A near-hit of passengers on live track highlights the importance of establishing clear roles and responsibilities and adhering to established rules and procedures.
The ATSB has completed its investigation into a 2014 incident near Kilbride, New South Wales in which passengers were brought off a stranded train without adequate measures being taken to keep them safe.
At 1137 on 22 May 2014, NSW Train XPT passenger service NT33 was travelling from Paterson to Kilbride. The track is a single standard-gauge line that mostly carries a mix of passenger and freight trains, and there is a crossing loop at Kilbride to allow trains to pass each other. As the train approached the loop at a speed of 118 kilometres an hour, the driver observed a bus at a road level crossing up ahead and realised that, beyond that, there were people on the track walking down towards him.
A disabled coal train had delayed an earlier passenger service (V938), and the passengers had been detrained to reach alternative road transport. The train crew of V938, however, had not complied with the Australian Rail Track Corporation network rules when detraining the passengers from their train.
At the time, Sydney Trains and NSW Trains were in a transitional period, assuming operation and maintenance functions that had previously been held by RailCorp. A services contract and protocols had been developed to identify the roles, responsibilities and limits of authority of personnel throughout the change, but on the day of this incident, there was confusion and assumptions among the crew as to who had done what in regards to ensuring appropriate track protection.
All of this had resulted in the crew unknowingly placing the passengers in the path of the oncoming NT33.
We cannot afford to make assumptions when it comes to safety.
The driver of NT33 immediately made an emergency brake application and sounded the horn continuously. The train finally came to a stand approximately 80 m short of the people.
There were no reported injuries as a result of the incident, but this near-miss shows the importance of strict adherence to recognised detraining and track protection procedures when transferring passengers from a stranded train to a safe place.
The investigation also found that key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority. This misunderstanding of roles, responsibilities and limits of authority by operational employees likely contributed to inadequate communication between critical safe working positions.
ATSB Executive Director of Transport Safety Nat Nagy says it is essential that safety systems are fully developed and understood by all.
“Thankfully, no one was injured,” Mr Nagy said. “But this shows that we cannot afford to make assumptions when it comes to safety.”Last update 17 January 2018