Download Final Report
[PDF: 2.83MB]

 

 

Listen to this PDF

Alternate: [DOCX: 2.64MB]

 

What happened

On 24 May 2012, three Transfield Services Australia (Transfield) road-rail vehicles were travelling in convoy in a westerly direction between Forrest and Haig in Western Australia, where they were to be taken off the track.

Shortly before 1700, on arrival at the Haig level crossing, the lead vehicle was off-tracked, but a problem with the second vehicle prevented its removal from the track. At about 1711, while work was continuing to remove the second vehicle from the track, the third vehicle in the convoy, a flatbed truck, collided with the rear of the second vehicle. The force of the impact shunted the stationary vehicle forwards with both vehicles running over one worker, fatally injuring him, while the other jumped clear. The driver of flatbed truck was not injured.

What the ATSB found

The ATSB determined that the flatbed truck could not be stopped in time to avoid the collision because the brakes that were originally fitted to its front rail guidance equipment had been removed, and the vehicle’s rear wheel brakes were in a poor state of repair. The investigation also identified that the rail workers had developed localised practices that were not compliant with Transfield’s operational procedures.

A sample of the deceased worker’s blood tested positive to both the active and inactive metabolite of cannabis. The other workers were not tested for the presence of drugs and alcohol following the accident.

The ATSB identified a number of systemic issues associated with Transfield’s road-rail vehicle maintenance regime, rail safety worker training, management oversight and drug and alcohol policy and procedures.

In addition, the ATSB highlighted the absence of a national standard for road-rail vehicles which addresses the fitment, modification and maintenance of road-rail equipment and the consequent risk that unsuitable modifications may adversely affect the safe operation of a road-rail vehicle.

What's been done as a result

Transfield Services Australia has reviewed and updated its road-rail vehicle maintenance regime. The company has also taken action to improve its management oversight of rail safety workers, its training processes for maintenance and operational staff and its drug and alcohol policies and procedures.

The Rail Industry Safety Standards Board (RISSB) is facilitating the development of Australian Standard, AS 7502, Road Rail Vehicles. The standard will cover the basic requirements for road-rail vehicles across their life cycle, including design, construction, testing and certification, operation, maintenance, modification and disposal.

Safety message

Rail operators should ensure that safety critical road-rail vehicle equipment is appropriately maintained. Maintenance regimes and activities should consider the increased loading and wear and tear on the vehicle and its various components as a result of fitting of rail guidance equipment and of the operation of the vehicle on rail.

Rail Operators should also conduct regular reviews of staff members’ and contractors’ ability and competency to ensure they are consistently performing their duties in accordance with the most up to date and endorsed working instructions.

Download Final Report
[PDF: 2.83MB]

 

 

Listen to this PDF

Alternate: [DOCX: 2.64MB]

 

Download Preliminary Report
[PDF: 455KB]

 

 

Listen to this PDF

Alternate: [DOC: 2.6MB]

 

Preliminary report released 27 July 2012

On Thursday 24 May 2012 Transfield Services Australia Pty. Ltd. road/rail vehicles TS24, TS45 and TS63 were travelling in convoy in a westerly direction between Forrest and Haig, Western Australia.

On arrival at the Haig level crossing the lead vehicle TS24 left the track. The second vehicle, Toyota utility TS45 was stationary on the level crossing being prepared to leave the track. At approximately 1711 the following Hino truck road/rail vehicle (TS63) collided with the rear of Toyota TS45.

The driver of the road/rail vehicle TS45 was fatality injured and the driver of TS24 incurred minor injuries following the collision.

Download Preliminary Report
[PDF: 455KB]

 

 

Listen to this PDF

Alternate: [DOC: 2.6MB]

 

Road-rail vehicle maintenance regime

The maintenance regime for Hino TS63 was inadequate and did not account for the accelerated wear and tear on the vehicle when used as a road-rail vehicle.

Oversight

Transfield did not provide oversight sufficient to identify and rectify the non-compliant work practices in the road-rail vehicle operation involved in this occurrence.

Training

Transfield’s training regime did not ensure that the track workers involved in this occurrence were trained in new or updated work practices relating to road-rail vehicle operations. Similarly, relevant amended procedures, safety bulletins and alerts had not been effectively promulgated to these employees.

Drug & alcohol management

Transfield did not have adequate systems in place to ensure workers were not adversely affected by drugs or alcohol while conducting safety related work in a remote work environment.

Road-rail vehicle national standards

The absence of a national standard that addresses the design, fitment and maintenance of rail guidance equipment and the safety performance for road-rail vehicles while on-rail, increases the risks associated with operating road-rail vehicles.