ATSB: Collision between track worker and passenger train at Guildford, Western Australia on 10 February 2015


Meadow St pedestrian gate

On 10 February 2015, a Public Transport Authority (PTA) maintenance crew commenced work at Meadow Street in Guildford. The crew was maintaining the pedestrian gates adjacent to the level crossing.

At about 10.35 am, one of the track workers was struck by a Perth-bound suburban passenger train. Tragically, the track worker died in the accident.

The ATSB investigation found that the PTA maintenance workers had not implemented any form of track worker protection at the work site. This was partially due to the PTA not having documented instructions specifying the level of protection required, preferring that track workers make their own assessment based on their knowledge of the Network Rules. The ATSB found that, under these arrangements, track workers could make an incorrect assessment, placing themselves at a greater risk of being struck by a train.

A review of the safeworking training provided to the track workers found that the training material did provide a suitable level of safe-working knowledge.

Following the occurrence, the toxicology report on the deceased track worker identified the presence of amphetamine and methamphetamine; methamphetamine being a prescribed drug under the Rail Safety Regulations 2011. The use of stimulants such as methamphetamine is associated with a range of neurocognitive effects in humans that may affect performance.

The ATSB found that in this instance, the presence of a prescribed drug within the worker’s system appeared to be a relatively isolated case. An examination of the company’s drug and alcohol policy/procedures found them to be generally effective in managing drugs and alcohol in the workplace.

The PTA issued a safety alert following the incident to highlight the importance of implementing the correct level of track worker protection. The subsequent introduction of new safeworking rules, track access accreditation levels and training further supported this.

Further, the PTA has created the role of Workplace trainer and assessor with the task of ensuring track workers comply with the network rules by way of competency-based assessments. Implementation of a new track access accreditation system, with improved training and job mentoring, has also commenced.

Safety message
This incident strongly emphasises the need for rail transport operators to provide clear and concise work instructions to employees working within the railway corridor. It also highlights the potential for recreational and other drug use to impair performance and affect workplace safety.

ATSB investigation report:

Collision between track worker and passenger train at Guildford, Western Australia on 10 February 2015

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The Australian Transport Safety Bureau: Collision between freight trains 2MP1 and 2MP9 at Mile End, SA on 31 March 2014


At about 0730 (CDT) on 31 March 2015, intermodal freight train 2MP9 passed No. 1 signal at the southern end of the Mile End crossing loop (South Australia). The signal was displaying a ‘Calling on/Low speed’ indication. The train proceeded at low speed, but subsequently collided with the rear end of intermodal freight train 2MP1, which was stationary on the main line. The collision resulted in moderate track damage and the derailment of three wagons at the rear of train 2MP1. There were no injuries to train crews.

The ATSB determined that the signalling and communications systems were operating correctly and as designed. The investigation found that the driver of train 2MP9, on receiving a ‘Calling on/Low speed’ signal indication, proceeded at the prescribed speed of less than 25 km/h, but was unable to stop the train. The driver was aware that the operational rules stipulate that ‘block ahead may be occupied or obstructed’, but did not expect that train 2MP1 was stationary on the track so close ahead. As he approached train 2MP1, some stumpy vegetation and a low fence initially obscured his view of the empty flat wagons at the rear of the train. When the driver finally saw the rear of train 2MP1, he immediately made an emergency brake application, but was unable to stop the train before it collided with 2MP1.

Fig 7

The ATSB noted that the pathing of a train by a network control officer (NCO) onto a line occupied by a preceding train, when an alternate route is available and not obstructed, presents an elevated level of risk. Similarly, well thought out and clear communications between an NCO and crew of an approaching train, as to the proximity of a train occupying the track ahead, can significantly enhance situational awareness and reduce operational risk.

The Australian Rail Track Corporation (ARTC) and SCT Logistics have implemented a range of proactive strategies for enhancing the safe operation of train movements when entering an occupied section of track under a ‘Proceed restricted authority’ (PRA). This includes the use of all available infrastructure to reduce risk, encouraging communications between train drivers and NCOs where clarification of operational conditions is necessary, and a review of the National Train Communications System (NTCS) for the Adelaide area.

Safety message

Train drivers should carefully consider their obligations when accepting a ‘Calling on/Low speed’ signal indication in relation to sighting constraints, train speed and occupation of the track ahead. In circumstances where sighting constraints may exist, drivers should consider requesting further information from the NCO before moving through the track ahead.

NCOs should carefully consider the pathing of trains under their control, and the communication of information that may mitigate collision risk when dispatching trains.

Final report: Collision between freight trains 2MP1 and 2MP9 at Mile End, SA on 31 March 2014

The ATSB has released its investigation report: Derailment of Sydney Trains Passenger Train 602M near Edgecliff station, Sydney, NSW on 15 January 2014

rId24 Picture 15_512x302

 Source: Office of Transport Safety Investigations (OTSI)

At about 1654 on 15 January 2014, a Sydney Trains service made up of two four-carriage Tangara electric multiple units, entered the underground section of the Eastern Suburbs Line under Sydney city centre heading towards its destination, Bondi Junction. Some smoke and a burning smell were apparent emanating from the train at Central station and at all subsequent stations to Bondi Junction. A number of station and train crewing staff were aware of this but the condition was not reported to the appropriate network control officer as required under Sydney Trains’ Network Rules and Procedures.

The train terminated at Bondi Junction where a different driver took control of the train before it departed on its return journey. It then travelled to the next station, Edgecliff. Shortly after departure from Edgecliff, at 1726, the lead bogie of the third carriage derailed due to a broken axle on the leading bogie of the third carriage. A piece of angle iron that became dislodged from the track infrastructure penetrated the floor of the third carriage and entered a space occupied by passengers.

The ATSB found that an unauthorised, non-standard repair had been carried out on the axle in December 1998 or January 1999 which introduced stress initiators, causing a crack to develop which over time propagated to the extent that the axle failed in service.

It was also determined that a number of organisational factors contributed to the incident with examples of poor communication and lack of adherence to procedures and reporting lines leading to the train continuing in service and subsequently derailing.

Sydney Trains and their maintenance contractors undertook an archival document search and determined that seven axles, including the failed axle, had been repaired in the same way. All were immediately removed from service.

Sydney Trains, after conducting its own investigation into the circumstances surrounding the incident, produced a number of safety recommendations which the organisation is considering through its own Safety Action Management procedures.

Safety message
Rail operators should ensure that maintenance procedures are followed and that non-standard repairs comply strictly with an approved variation and do not introduce new risks to operations.

Also, rail operators should review their internal training and communication pathways both within and between business units / operational areas to ensure that critical communication can occur in line with best current Rail Resource Management principle.

Full report: Derailment of Sydney Trains Passenger Train 602M near Edgecliff station, Sydney, NSW on 15 January 2014

News: Unauthorised repairs contribute to Sydney train derailment