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Signals passed at danger

The ATSB has identified issues with fatigue management after a train passed three signals without taking any action.

The incident occurred at about 0229 on 30 January 2013, when a work crew was picking up litter on the track at Hurlstone Park. They had arranged for Absolute Signal Blocking (ASB)—a protection measure in which the area controller sets signals at ‘stop’ to prevent rail traffic from entering the affected section. The stop signals are preceded by signals set to ‘caution’, so as to give train drivers enough time to brake and come to a stop at the signal.

At that time, Pacific National freight train 9837 was travelling from Nowra to Orange, crewed by a trainee driver and a more senior co-driver. As the train reached the area of Marrickville, it passed a caution signal but the brakes were not applied as required. Forty seconds later, it passed through a stop signal.

...the ATSB investigation found that the more senior co-driver had inadvertently fallen asleep during the approach to the signals.

Immediately, a visible alert appeared and an alarm sounded at Sydenham signal complex. The area controller broadcast an emergency message ‘9837, stop, stop, stop!’ over the open channel radio to attract the attention of the crew of the train. There was no response. Ten seconds later, the area controller again broadcast the same message, and again there was no response from the train crew.

Meanwhile the work crew picking up litter on the track heard a warning from their lookouts that there was a train coming towards them on the Down Goods line. At this point the train was approximately 300 m away from them. The two members of the work crew on track moved to a safe area behind the platform.

Just before the train passed another stop signal the driver reduced the throttle from power to idle and, shortly after passing the signal, he applied the brakes, bringing the train to a stop.

There had been no injuries or damage, but the ATSB investigation found that the more senior co-driver had inadvertently fallen asleep during the approach to the signals. The trainee driver, in a reduced state of alertness, missed the first signal at caution, and the next signal at stop. He applied the brakes once the train passed the final signal at stop after realising this signal applied to his train.

A number of Pacific National’s policies and procedures were examined to determine if any area of the management or training of the train crew contributed to the incident. Fatigue management, and in particular, over- reliance on the use of bio-mathematical model scores used to roster train crew, was one area where improvement was needed. The ATSB also found that there was an absence of adequate procedures and training for drivers who were performing co-driving duties while coaching trainee drivers.

As a result of the incident Pacific National has undertaken a range of actions to improve its approach to fatigue management and the implementation of fatigue training. They have also commenced a review of ‘signals passed at danger’ risk management processes and training requirements for coach/tutor drivers. A trial has commenced of improved data loggers for the Bulk Rail fleet.

Read the investigation report, RO-2013-003.

 
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Last update 15 November 2013