Rail safety investigations & reports

Collision of passenger train T842 with station platform Cleveland, Qld, 31 January 2013

Investigation number:
RO-2013-005
Status: Completed
Investigation completed

Summary

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[Download  PDF: 3.5MB]
 

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.

 

Download Final Report
[Download  PDF: 3.5MB]
 
 
 

Progress updates

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.

Preliminary

Download Preliminary Report
[Download  PDF: 2.19MB]
 

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
[Download  PDF: 2.19MB]
 
 
 
General details
Date: 31 January 2013   Investigation status: Completed  
Time: 0940 EDT    
Location   (show map): Cleveland Station   Investigation level: Complex  
State: Queensland    
Release date: 20 December 2013    
Report status: Final   Occurrence category: Accident  
  Highest injury level: Minor  

Train details

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  
Last update 14 November 2018