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Safety Summary

Summary

What happened

At about 1116 on 5 May 2010 a collision occurred between an XPT passenger train and a track-mounted excavator near Newbridge, New South Wales. The operator of the track-mounted excavator was fatally injured. During the course of the investigation a similar incident occurred near Wards River, New South Wales (17 March 2011), where two work groups had to hurriedly vacate their on-track worksite due to an approaching train (there were no injuries). Both incidents occurred despite the fact that the work groups had been authorised, under a Track Occupancy Authority (TOA), to occupy and work on the track.

What the ATSB found

The ATSB established that, for the accident at Newbridge, a TOA was an appropriate method of authorising the work to be performed. However, a combination of individual actions and systemic issues contributed to the collision. When requesting the TOA, neither the Protection Officer (PO) nor the Network Control Officer (NCO) positively identified the location and type of worksite. Their actions were influenced by a deficiency in the TOA form, in that no provision was provided to record this critical information. Consequently, both the PO and NCO incorrectly concluded that the train had already passed beyond the limits of the worksite. In addition, the workers accessed the danger zone before additional site protection measures (detonators and flags) had been put in place. The ATSB also found that the workers were relatively inexperienced and that their training had not specifically discussed the hazards and protections that were relevant when working under a TOA.

The scenario for the Wards River incident was similar in that the track access point for the work was about 16 km into the section defined by the limits of the proposed TOA. In this case, the location of the work (Wards River) was communicated at about 0735 when the TOA was first requested. Due to operational reasons the TOA was not issued until 0840. Similar to the Newbridge event the PO did not clearly identify the location of the worksite and the NCO did not ensure the train had passed beyond the worksite or track access point.

What has been done as a result

As a result of the incident at Newbridge on 5 May 2010, the Australian Rail Track Corporation (ARTC) took action to reinforce the rules and procedures associated with the issuing of TOAs. The ARTC also implemented the use of a revised TOA form that provides for the recording of critical information regarding the location and type of worksite. It is likely that implementation of the new form should reduce the risk of similar incidents.

Safety message

It is essential that information critical to the safe implementation of a TOA be clearly communicated between the Protection Officer and the Network Control Officer.

It is also essential that workers do not access the track until all levels of worksite protection have been fully implemented.

 
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