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At about 0217 on Thursday 12 November 2009, train ST22, an XPT passenger service, was being routed into No.1 Platform Road at Cootamundra, New South Wales. The driver of the XPT received a Medium Turnout indication on signal CA74 signifying that the route into No.1 Platform Road was set and unobstructed. Shortly after passing over the Gundagai Road level crossing and traversing 136 points set into No.1 Platform Road, the driver of the XPT observed the last wagon of freight train 4MB7, located on the Up Main line, was obstructing the path of his train. He applied the train brakes and stopped just short of train 4MB7.

The driver of the XPT immediately contacted the network controller and advised him of the problem. Shortly thereafter the freight train was moved forward, at the request of the network controller, to clear a path for the XPT into No.1 Platform Road.

The investigation determined that a signalling system design error allowed signal CA74 to be cleared for the passage of the XPT even though the route into No.1 Platform Road was obstructed by the last vehicle of freight train 4MB7 which was stationary on the adjacent Up Main line.

The Australian Transport Safety Bureau has determined that actions taken by the Australian Rail Track Corporation (ARTC) should mitigate the risk of a similar occurrence but has identified further issues relating to signal design, installation and commissioning where further action may enhance the strategies already put in place by the ARTC.

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Download Preliminary Report
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Preliminary report released 4 December 2009

At about 0217 on Thursday 12 November 2009, train ST22, an XPT passenger service, was being pathed into the 'Platform Road' at Cootamundra, NSW. The driver of the XPT received a 'PROCEED' indication on signal CA74, signifying that the line into the Platform Road was clear. Shortly after passing over 136B points set reverse, the driver of the XPT observed the last wagon  of freight train 4MB7 to be obstructing the path of his train. He made an emergency brake application and stopped his train just short of train 4MB7.

The driver of the XPT immediately contacted the ARTC Network Controller and advised of the problem. Shortly thereafter, the freight train was moved forward to clear a path for the XPT into the Platform Road.

Preliminary investigation of the event has determined that a signalling design irregularity affecting the 'Up Main Line' at Cootamundra allowed signal CA74 to be cleared for the passage of the XPT even though the route was obstructed by the last wagon of train 4MB7.

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Safety issues

RO-2009-009-SI-01 - RO-2009-009-SI-02 - RO-2009-009-SI-03 - RO-2009-009-SI-04 - RO-2009-009-SI-05 - RO-2009-009-SI-06 - RO-2009-009-SI-07 -  

Identification of clearance points

The South Improvement Alliance engineers did not effectively identify and record that the interface between CA74C and CA74D was the fouling point between the Up Main line and No.1 Platform Road and thus did not recognise that the rear of a train sitting on the Up Main line at this location would foul No.1 Platform Road. The design deficiency was caused by a long standing practice of not explicitly recording the clearance point on the Signal Arrangement Plan, Track Insulation Plan or in the Control Tables.

Safety issue details
Issue number:RO-2009-009-SI-01
Who it affects:Rail infrastructure managers and signal system designers
Status:Adequately addressed


 

Design philosophy

A design based on using a clearance point at the interface of CA74C and CA74D should not have been implemented until it was established that the clearance between the Up Main line and No.1 Platform Road at the interface of CA74C and CA74D tracks was adequate.

Safety issue details
Issue number:RO-2009-009-SI-02
Who it affects:Rail infrastructure managers and signal system designers
Status:Not addressed


 

Quality control process

The documentation and quality control processes used by the South Improvement Alliance for the Cootamundra re-signalling project were not sufficiently robust, in particular, the closing out of identified design issues was inadequate.

Safety issue details
Issue number:RO-2009-009-SI-03
Who it affects:Rail infrastructure managers and signal system designers
Status:Adequately addressed


 

Project resourcing

Although the Australian Rail Track Corporation was not resourced to actively participate in the design or commissioning phases of the Cootamundra re-signalling project, greater involvement by the Australian Rail Track Corporation (local knowledge of site geography and layout) during these phases may have assisted the South Improvement Alliance engineers in detecting the design error.

Safety issue details
Issue number:RO-2009-009-SI-04
Who it affects:Rail infrastructure managers
Status:Not addressed


 

Project scheduling

As the re-signalling of Cootamundra neared completion it became necessary to undertake control table and software development concurrently to meet the targeted commissioning date. Normally control table and software development is done sequentially to ensure that all the control table logic is fully reflected in the final software and associated validation/testing processes.

Safety issue details
Issue number:RO-2009-009-SI-05
Who it affects:Signal system designers
Status:Partially addressed


 

On site and pre-commissioning test phase

Where a design involves complex signalling arrangements, it may be beneficial to involve the designing engineer during the final onsite field testing phase as they have the best understanding of the interlocking principles. This places them in a strong position to identify any design omissions or deficiencies that may not have been evident during earlier phases of a project.

Safety issue details
Issue number:RO-2009-009-SI-06
Who it affects:Rail infrastructure managers and signal system designers
Status:Not addressed


 

Check notes and plan information

Where a signalling design has implicit safety requirements that need to be validated onsite, field testers should be provided with comprehensive check notes and/or clearly annotated information that ensures specific testing requirements are not omitted.

Safety issue details
Issue number:RO-2009-009-SI-07
Who it affects:Rail infrastructure managers and signal system designers
Status:Adequately addressed

 
General details
Date: 12 November 2009 Investigation status: Completed 
Time: 0217 EDT Investigation type: Occurrence Investigation 
Location   (show map):Cootamundra  
State: New South Wales  
Release date: 20 January 2011 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Train 1 details
Train registration: Train ST22 
Type of operation: Passenger Train 
Damage to train: Nil 
Departure point:Melbourne, Vic
Destination:Sydney, NSW
Train 2 details
Train registration: 4MB7 
Type of operation: Freight train 
Damage to train: Nil 
Departure point:Melbourne, Vic
Destination:Brisbane, Qld
 
 
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Last update 25 January 2017