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COLLISION between 9221 & 9T66 (TIMELINE OF EVENTS (9221 driver…
COLLISION between 9221 & 9T66
PEOPLE
National Control Office (NCO)
Once 9221 crew advised clear track, NCO approved 9T66 to proceed (Australian Transport Safety Bureau, 2018)
Provided limiting authority to both train crews (Australian Transport Safety Bureau, 2018)
Aurizon rail crew - train 9T66/locomotive 2838
Attempted visual check to confirm clear track, however sight impeded by sweeping curve (Australian Transport Safety Bureau, 2018)
When they discovered the hazard, applied emergency brakes however impact could not be averted (Australian Transport Safety Bureau, 2018)
Waited for NCO signal and then attempted to pass 9221 (Australian Transport Safety Bureau, 2018)
Crew consisted of two members, without a spare crew as they only completed short distance trips at the time of the incident (Australian Transport Safety Bureau, 2018)
Working hours? Fatigue? Decision-making?
Pacific National rail crew - train 9221/locomotive 8316
Relied solely on train distance measurement systems with no visual inspections undertaken to confirm clear track (Australian Transport Safety Bureau, 2018)
Were unaware that ground distance system was not working properly (Australian Transport Safety Bureau, 2018)
Contacted NCO to advise track was clear and block could be lifted (Australian Transport Safety Bureau, 2018)
Contacted crew of 9T66 to confirm track was clear (Australian Transport Safety Bureau, 2018)
Crew consisted of two teams of two members, with the other two resting while two operated the train on a rotating shift basis (Australian Transport Safety Bureau, 2018)
Working hours? fatigue? Decision-making?
WORKPLACE
Queensland Rail (including NCO)
Some methods of determining clear track (reviewing distance from leading locomotive to front BLB) not specified in manual
Install and maintain Block Limit Boards (BLB's)
Produce Standard General Operational Safety Manual
Pacific National
Maintenance facility disconnected ground radar equipment and put train back into service (Australian Transport Safety Bureau, 2018)
Two rear train markers located on rear and fourth from rear wagons on 9221, despite QR standards calling for one only on rear wagon (Australian Transport Safety Bureau, 2018)
MANAGEMENT
Queensland Rail (including NCO)
Positioning of passing track with western end close to sweeping bend reduced visibility of blocked track until it was too late for 9T66 to stop (Australian Transport Safety Bureau, 2018)
Pacific National
No notification to train crew of ground radar being disconnected by maintenance staff
No information available in the locomotive to advise crew (Australian Transport Safety Bureau, 2018)
No information conveyed during pre-start briefing to advise crew (Australian Transport Safety Bureau, 2018)
No information displayed on on-board information system to advise crew (Australian Transport Safety Bureau, 2018)
Use of longer trains on Mt Isa railway meant drivers had to bring lead locomotive close to limit of authority to ensure rear wagon is clear (Australian Transport Safety Bureau, 2018)
Train crew relied solely on ground radar and GPS in positioning train rather than a system of physical inspection being made to confirm clear track (Australian Transport Safety Bureau, 2018) - potential problems with training and procedures
ATSB noted that PN procedures to determine and communicate the serviceability of a locomotive to operate as a lead locomotive were inadequate (Australian Transport Safety Bureau, 2018)
TIMELINE OF EVENTS
9221 driver notified NCO that they had cleared the main track, and NCO then gave authority to 9T66 to proceed from Oonoomurra to Cloncurry. (Australian Transport Safety Bureau, 2018)
Crew of 9T66 were contacted by crew of 9221 on train-to-train channel to confirm that the trailable points were set for their arrival, so 9T66 entered Oonoomurra at around 25 km/h. (Australian Transport Safety Bureau, 2018)
Approaching the western end of Oonoomurra, the 9T66 crew entered a large left curve, and could only see the upper profile of the bulk wagons at the rear of 9221, which appeared to be clear of the main track. (Australian Transport Safety Bureau, 2018)
9221 driver used on-board information system to measure the distance travelled after entering the right side crossing track, and stopped when the information system had notified that they had travelled 1,069m. He reasoned that this put the rear wagon would be around 70m clear of the main track. (Australian Transport Safety Bureau, 2018)
Coming out of the curve, the driver of 9T66 realised that there were three empty container wagons with the rear wagon encroaching into the pathway of 9T66 on the main line. (Australian Transport Safety Bureau, 2018)
27/2/2018 at 2334pm – Driver of 9221 notified NCO that the train was approaching Oonoomurra, as this was the limit of their authority. Driver reduced speed to around 18 km/h and entered the western end of the Oonoomurra crossing location which is approximately 1,033m in length, with trailable points at both ends to divert approaching trains to the track on the right-hand side. (Australian Transport Safety Bureau, 2018)
27/2/2018 at 2310pm – 9T66 departed Undina travelling approximately 39km west towards Oonoomurra (Australian Transport Safety Bureau, 2018)
The 9T66 driver applied the brakes, but could not stop in time, impacting with the rear corner of the rear wagon on 9221. (Australian Transport Safety Bureau, 2018)
27/2/2018 at 2310pm – 9221 departed Cloncurry, travelling approximately 14.5km east towards its limit of authority at Oonoomurra (Australian Transport Safety Bureau, 2018)
23/2/2018 - locomotive 8316 ground radar system malfunctioned (Australian Transport Safety Bureau, 2018)
26/2/2018 - Locomotive 8316 put back into service with ground radar system turned off. No notification or advice provided to rail crew that the unit was disconnected (Australian Transport Safety Bureau, 2018)
Locomotive 2838 collides with rear wagon on 9221 (Australian Transport Safety Bureau, 2018)
25/2/2018 - locomotive 8316 taken to Pacific National
maintenance facility, where ground radar was disconnected (Australian Transport Safety Bureau, 2018)
PERTINENT SYSTEMS
Functionally Integrated Railroad Electronics (FIRE) system
Length counter feature (part of the FIRE)
Doppler speed sensor (ground radar) & Global Positioning System (GPS)
End of train marker devices
Block limit boards (BLB)
Emergency brake system
Qld Rail (QR) Standard General Operational Safety Manual
Qld Rail (QR) Network Control Office (NCO)
Pacific National Repairs & Maintenance System