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What happened

At about 0940 on 31 January 2013, a Queensland Rail passenger train (T842) failed to stop at the Cleveland station platform and collided with the end-of-line buffer stop, the platform and the station building at a speed of about 31 km/h. There were 19 people on board the train (including the driver and a guard); three people were on the platform and five were in the station building. A number of people were treated for minor injuries and transported to hospital for further examination.

At the request of the Queensland Government, the ATSB initiated an investigation into the accident.

What the ATSB found

The ATSB’s investigation found that local environmental conditions had resulted in the formation of a contaminant substance on the rail running surface. This caused poor adhesion at the contact point between the train’s wheels and the rail head. The braking effectiveness of train T842 was reduced as a result of reduced adhesion and the train was unable to stop before hitting the end-of-line buffer stop.

The ATSB concluded that Queensland Rail’s risk management processes prior to the accident had not adequately assessed, recorded, managed and communicated the risks associated with operating trains on their network under low adhesion conditions.

In addition, Queensland Rail had not undertaken exercises to test the preparedness and effectiveness of their emergency management system. Shortfalls were identified in the response to the accident with respect to internal communications within train control and between staff at Cleveland station which resulted in incomplete information being provided to key personnel.

What's been done as a result

Queensland Rail initiated a risk mitigation strategy in response to the collision of train T842 at Cleveland station on 31 January 2013. The strategy included the formation of a Wheel Rail Interface Working Group that identified the wheel/rail interface risks, particularly for Queensland Rail’s fleet of IMU160/SMU260 class trains being operated under certain conditions.

Queensland Rail have also implemented a series of risk controls including identifying localised black spot locations and applying vegetation control measures, treating rail-head contaminants, reviewing and updating driver training with enhanced train handling advice about wheel slide and the trialling of sanding equipment on IMU160/SMU260 class trains. Queensland Rail have now undertaken emergency exercises to test the effectiveness of their emergency response arrangements and are implementing new communication protocols for emergency incident response.

Safety message

Rail operators should recognise that train braking performance may be significantly impaired when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion. Rail operators should put appropriate measures in place to assess and mitigate the risk to the safe operation of trains under these conditions.

 

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The Australian Transport Safety Bureau (ATSB), at the request of the Queensland Government, has commenced an investigation into the passenger train accident at Cleveland Station in Brisbane on 31 January 2013.

The accident occurred when a QR passenger train over-ran the Cleveland station platform colliding with the end-of-line buffer-stop, the platform and the station building. There were 15 people on board the train (including the driver and a guard) while four people were on the platform and in the station building. A number of people were treated for minor injuries and transported to hospital for further examination.

 

Update 1 March 2013

The ATSB’s Cleveland investigation team continues to work hard gathering and analysing a very large amount of information associated with the accident.  

A preliminary factual report on this accident will be released within ten days.

 

Update 14 February 2013

As part of its on-going investigation, the ATSB conducted a series of tests last night on a Queensland Rail passenger train similar to the train involved in the Cleveland station accident.
 
The ATSB investigation team included the Investigator in Charge and recorded data specialists.
 
The testing focused on the train braking system and its performance under a range of track conditions. The raw data obtained from the testing is currently being analysed by the investigation team. If any safety issues are identified from that analysis, the ATSB will immediately bring it to the attention of QR.
 
A preliminary factual report on this accident will be available within two weeks.

 

Update 12 February 2013

The ATSB investigation team, comprising six senior investigators, have interviewed a range of critical witnesses including the train driver, guard, passengers and other QR train drivers as relevant. They have completed the download of the train’s data loggers and are in the process of analysing this information. Inspections on the train are continuing with a focus on the braking system and a braking test on a similar train will be conducted in the coming days. The rail line leading into Cleveland Station has been inspected and scanned using laser equipment. The team continues to liaise with the Department of Transport and Main Roads and Queensland Rail to gather all relevant evidence.

The ATSB expects to release a preliminary factual report within a month of the accident.

More information will be made available as it comes to hand.

  

Update 5 February 2013

The ATSB investigation team, comprising five senior investigators, have interviewed the train driver and guard. They will complete the download of the train’s data loggers and commence the inspection and testing of the train’s brake system in a test facility today. The team will continue to liaise with the Department of Transport and Main Roads and Queensland Rail to gather all relevant evidence and is also making contact with other witnesses to arrange interviews before the end of the week.  

The ATSB expects to release a preliminary factual report within a month.

More information will be made available as it comes to hand.

 
Download Preliminary Report
[PDF: 2.19MB]
 
 
Alternate: [DOCX: 2.43MB]
 

What happened

At about 0940 on 31 January 2013, a Queensland Rail passenger train failed to stop at the Cleveland station platform and collided with the end-of-line buffer stop, the platform and the station building at a speed of about 31 km/h. There were 19 people on board the train (including the driver and a guard); three people were on the platform and five were in the station building. A number of people were treated for minor injuries and transported to hospital for further examination.

At the request of the Queensland Government, the ATSB initiated an investigation into the accident.

What the ATSB found

The information contained in this preliminary report is derived from the initial investigation. The object of an ATSB safety investigation is the early identification of safety issues so that action can be taken to reduce any safety-related risk. Since the investigation is on-going, readers are cautioned that new evidence may become available that alters the circumstances depicted in this report.

Based on evidence available to date, the ATSB has found that local environmental conditions resulted in the formation of a contaminant substance on the rail running surface. This caused poor adhesion at the contact point between the train’s wheels and the rail head. The braking effectiveness of T842 was reduced as a result of reduced adhesion and the train was unable to stop before hitting the end-of-line buffer stop.

The ATSB has concluded that Queensland Rail’s risk management procedures did not sufficiently mitigate risk to the safe operation of trains when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion.

What's been done as a result

The ATSB has recommended that Queensland Rail take action to address the safety risk associated with contaminated rail running surfaces which lead to reduced wheel/rail adhesion.

Queensland Rail have proposed and initiated a precautionary risk mitigation strategy in response to the collision of train T842 at Cleveland station on 31 January 2013. The strategy includes the formation of a Wheel Rail Interface Working Group tasked to specifically identify and assess any potential wheel/rail interface risks, particularly for Queensland Rail’s fleet of 160/260 class trains being operated under certain conditions.

Queensland rail have also implemented precautionary risk controls including; identifying and treating rail-head contaminants at any localised black spot locations, a review of train speed limits around the network and by providing drivers with enhanced train handling advice. 

Safety message

Rail operators should recognise that train braking performance may be significantly impaired when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion. Rail operators should put appropriate measures in place to assess and mitigate the risk to the safe operation of trains under these conditions.


 

History

The Australian Transport Safety Bureau (ATSB), at the request of the Queensland Government, has commenced an investigation into the passenger train accident at Cleveland Station in Brisbane on 31 January 2013.

The accident occurred when a QR passenger train over-ran the Cleveland station platform colliding with the end-of-line buffer-stop, the platform and the station building. There were 15 people on board the train (including the driver and a guard) while four people were on the platform and in the station building. A number of people were treated for minor injuries and transported to hospital for further examination.

 

Update 1 March 2013

The ATSB’s Cleveland investigation team continues to work hard gathering and analysing a very large amount of information associated with the accident.  

A preliminary factual report on this accident will be released within ten days.

 

Update 14 February 2013

As part of its on-going investigation, the ATSB conducted a series of tests last night on a Queensland Rail passenger train similar to the train involved in the Cleveland station accident.
 
The ATSB investigation team included the Investigator in Charge and recorded data specialists.
 
The testing focused on the train braking system and its performance under a range of track conditions. The raw data obtained from the testing is currently being analysed by the investigation team. If any safety issues are identified from that analysis, the ATSB will immediately bring it to the attention of QR.
 
A preliminary factual report on this accident will be available within two weeks.

 

Update 12 February 2013

The ATSB investigation team, comprising six senior investigators, have interviewed a range of critical witnesses including the train driver, guard, passengers and other QR train drivers as relevant. They have completed the download of the train’s data loggers and are in the process of analysing this information. Inspections on the train are continuing with a focus on the braking system and a braking test on a similar train will be conducted in the coming days. The rail line leading into Cleveland Station has been inspected and scanned using laser equipment. The team continues to liaise with the Department of Transport and Main Roads and Queensland Rail to gather all relevant evidence.

The ATSB expects to release a preliminary factual report within a month of the accident.

More information will be made available as it comes to hand.

  

Update 5 February 2013

The ATSB investigation team, comprising five senior investigators, have interviewed the train driver and guard. They will complete the download of the train’s data loggers and commence the inspection and testing of the train’s brake system in a test facility today. The team will continue to liaise with the Department of Transport and Main Roads and Queensland Rail to gather all relevant evidence and is also making contact with other witnesses to arrange interviews before the end of the week.  

The ATSB expects to release a preliminary factual report within a month.

More information will be made available as it comes to hand.

Download Preliminary Report
[PDF: 2.19MB]
 
 
Alternate: [DOCX: 2.43MB]
 
 

Safety issues

RO-2013-005-SI-01 - RO-2013-005-SI-03 - RO-2013-005-SI-04 - RO-2013-005-SI-05 - RO-2013-005-SI-06 - RO-2013-005-SI-07 - RO-2013-005-SI-08 - RO-2013-005-SI-09 - RO-2013-005-SI-10 - RO-2013-005-SI-11 - RO-2013-005-SI-12 -  

Management of risk associated with poor adhesion

Queensland Rail’s risk management procedures did not sufficiently mitigate risk to the safe operation of trains in circumstances when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion.

 

Issue Number:RO-2013-005-SI-01
Who it affects:All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Status:Safety action pending


 

Assessment and recording of rail safety risks

Poor wheel/rail adhesion was not recognised as a risk in any of Queensland Rail’s risk registers and therefore this risk to the safety of rail operations was not being actively managed.

Issue Number:RO-2013-005-SI-03
Who it affects:All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Status:Safety action pending


 

Cross divisional recognition of rail safety risks

Despite numerous occurrences of slip-slide events in the years leading up to the accident at Cleveland, Queensland Rail’s risk management processes did not precipitate a broad, cross-divisional, consideration of solutions to the issue including an investigation of the factors relating to poor wheel/rail adhesion.

Issue Number:RO-2013-005-SI-04
Who it affects:All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Status:Adequately addressed


 

Application of safety actions from internal investigations

Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in precipitating appropriate safety action to the findings and recommendations of their investigations into the Beerwah SPADs in 2009 which identified wheel/rail adhesion issues.

Issue Number:RO-2013-005-SI-05
Who it affects:All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Status:Safety action pending


 

Buffer stop design criterion

The mass of the two IMU or SMU class train units travelling on the Cleveland line was commonly heavier than the design specification of the buffer stop at Cleveland station. It is probable that Queensland Rail’s risk management systems did not consider this design criterion for these train configurations arriving at Cleveland station.

Issue Number:RO-2013-005-SI-06
Who it affects:All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Status:Adequately addressed


 

Awareness of rail safety occurrences in other jurisdictions affecting rail fleet type

Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in identifying safety issues pertinent to their fleet from rail safety occurrences in other jurisdictions involving poor wheel/rail adhesion.

Issue Number:RO-2013-005-SI-07
Who it affects:All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Status:Safety action pending


 

Occurrence notification standard and guideline

The national rail occurrence standard and guidelines (ON-S1/OC-G1) do not include significant train wheel slip/slide occurrences as a notification category/type which has the potential to lead to rail safety regulators being unaware of significant and/or systemic safety issues related to wheel/rail adhesion.

Issue Number:RO-2013-005-SI-08
Who it affects:Railway safety regulators and railway network owners and operators responsible for the classification and review of railway occurrence notifications.
Status:Adequately addressed


 

Driver’s manual explanation of effects and control of low adhesion

The Queensland Rail driver’s manual did not explain the effects of low adhesion at the wheel/rail interface, how low adhesion is a precursor to prolonged wheel slide events and why these elements reduce the likelihood of achieving expected braking rates.

Issue Number:RO-2013-005-SI-09
Who it affects:All owners and operators of rolling stock fitted with electro-pneumatic disc actuated braking systems incorporating wheel slip-slide protection control.
Status:Adequately addressed


 

Effective coordination of emergency communications

The successful management of an emergency event from a remote location is critically dependent on clear and effective communication protocols. Communications within train control, and between train control and Cleveland station, were not sufficiently coordinated and resulted in misunderstandings at the Cleveland station accident site.

Issue Number:RO-2013-005-SI-10
Who it affects:All railway network owners and operators responsible for the management and coordination of operational training and emergency communications.
Status:Safety action pending


 

Emergency management exercises

Emergency management simulation exercises to test the preparedness of network control staff, train crew, and station customer service staff to respond cooperatively to rail safety emergencies had not been undertaken in accordance with the Queensland Rail Emergency Management Plan.

Issue Number:RO-2013-005-SI-11
Who it affects:All railway network owners and operators responsible for the management and coordination of operational training and emergency communications.
Status:Adequately addressed


 

Post emergency debrief and findings

The Queensland Rail internal emergency debrief following the Cleveland station collision identified issues related to working with external agencies but did not address critical communication shortfalls within train control and between train control and the staff located at the Cleveland station accident site.

Issue Number:RO-2013-005-SI-12
Who it affects:All railway network owners and operators responsible for the management and coordination of operational training and emergency communications.
Status:Safety action pending

 

General details

Date: 31 Jan 2013 Investigation status: Completed 
Time: 0940 EDT Investigation type: Occurrence Investigation 
Location   (show map):Cleveland Station  
State: QLD  
Release date: 20 Dec 2013 Occurrence category: Accident 
Report status: Final Highest injury level: Minor 
 

Train details

Line operator: Queensland Rail 
Train operator: Queensland Rail 
Train registration: T842 
Type of operation: Metro Passenger 
Sector: Passenger - metropolitan 
Damage to train: Substantial 
Destination:Cleveland Station
 
 
 
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Last update 23 January 2014