possibilities existed

within the system for the lights to cease working without

intervention of the operator, neither of which was

recognised by the operator.

Equipment, plant

and

infrastructure

Functionality On-train operations



45. Summit Tank – Safeworking incident – 17 July 2012

Shortly after 2.00pm three workers commenced an inspection of a rail viaduct located in the

section between Summit Tank and Dombarton on the Unanderra to Moss Vale Branch line.

This was one of several site inspections which had been organised and supervised by an

Australian Rail Track Corporation (ARTC) structures manager to allow two contractors to

familiarise themselves with site conditions so that they could quote on the works required to

effect repairs to various bridges, viaducts and other rail structures. When it was necessary

during the site inspections, the Structures Manager also performed the duties of Protection

Officer.

During the inspection of the viaduct, the contractors

became concerned about the apparent structural

damage to the first pier at the Country end of the

viaduct and explained their need to examine the

damage from track level. Shortly afterwards, they

walked up onto the viaduct and along the walkway

immediately beside the track for approximately 10m until they were directly above the

damaged pier. The ARTC structures manager followed the two contractors up onto the

walkway.

At approximately 1448, Port Kembla-bound Pacific National bulk freight service 2928N

approached the viaduct from the Country end while the three workers were on the viaduct

directly ahead of it. When the train driver saw them on the

viaduct, he immediately blew the horn and applied the

brakes. On becoming aware of the train, the three

workers turned and, seeing the train approaching,

immediately moved quickly towards the Country end of

the viaduct (towards the oncoming train). All three men

were able to step to safety clear of the end of the viaduct

with the train approximately 5m from them. No one was injured in the incident.



Occurrence details

Event description: Near miss with track maintenance workers on viaduct.




procedure breach


Individual actions


The Protection Officer was required to combine the

primary responsibilities of his Structures Manager position

and those of protection officer while supervising the

viaduct engineering inspection. As inspecting the structure

from other than below the deck was not anticipated, no

worksite protection planning was undertaken. When the

circumstances changed and the group needed to move

onto the viaduct and into the danger zone, the Protection

Officer made no worksite protection arrangements.

Infrastructure

maintainers

Preparation

and planning

Error


Findings Local

Condition/Organi

sational factor


All three members of the group appear to have been

focused on the inspection of the viaduct pier and oblivious

to the potential danger of their situation.

Task demands Distractions Infrastructure

construction and

maintenance

The Protection Officer felt there were times where there

was an unreasonable degree of pressure on him to

manage contractors, which he found particularly difficult,

while having to concurrently perform non-core functions

such as those of protection officer and project manager.

He felt this was the case on the day of the incident.

Social

environment

Norms and

values

Infrastructure

construction and

maintenance



46. Boggabri – Coal train derailment – 28 Nov 2012

At approximately 2.13pm a Pacific National coal service NB942 derailed the last six wagons

on the Coxs Creek Bridge near the township of Boggabri. NB942 consisted of 71 loaded coal

wagons which were being hauled by three locomotives at the front of the train. The train was

travelling from Narrabri Coal to Port Waratah near Newcastle where it was to be unloaded.

The majority of the train had passed over the Coxs

Creek Bridge when it experienced an automatic

emergency application of the train’s brakes. Upon

investigation, the crew found the last six wagons had

derailed, with five of the six toppling off the bridge and

spilling their payload. The last (sixth) of the derailed

wagons remained in a precarious upright position on the bridge. There were no personnel

injured as a result of the derailment. All of the derailed wagons were damaged beyond

economical repair. The bridge was extensively damaged with 130 metres of track destroyed

as a result of the incident. The line was reopened to rail traffic on 20 December 2012

following major partial reconstruction of the bridge.

The wagons derailed due to a lateral misalignment which formed under one or more of the

last six vehicles in the consist of train NB942.

The lateral misalignment resulted from track not being

able to contain a build up of excessive compressive

forces in the rail primarily due to: errors being made

completing track stability calculations, creep in the rails

not being controlled, the track infrastructure being in

generally poor and variable condition, inappropriate lifting

of a speed restriction, and the track leading up to the bridge not being maintained to the

applicable engineering standards.

The bridge was repaired and normal traffic resumed within a month of the derailment. The

Australian Rail Track Corporation (ARTC) subsequently completed a planned project to

significantly upgrade and strengthen the track between Gunnedah and Turrawan (near

Narrabri).



Occurrence details

Event description: Derailment of a freight train.




Technical failure


mechanism

Failure origin

Pacific National coal service NB942 derailed as a buckle

formed in the track under it as it traversed the track in the

vicinity of kilometrage 513.002. The buckle resulted from

track not being able to contain a build-up of excessive

compressive forces in the rail.

Infrastructure Track Deformation Maintenance


Findings Local


onal factor


Incorrect calculation of track stability which masked a

significant deficiency that would have alerted track

maintainers to a situation requiring ‘immediate attention or

evasive action’.

Knowledge, skills

and experience

Normal

operations

knowledge

and skills

Infrastructure

construction and

maintenance

With the exception of one incorrect adjustment, creep was

allowed to remain uncontrolled.

Organisation

management

Monitoring,

review and

validation

Infrastructure

construction and

maintenance

With the exception of the bridge, the track infrastructure

was in generally poor and variable condition.

Organisation

management

Monitoring,

review and

validation

Infrastructure

construction and

maintenance

The track leading up to the bridge abutment not being

managed as a bunching point.

Organisation

management

Monitoring,

review and

validation

Infrastructure

construction and

maintenance

The lifting of a speed restriction in association with spot

tamping of the track nearby.

Knowledge, skills

and experience

Normal

operations

knowledge

and skills

Infrastructure

construction and

maintenance



47. Gulgong – Wagon structural failure – 5 Dec 2012

At 3.25am at Gulgong in NSW a train crew conducting a roll by inspection noticed that a

wagon had sagged in the middle and was almost dragging on the ground. The wagon was

one of a fleet of 100 skeletal type container wagons belonging to QUBE Logistics (Rail) Pty

Ltd, all of which had entered service within the previous 12 months.

The immediate cause of the wagon sagging was the

failure of a weld that ran transversely across the centre

of the underside of the wagon’s main structural beam.

The bending forces applied to the welded joint then

transferred to the side members (sills) which gradually

split, from the location of the failed welded joint,

upwards to the top member of the beam.

A second wagon on the same train was found to have welding defects in the same joint as

the failed wagon. Both welds were performed by the same welder on consecutive days.

Inspections during manufacture, including ultrasonic

testing in the case of the joint that failed, did not identify

any defects, nor did visual inspections carried out during

routine maintenance after the wagons entered service.

The investigation found that the wagon manufacturer,

located in the United States of America, used a welded joint that may not have complied with

relevant Australian Standards. Also, the manufacturer did not provide accurate instructions

for performing the weld to its welding personnel; did not have complete records in relation to

welder experience and qualifications; and did not detect flaws present in the failed wagon, or

some other wagons, through testing or inspection during the manufacturing process.



Occurrence details

Event description: Wagon structural failure.



Occurrence Classification Rolling stock irregularity Other irregularity - wagon

Individual actions Findings Person type Activity type Error/Violation

type

The welding of the joint had not been performed

proficiently. The weld had not penetrated through to or

fused with the backing bar and the weld lacked side fusion

with the steel plates.

Rolling stock maintainer Operating

equipment

Error

Technical failure


mechanism

Failure origin

The structural failure of container wagon SQDY 00060G

was due to the failure of the welded joint in the centre of

the bottom member of the wagon’s spine.

Rolling stock – Car-

body

Fracture Manufacture


Findings Local


onal factor


The welding process specified by ARI had not been

modified for the thicker plate used and the gap between

the plates had not been increased commensurate with the

increased thickness of plate. This made the weld

technically difficult for the welder.

People management Job/task

design

Rolling stock

construction and

maintenance

The defective welded joint had not been detected during

inspections, including Ultrasonic Testing, carried out as

part of the manufacturing process.

Knowledge, skills

and experience

Normal

operations

Rolling stock

construction and

maintenance

The defective welded joint was not detected during routine

maintenance inspections after the wagon had entered

service.

Knowledge, skills

and experience

Normal

operations

Rolling stock

construction and

maintenance

The joint was of a square butt welded configuration. This

type of joint is technically more difficult to perform than a

‘V’ type joint.

Equipment, plant

and infrastructure

Other -

design

Rolling stock

construction and

maintenance

The design of the wagon placed a transverse welded joint

in the centre of the bottom member of the central spine. As

this is within a region of relatively high stress, it is not

considered to be an optimum location for such a joint

Equipment, plant

and infrastructure

Other -

design

Rolling stock

construction and

maintenance

ARI was unable to provide records to demonstrate that all

the welders who performed the welds were ‘qualified’ or

otherwise proficient in the execution of this particular weld.

Organisation

management

Information

management

Rolling stock

construction and

maintenance

The standard of the final product was poor as evidenced

by flame cut plate edges, poor weld finish, undercut welds

and gaps present between plate and backing bar.

Knowledge, skills

and experience

Normal

operations

Rolling stock

construction and

maintenance



48. Rennie – Derailment – 3 January 2013

On 3 January 2013, El Zorro loaded grain service 5CM7 derailed 10 of its 40 wagons just

south of the township of Rennie while en route from Oaklands in southern New South Wales

to Melbourne via Benalla in Victoria. All 10 derailed wagons were extensively damaged and

approximately 260 metres of track infrastructure was destroyed. No injuries were reported as

a result of the derailment and none of the contents from the derailed wagons was spilt.

The investigation found that the train derailed when it

traversed a buckle in the track. The buckle was due to

the build-up of excessive compressive stress resulting

from rail creep which was exacerbated by high

temperatures on the day of the incident and the week

leading up to it.

There was evidence that rail creep had persisted over a number of years, that track

geometry was progressively deteriorating, and that sleepers and fasteners were becoming

life-expired. Despite a number of indicators that the track

was deteriorating, preventative maintenance had not been

initiated. Additionally, there was no extant document

providing guidance as to how to respond to a situation

where a combination of track parameters on this line had

reached a limit that must not be exceeded.

As had been the case in previous investigations, difficulties were encountered in obtaining

downloads from locomotive data loggers.



Occurrence details

Event description: Freight train derailment.




Technical failure


mechanism

Failure origin

El Zorro grain service 5CM7 derailed when the train

traversed a buckle in the track at 289.852 km. The track

buckle was likely to have been caused primarily by rail

creep that had accumulated in the last three years,

producing excessive compressive (or buckling) stress

during periods of high temperature. The ability of the track

structure to resist buckling had been progressively

diminished by: deteriorating track geometry as measured

by the Track Condition Index (TCI); and poor sleepers with

loose fastenings not holding the rail to the sleepers,

thereby compromising the rigidity of the track structure.

Infrastructure

Track



Findings Local

Condition/Organis

ational factor


ARTC does not have a standard or guideline to assist track

managers in responding to an unfavourable aggregate of

individual track geometry measurements, as expressed by

the TCI.

Procedures Absent

procedure

Infrastructure

construction and

maintenance

In the absence of mandatory detailed inspection of factors

that govern track stability on Light Weight Lines, ARTC’s

governance and performance monitoring arrangements did

not provide a level of oversight of track stability

management sufficient to detect and correct the sort of

deficiencies that were discovered to exist during this

investigation.

Organisational

management

Information

management

Infrastructure

construction and

maintenance



49. Moree – Level crossing collision – 21 May 2013

At 7.20am on Tuesday 21 May 2013, track measuring and recording train NK81 travelling

north from Narrabri towards Moree collided with the rear left corner of a utility travelling west

across a railway crossing on Tapscott Road, known locally as Dunavant’s Crossing. The

driver of the utility was uninjured in the collision and drove from the scene after speaking to

the train crew.

The train, operated by Pacific National for the

Australian Rail Track Corporation, consisted of three

specially equipped carriages instrumented to record a

range of track geometry parameters. It was hauled by

PN locomotives 48138 and 48104, and was travelling

at approximately 96 km/h. The railway crossing was

passively protected by stop signs and associated roadside signs.

The driver of the utility stopped at the stop sign on the eastern side of the crossing before

proceeding across the crossing into the path of the approaching train. Although he believes

he did look out for trains, he could not explain why he did

not see the train. The most likely explanation is that it was

a case of inattentional blindness, the phenomenon of ‘look

but did not see’.

There were no matters directly associated with the

incident that warranted a recommendation to any party

involved. However, in the course of the investigation, it was noted that the required interface

agreement for the crossing had not been finalised between the Moree Plains Shire Council

and the Australian Rail Track Corporation.



Occurrence details

Event description: Level crossing collision between road motor vehicle and freight train.





Individual actions


type

The collision occurred as a result of the utility driver, after

stopping at the crossing, proceeding across without first

giving way to the approaching train.

Light passenger

vehicle driver

Monitoring and

checking

Error


Findings Local

Condition/Organis

ational factor


It is possible that the utility driver either did not look in the

direction of the train or, due to inattentional blindness,

looked but failed to see the train.

Personal factors

Pre-occupation

Road

environment



50. East Maitland – Safeworking incident – 27 November 2013

At about 2.15pm on 27 November 2013, a group of five rail safety workers was engaged in

manually removing rubbish and surplus materials from a track near East Maitland station.

They were exposed to the danger of being hit by a train when the Protection Officer’s view of

an approaching train was obscured by a train passing on the adjacent track. The Protection

Officer (PO) had not anticipated such an eventuality in planning the worksite protection.

When the PO (acting as a lookout) saw the

approaching train, he gave warning using a handheld

air horn. The workers responded and were able to

move to a safe place just before the approaching train

reached their location. The PO had recently been

assessed and certified as competent by the Centre for

Excellence in Rail Training which used documentation provided by the Australian Rail Track

Corporation (ARTC) for the on-the-job training component. The safeworking incident

occurred on his second day of work following certification.

The investigation identified deficiencies in the process used by training providers to establish

current competency in vocational rail safety functions. Leighton Contractors Pty Limited, who

were undertaking the work under contract to the ARTC,

had recognised this and introduced a process to satisfy

themselves that all safeworking personnel, whether direct

employees or contractors, were suitably qualified and

experienced to carry out the tasks to which they were

assigned. However, the PO’s employer, Momentum Rail,

had no such process, instead relying on the fact that personnel had been issued with

certificates of competency as evidenced by their rail safety worker’s competency cards.

Leighton Contractors were unaware of this and accepted the PO to be in charge of the

worksite. In response to the incident, Leighton Contactors tightened their procedures to

ensure that supplied contractor personnel met their standards.



Occurrence details

Event description: Near miss with workers.




procedure breach



The Momentum Rail PO had not previously experienced a

loss of sighting distance due to the passage of rail traffic

on an adjacent track and had not taken it into account

when planning his worksite protection.

Infrastructure

maintainers

Preparation

and planning

Error

The Leighton’s’ site supervisor, a protection officer with 39

years experience, did not question the work method,

specifically continuing to work while the Up train passed.

Infrastructure

maintainers

Monitoring and

checking

Error


Condition/Organi

sational factor


The training and assessment leading to the issue of the

PO’s certification had not identified this gap in his

experience and therefore his competence.

Training and

assessment

Currency

tracking

Infrastructure

construction and

maintenance

Leightons made an assumption that their supplier,

Momentum Rail, had a system in place to ensure that the

PO provided for the job was suitably qualified, experienced

and competent, beyond being the holder of an appropriate

certificate of competency, to undertake the required tasks

at the worksite.

Organisational

management

Contractor

management

Infrastructure

construction and

maintenance

The request from Leightons for the supply of a PO at the

same location on 14 and 15 November had included the

following passage: “It is important that the candidate has

knowledge of the area as tight track curvature and high

track speeds exist”. This requirement was not reiterated in

the request for the supply of a PO for 26 to 28 November.

Organisational

management

Contractor

management

Infrastructure

construction and

maintenance

The planned work was not reviewed during one of

Leighton’s weekly safeworking meetings and so the

opportunity to review the method of work and stipulate

minimum safeworking requirements was lost.

Organisational

management

Risk and/or

change

management

Infrastructure

construction and

maintenance

The on-job training provided to the PO was inadequate.

Although the PO’s on-job workbook was signed off to

confirm that the PO had demonstrated knowledge in a

wide range of tasks and procedures, the reality was

different.

Training and

assessment

Initial training Infrastructure

construction and

maintenance



51. Moss Vale – Safeworking incident – 21 December 2013

At approximately 10.14pm on 21 December 2013 near Moss Vale station, passenger service

ST21 travelling on the Down Main line passed stationary Pacific National freight service

6AB6 on the Up Main line. This alerted the crew of 6AB6 to the fact that worksite protection

had not been in place for the co-driver while he was investigating the report of a warm axle

on one of the train’s wagons.

The protection was sought by the driver of 6AB6 and

was understood to have been implemented by the

network controller located at the Australian Rail Track

Corporation’s Network Control Centre South at Junee.

However, when the network controller was about to

implement protection arrangements, he was distracted

by a personal phone call which resulted in him moving away from his control panel. During

his absence, he was not relieved at the panel and, on return, took no further action to

implement the worksite protection.

Even though controlled signal blocking was not implemented, the network controller told the

crew that it had. In addition to the distraction, the investigation found that the network

controller’s performance may have been fatigue-impaired. He had been working for 9 hours

of a 10 hour shift without a scheduled break. It was normal practice in the control centre not

to have scheduled breaks.

The investigation also identified inadequacies in the use of verbal communication protocols,

post-incident drug and alcohol testing and the train driver’s adherence to procedures in the

implementation of controlled signal blocking.



Occurrence details

Event description: Near miss with workers.



Occurrence Classification Safeworking Rule or procedure breach Track work procedure/rule breach


The network controller working the Main South ‘A’ Panel in

the Network Control Centre South at Junee did not apply

controlled signal blocking to the Down Main line as

requested by the driver of 6AB6.

Network controller Operating

Equipment

Error

The driver of 6AB6 did not confirm that there were no trains

already in the section; he did not confirm the signal numbers

and there was no read back when he requested controlled

signal blocking as required by the Network Rules and

Procedures.

Train crew Communicating Error



onal factor


The network controller was distracted by a personal phone

call and then a visit by a family member at the Network

Control Centre South at a critical time during the application

of controlled signal blocking. There was no relief staff

provided to cover his absence from the panel.

Task demands Distraction Off-train operations

It is likely that the performance of the network controller may

have been degraded due to fatigue-impairment. This

likelihood was due to the length of time on task and the lack

of any scheduled rest breaks.

Personal factors Fatigue Off-train operations

Communication between the Control Centre and the train

crew lacked the use of standard terms required by the

network procedures. In general, transmissions were informal

and conversational rather than operationally formal

according to prevailing communications protocols.

Social environment Norms and

values


The requirements for Drug and Alcohol testing were not

followed in that the network controller was not drug tested

following the incident and the train crew were not tested for

the presence of drugs and alcohol.

Organisational

management

Compliance Off-train operations

The initial incident report by ARTC did not include critical

information about the safeworking incident.

Organisational

management


The recertification process of the network controller did not

include any reference to controlled signal blocking.

Organisational

management


The network controller started his shift at 0700 on 22

December 2013 after a short turnaround time since he

finished his last shift the previous evening at 2300.

Organisational

management

Business

planning


There are no designated locations where train crew are able

to conduct axle bearing inspections after an axle alert is

triggered by a trackside detector.


infrastructure

Absent

infrastructure




Appendix A: Contributing factors framework overview

Individual/team actions Person Type Activity Type Error/violation type

Infrastructure maintainers Preparation and planning Error

Network Controllers Operating equipment Violation

Rolling stock maintainers Communicating Unknown error/violation

Train crew Monitoring and checking

Station crew Handover/takeover

Terminal staff Other activity type

Light Passenger vehicle drivers

Heavy freight vehicle drivers

Emergency service staff

Technical failure mechanism Failed Component Failure Mechanism Failure origin

Rolling stock – bogies, braking, car-body,

coupler/drawgear, load restraint, on board traction

system, on board train protection system. Other.

Corrosion Design

Infrastructure – bridge, building, drain/flood

mitigation, lineside rolling stock fault detection

system, overhead power system, road-rail interface,

switches crossings, track, track protection device,

track support, tunnels, other.

Deformation Manufacture

Signalling and communications – communication

systems, control interface equipment, interlocking

system, traffic control, train detection system,

wayside signalling equipment, other.

Electrical Installation

Other – other vehicles Fracture Operation

Mechanical Maintenance

Software/firmware Decommissioning

Wear Unknown failure origin

Other failure mechanism

Unknown failure mechanism

Local conditions and organisational factors Local Conditions Organisational Factors Functional Area

Personal factors Procedures Freight handling

Knowledge, skills and experience Training and assessment Infrastructure construction &

maintenance

Task demands Equipment, plant and

infrastructure


Physical Environment People management On-train operations

Social environment Organisational management Passenger management

External organisational

influences

Rolling stock construction &

maintenance

Road environment

Emergency Management

OTSI Rail Summary Report


Appendix B: Contributing factors framework analysis

Individual/team action

Person

Activity Error/violation No. Report ID number

Infrastructure maintainer Communicating Error 3 33,35,44

Infrastructure maintainer Monitoring and checking Error 4 21,30,35,50

Infrastructure maintainer Monitoring and checking Violation 1 31

Infrastructure maintainer Operating equipment Error 2 12,17

Infrastructure maintainer Preparation and planning Error 4 33,44,45,50

Light passenger vehicle driver Monitoring and checking Error 3 34,39,49

Light passenger vehicle driver Monitoring and checking Unknown 3 1,6,43

Network controller Communicating Error 3 28,33,42

Network controller Monitoring and checking Error 3 7,33,41

Network controller Operating Equipment Error 1 51

Network controller Preparation and planning Error 1 14

Rolling stock maintainers Operating equipment Error 1 47

Terminal staff Monitoring and checking Unknown 1 25

Terminal staff Operating equipment Error 1 38

Terminal staff Operating equipment Violation 1 2

Train crew Communicating Error 3 7,28,51

Train crew Monitoring and checking Error 6 10,14,23,24,29,42

Train crew Operating equipment Error 8 11,15,25,26,36,37

Technical failure

Component

Mechanism Origin No. Report ID number

Infrastructure - Track Deformation Maintenance 10 3,5,18,19,20,22,25,46,

48

Infrastructure - Track Fracture Maintenance 1 16

Infrastructure - Track Other Installation/

commissioning

1 8

Rolling stock - Bogies Fracture Unknown 2 4,40

Rolling stock - Bogies Wear Installation/

commissioning

1 9

Rolling stock – Braking system Mechanical discontinuity Design 1 27

Rolling stock – Car body Mechanical discontinuity Operation 1 32

Rolling stock –Car-body Fracture Manufacture 1 47

Rolling stock- Train Detection

System

Software/

firmware anomaly

Design 1 29

Signalling and Communications

item: Control interface equipment

Other Installation/

commissioning

1 13



Local Condition/Organisational

Factor

Keywords No. Report ID number

Equipment, plant & infrastructure Absent equipment, plant & infrastructure 12 7,12,14,27,37,39,40,41,

42, 44,51

Equipment, plant & infrastructure Availability 4 1,6,9

Equipment, plant & infrastructure Control input devices design 1 40

Equipment, plant & infrastructure Functionality 15 1,2,6,15,17,22,25,26,27

,29,31,36,40,44

Equipment, plant & infrastructure Infrastructure design 6 1,14,23,24,42

Equipment, plant & infrastructure Other - design 2 47

Equipment, plant & infrastructure Reliability 1 35

Equipment, plant & infrastructure Signage 3 6,39,43

External organisational influences Industry standards or guidance 1 36

External organisational influences Regulatory activities 1 3

Knowledge, skills & experience Abnormal/emergency operations knowledge &

skills

5 1,3,6,7,15

Knowledge, skills & experience Communication skills 11 21,22,28,31,33,35,37,4

1,44

Knowledge, skills & experience Normal operations knowledge & skills 19 10,11,18,20,26,27,32,3

7,41,46,47

Knowledge, skills & experience Task experience 7 7,23,26,28

Knowledge, skills & experience Teamwork skills 2 25,37

Organisational management Business planning and asset/ resource

management

3 5,8,51

Organisational management Competence of senior personnel 2 11,37

Organisational management Communication and consultation process 3 20,38

Organisational management Compliance 3 51

Organisational management Contractor/ interface management 6 8,25,30,50

Organisational management Interface management 1 3

Organisational management Information management 10 8,10,11,30,33,36,41,47,

48

Organisational management Monitoring, review and validation 21 3,5,11,16,17,18,19,20,2

2,33,36, 46

Organisational management Policy 4 1,6,8,11

Organisational management Risk and/or change management 23 2,3,5,8,11,16,17,18,24,

31,36,38,50

People management Fitness for duty monitoring 1 11

People management Job/task design 5 31,44,47

People management Rostering/ scheduling 2 14

People management Supervision 2 30,33

Personal factors Fatigue/alertness 8 10,11,

21,23,24,33,37,51

Personal factors Health-related condition 1 25

Personal factors Motivation/attitude 4 10,19,25

Personal factors Preoccupation 2 24,49

Personal factors Stress/anxiety 1 24



Physical environment Lighting/visibility 8 10,17,21,29,42,43,44

Physical environment Noise 2 17,21

Physical environment Other –Unstable surface 1 12

Physical environment Temperature/

Humidity

2 20,25

Physical environment Weather-related factors 2 15,44

Procedures Absent procedure 13 2,7,12,18,19,20,21,36,3

7,38,44,48

Procedures Accuracy/clarity 17 7,9,12,18,21,26,33,35,3

7,40,44

Procedures Availability/

accessibility

1 41

Social environment Norms and values 5 37,44,45,51

Social environment Peer pressure 2 31,42

Task demands Distraction 12 11,17,24,26,28,29,33,3

5,37,43,45,51

Task demands High workload 3 7,28,39

Task demands Other- familiarity 1 21

Task demands Time pressure 4 12,18,31,35

Training and assessment Competency assessment 2 11,30

Training and assessment Currency tracking 2 30,50

Training and assessment Initial training 5 28,33,38,44,50

Training and assessment Ongoing training 2 24,33



Appendix C: OTSI rail investigation reports with keywords

No. Date Location Event Keywords

1 4/05/04 Baan Baa Passenger train collision with

car at level crossing

Collision; Emergency operations

knowledge & skills; Equipment

availability; Equipment functionality;

Fatality; Infrastructure design; Level

Crossing; Policy

2 1/07/04 Port Botany Shunter killed after falling from

flat top container wagon

Absent procedure; Collision, Equipment

functionality; Fatality; Risk Management

3 22/12/04 Bethungra Derailment of a freight train Abnormal/emergency operations

knowledge & skills; Deformation;

Derailment; Maintenance; Interface

management; Monitoring, review and

validation; Regulatory activities; Risk

Management; Track

4 1-7/03/05

Wauchope &

Lapstone

Derailment of freight trains Axle; Derailment; Fracture; Screwed

journal

5 6/04/05 Old Burren Derailment of a freight train Business planning and asset/ resource

management; Deformation; Derailment;

Maintenance; Monitoring, review and

validation; Risk/change management;

Track

6 31/05/05 Grawlin Plains Freight train collision with car at

level crossing

Emergency operations knowledge &

skills; Equipment Availability; Equipment

Functionality; Fatality; Level Crossing;

Policy; Signage

7 20/08/05 Bloomfield Opposing movement between

two freight trains

Abnormal/emergency operations

knowledge & skills; Absent equipment,

plant & infrastructure; Absent procedure;

High workload; Opposing movement;

Procedure Accuracy/clarity; Task

experience

8 2005 NSW A systemic investigation into

the installation of steel sleepers

Business planning & asset/ resource

management; Contractor/ interface

management; Derailment; Information

management; Installation; Policy;

Risk/change management; Track

9 16/10/05 Conoble Derailment of a freight train Bogie; Derailment; Equipment Availability;

Installation; Procedure – Clarity; Wear

10 4/11/05 Lidcombe SPAD and derailment of a

freight train

Catchpoints; Derailment;

Fatigue/alertness; Information

management; Motivation/ attitude; Normal

operations knowledge & skills; SPAD;

Visibility

11 15/04/06 Ariah Park Shunter killed crushed between

rolling stock

Collision; Competency assessment;

Competence of senior personnel;

Distraction; Fatality ; Fatigue/ alertness;

Fitness for duty monitoring; Information


validation; Normal operations knowledge

and skill; Policy; Risk/ change

management

12 22/05/06 Baan Baa Track worker killed after falling Absent equipment; Absent procedure;



from ballast wagon Procedure Accuracy/adequacy; Fatality;

Time pressure

13 30/08/06 Central to

Town Hall

tunnel

Self harm fatality in rail tunnel Fatality; Suspected suicide

14 2/09/06 North

Strathfield

SPAD and opposing movement Absent equipment, plant & infrastructure;

Infrastructure design; Opposing

movement; Rostering/ scheduling; SPAD

15 6/09/06 Thirroul SPAD and derailment of a

passenger train

Abnormal/emergency operations

knowledge and skills; Catchpoints;

Derailment; Functionality; SPAD

Weather-related factors

16 1/10/06 Nyngan Derailment of a freight train Derailment; Fracture; Maintenance;

Monitoring, review & validation; Risk

change management; Track

17 7/11/06 Sandgate Track work injury Collision; Equipment Functionality; High

Workload; Monitoring, review & validation;

Noise; Risk/ change management

18 11/0107 Leeton Derailment of a freight train Absent procedures; Deformation;

Derailment; Maintenance; Monitoring,

review & validation; Normal operations

knowledge and skills; Procedures

accuracy/clarity; Risk/ change

management; Time pressure; Track

19 14/01/07 Euabalong

west

Derailment of a freight train Absent procedures; Deformation;


review & validation; Motivation/attitude;

Track

20 8/0207 Connemarra Derailment of a freight train Absent procedures; Communication and

consultation process; Deformation;


review & validation; Normal operations

knowledge and skills;

Temperature/humidity; Track

21 16/07/07 Singleton Track worker fatalities Absent procedures; Communication ;

Collision; Familiarity; Fatigue/alertness;

Fatality; Lighting/visibility; Noise

Procedures Accuracy

22 29/0108 Breeza Derailment of a freight train Communication; Derailment; Deformation;

Maintenance; Monitoring, review &

validation; Equipment Functionality; Track

23 7/109 Homebush SPAD and derailment of a

passenger train

Catchpoints; Derailment; SPAD;

Fatigue/alertness; Infrastructure design;

Task experience

24 24/01/09 Unanderra SPAD and derailment of a

passenger train

Catchpoints; Derailment; SPAD;

Distractions; Fatigue/alertness;

Infrastructure design; Preoccupation;

Ongoing training; Stress/anxiety

25 8/0209 Peak Hill Derailment of a freight train Derailment; Track; Deformation;

Maintenance; Contractor/ interface

management; Equipment Functionality;

Health-related condition;

Motivation/attitude; Teamwork skills



26 10/0509 Goobang SPAD and collision Collision; Distractions; Equipment

Functionality Normal operations

knowledge and skill; Procedures

Accuracy/clarity; Task experience; SPAD

27 28/07/09 Temora Runaway wagon Absent equipment, Equipment

Functionality; Normal operations

knowledge and skills; Plant and

infrastructure; Runaway

28 28/10/09 Glenlee Near miss with train crew Communications skills; Distractions; High

workload; Initial training; Task experience;

Safeworking

29 27/02/10 Darling Park Collision between two Monorail

trains

Collision; Communications skills; Design;

Distractions; Equipment Functionality

Lighting/ visibility; Software/firmware

anomaly ; Train Detection System

30 13/03/10 Whittingham Derailment of a freight train Contractor/ interface management ;

Derailment; Points; Information

management; Supervision; Training

Competency assessment; Training

Currency tracking

31 1/04/10 Strathfield Near miss with maintenance

staff

Communication skills; Equipment

Functionality Job/task design; Peer

pressure; Risk/change management;

Safeworking; Time pressure

32 11/04/10 Woy Woy Container gate detached Collision, Normal operations knowledge

and skills

33 13/04/10 Kogarah Track worker killed after being

struck by passenger train

Collision; Fatality; Communication skills;

Distraction; Fatigue/alertness; Information


validation; Ongoing training; Procedures

Accuracy/Clarity; Supervision; Training

Initial training

34 1/09/10 Wee Waa Level Crossing Collision Fatality; Level Crossing

35 29/10/10 Bankstown Near miss with track workers Communication skills; Distraction;

Equipment Reliability; Procedures Clarity;

Safeworking; Time pressure

36 7/02/11 Unanderra Uncontrolled movement Absent procedures; Equipment

Functionality; Industry standards or

guidance ; Information management;

Monitoring review and validation; Risk

change management; SPAD,

37 1/04/11 Zig Zag railway Collision between a train and a

track vehicle

Absent equipment, Collision; plant &

infrastructure; Competence of senior

personnel; Communication skills;

Fatigue/alertness ; Normal operations

knowledge & skills; Teamwork skills

38 3 /05/11 Enfield yard Runaway Absent procedures; Communication and

consultation process, Derailment, Initial

training; Risk management; Runaway

39 2/09/11 Woy Woy Level crossing collision

passenger train and car

Absent equipment; High workload; Level

Crossing; Signage

40 23/11/11 Clifton Derailment of a freight train Absent equipment; Axle; Bogie; Control

input devices design; Derailment;



Functionality equipment ; Fracture;

Procedures Accuracy/adequacy

41 12/12/11 Unanderra Safeworking incident Absent equipment; Communication skills;

Information management ; Normal

operations knowledge and skills;

Procedures Availability/ Accessibility;

Safeworking

42 7/03/12 Gunnedah SPAD and opposing movement Absent plant; Infrastructure design;

Lighting/visibility; Opposing movement ;

Peer pressure; SPAD

43 4/05/12 Nundah Level crossing collision Fatality; Level Crossing; Distractions;

Lighting/visibility; Signage

44 18/05/12 Bengalla Ballast train collision Absent equipment ; Absent procedure;

Collision; Communication skills ;

Equipment Functionality; Initial training ;

Job/task design; Lighting/visibility; Norms

and values; Procedures Clarity; Weather-

related factors

45 17/07/12 Summit Tank Safeworking incident Distractions; Norms and values;

Safeworking

46 28/11/12 Boggabri Derailment of a freight train Deformation; Derailment; Maintenance;

Monitoring, review and validation; Normal

operations; Track

47 5/12/12 Gulgong Wagon structural failure Job/task design; Equipment design;

Information management; Normal

operations; Rolling stock

48 3 /01/13 Rennie Derailment of a freight train Absent procedure; Deformation;

Derailment; Maintenance; Information

management; Track

49 21/05/13 Moree Level crossing collision Level Crossing; Pre-occupation

50 27/11/13 East Maitland Safeworking incident Contractor management; Initial training;

Risk and/or change management;

Safeworking; Training Currency tracking

51 21/12/13 Moss Vale Safeworking incident Absent infrastructure; Business planning;

Compliance; Distraction; Fatigue; Norms

and values; Safeworking



Appendix D: Incident notification and classification

Incident Notification

The Rail Safety National Law requires notifiable occurrences to be reported. A notifiable

occurrence means an accident or incident associated with railway operation that has, or

could have, caused significant property damage, serious injury, death or that is, or is of a

class that is, prescribed by the national regulations to be a notifiable occurrence or class of

notifiable occurrence.

Incident Classification

Each notifiable occurrence can be classified according to the Office of National Rail Safety

Regulator Guideline: Classifying Notifiable Occurrences – Occurrence Classification–

Guideline (OC-G1) (ONRSR, 2012).

This was done for each of the OTSI rail investigations from 2004-2013 and the top event6

classification is listed below.

OC-G1 Occurrence Categories CATEGORY SUB-CATEGORY OTSI INVESTIGATION

Derailment 1.1 Running line 3. Bethungra 2004

4. Lapstone & Wauchope 2004

5. Old Burren 2005

8. Steel Sleepers 2005

9. Conoble 2005

10. Lidcombe 2005

15. Thirroul 2006

16. Nyngan 2006

18. Leeton 2007

19. Eubalong West 2007

20. Connemarra 2007

22. Breeza 2008

23. Homebush 2009

24. Unanderra 2009

25. Peak Hill 2009

30. Whittingham 2010

40. Clifton 2011

46. Boggabri 2012

48. Rennie 2013

1.2 Yard derailment 38. Enfield 2011

6 The top event is the event with the greatest adverse outcome. It is independent of the sequence

of events.



Collision 2.1 Running line collision 11. Ariah Park 2006

21. Singleton 2007

26. Goobang 2009

29. Darling Park 2010

32. Woy Woy 2010

33. Kogarah 2010

37. Zig Zag 2011

2.2 Yard collision 2. Port Botany 2004

17. Sandgate 2006

12. Baan Baa 2006

44. Bengalla 2012

Level crossing occurrence 3.1 Collision with road vehicle 1. Baan Baa 2004

6.Grawlin Plains 2005

34. Wee Waa 2010

39. Woy Woy 2011

43. Nundah 2012

49. Moree 2013

3.2 Collision with person

3.3 Level crossing equipment failure

3.4 Level crossing equipment damage

3.5 Near miss with road vehicle

3.6 Near miss with person

3.7 Other level crossing occurrence

Signal passed at danger 4.1 Driver misjudged 36. Unanderra 2011

4.2 Completely missed while running 14. North Strathfield 2006

42. Gunnedah 2012

4.3 Starting against signal

4.4 Signal restored as train approached

4.5 Other signal passed at danger

Proceed authority exceeded 5.1 Driver misjudged

5.2 Completely missed while running

5.3 Other proceed authority exceeded

Signalling and other proceed authority

systems irregularity

6.1 Wayside systems signal irregularity

6.2 In-cab signalling systems

irregularity

6.3 Token based systems irregularity

6.4 Communications based train

authority systems irregularity

6.5 Other Signalling and other proceed

authority systems irregularity



Slip, trip or fall 7.1 To/from train

7.2 Between platform and train

7.3 On train

7.4 On track

7.5 On platform/concourse

7.6 On/from escalator/lift

7.7 On/from stairs/ramps

7.8 From structure

7.9 Caught in train doors

7.10 Other slip trip fall

Load irregularity 8.1 Door open

8.2 Out of gauge

8.3 Load shift

8.4 Uneven distribution of load

8.5 Loose load fastening

8.6 Other load irregularity

Dangerous goods 9.1 On train

9.2 Off train

Safeworking rule or procedure breach 10.1 Wayside signalling system

procedure/rule breach

10.2 In-cab signalling system


10.3 Token based system


7. Bloomfield 2005

10.4 Communication based system


10.5 Track work procedure/rule breach 28. Glenlee 2009

31. Strathfield 2010

35. Bankstown 2010

41. Unanderra 2011

45. Summit Tank 2012

50. East Maitland 2013

51. Moss Vale 2013

10.6 Work scheduling

practice/procedure/rule breach

10.7 Other safeworking rule or

procedure breach



Track and civil infrastructure

irregularity

11.1 Broken rail

11.2 Misaligned track

11.3 Spread track

11.4 Points irregularity

11.5 Track obstruction

11.6 Civil infrastructure irregularity

11.7 Bridge strike

11.8 Other track infrastructure

irregularity

Rolling stock irregularity 12.1 Train parting

12.2 Wheel/axle failure

12.3 Defective bearing

12.4 Faulty passenger door

12.5 Braking system

12.6 Other rolling stock irregularity 47. Gulgong 2012

Electrical infrastructure irregularity 13.1 Overhead traction supply

13.2 Other electrical irregularity

Fire 14.1 Fire on train

14.2 Lineside fire

14.3 Station/terminal fire

Explosion 15

Suspected suicide or attempted

suicide

16.1 Suspected suicide 13. Town Hall tunnel 2006

16.2 Attempted suicide

Alcohol or drugs irregularity 17

Train warning enforcement systems

irregularity

18.1 Warning systems irregularity

18.2 Enforcement systems irregularity

Communication systems failure 19

Railway network security 20.1 Railway trespass

20.2 Alleged assault

20.3 Terrorism/sabotage

20.4 Vandalism

20.5 Theft

20.6 Other railway network security

Runaway 21 27. Temora 2009

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