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What happened

At approximately 0105 on 11 October 2011, empty ore train 1901S, operated by Specialised Bulk Rail Pty Ltd, passed signal 13 displaying a stop indication at Dry Creek Junction in South Australia.

Train 1901S subsequently collided with loaded grain train 5132S, operated by Genesee and Wyoming Australia Pty Ltd, that was travelling in the opposite direction and traversing the turnout at Dry Creek Junction to enter the Dry Creek North Yard.

The collision was at low speed and there was no injury to the train crew of either train. There was significant damage to the crew cab of the lead locomotive of train 1901S and to the grain wagons of train 5132S that were struck during the collision.

What the ATSB found

The ATSB determined that the collision between train 1901S and 5132S was a result of train 1901S passing signal 13 at stop (SPAD). The SPAD of signal 13 was a result of the driver-in-training and co-driver (supervising driver) of train 1901S becoming distracted during the approach to the preceding signal, 135, which was displaying a caution aspect indicating that signal 13 ahead was at stop.

The investigation revealed that a combination of individual actions and systemic issues contributed to the collision. The driver’s lack of route knowledge, combined with an expectation of a clear run through the area probably influenced his failure to observe signal 135 at caution. The supervising driver was completing an administrative task that diverted his attention away from the primary task of supervising the actions of the driver-in-training.

The absence of adequate procedures to provide supervising drivers with sufficient direction as to the nature of their supervisory role and to inform of the level of competency attained by a driver-in-training resulted in the breakdown of operational risk controls.

The ATSB investigation explored fatigue impairment as a causal factor related to the SPAD of signal 13. While fatigue impairment was not considered a contributing safety factor in this occurrence, the importance of a rigorous fatigue risk management program subject to continual improvement is highlighted.

What has been done as a result

Following the collision at Dry Creek Junction, Specialised Bulk Rail Pty Ltd amended procedures that clarify the role and responsibilities of a driver supervising a trainee, and introduced arrangements to inform the supervising driver of the trainee’s level of competency.

Safety message

Rail operators must implement robust procedures that systematically manage the supervision, training, and assessment of drivers’ route knowledge to ensure competency and address any risks inherent in the operational task.

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Download Preliminary Report
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Preliminary report published 19 December 2011

At about 0105 on 11 October 2011 an empty (northbound) ore train (1901S) travelling on the interstate main line from Pelican Point (Outer Harbor, South Australia) to Rankin Dam (Coober Pedy) passed signal 13 at Dry Creek Junction displaying a stop (red) indication. Train 1901S subsequently collided at low speed approximately mid-consist with a loaded (southbound) grain train (5132S) that was traversing a turnout at Dry Creek Junction to enter the Dry Creek North Yard in South Australia.

There was no injury to the train crews as a result of the collision. There was significant damage to the crew cab of the lead locomotive of train 1901S and to the grain wagons of train 5132S that were struck during the collision.

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Safety issues

RO-2011-016-SI-01 - RO-2011-016-SI-02 - RO-2011-016-SI-03 - RO-2011-016-SI-04 -  

Procedures for supervising drivers

Specialised Bulk Rail’s Safety Management System procedures did not provide the supervising drivers with sufficient direction as to the nature of their supervisory role.

Safety issue details
Issue number:RO-2011-016-SI-01
Who it affects:All owners and operators of rollingstock
Status:Adequately addressed


 

Information of the status of learning

There were no formalised processes for a driver-in-training to record their experience in learning a route, or to document feedback related to their performance, which could be used by supervising drivers or assessors to assist in mentoring them.

Safety issue details
Issue number:RO-2011-016-SI-02
Who it affects:All owners and operators of rollingstock
Status:Partially addressed


 

Procedures to attain route knowledge competency

Worker competency procedures were deficient in providing a structured program for the development of route knowledge by the driver-in-training.

Safety issue details
Issue number:RO-2011-016-SI-03
Who it affects:All owners and operators of rollingstock
Status:Partially addressed


 

Fatigue management controls

SBR’s process for assessing its drivers’ roster for relay operations relied excessively on a score produced by a bio-mathematical model, and it had limited mechanisms in place to ensure drivers received an adequate quantity and quality of sleep during relay operations.

Safety issue details
Issue number:RO-2011-016-SI-04
Who it affects:All owners and operators of rollingstock
Status:Partially addressed

 
General details
Date: 11 October 2011 Investigation status: Completed 
Time: 0105 CDT Investigation type: Occurrence Investigation 
Location   (show map):Dry Creek   
State: South Australia  
Release date: 03 April 2013 Occurrence category: Accident 
Report status: Final Highest injury level: None 
 
Train 1 details
Train registration: 1901S 
Type of operation: Bulk ore train 
Damage to train: Serious 
Train 2 details
Train registration: 5132S 
Type of operation: Bulk grain train 
Damage to train: Serious 
 
 
 
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Last update 03 April 2013