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Summary

Summary

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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