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What happened

On 4 June 2013, track workers were preparing a road-rail vehicle to travel to a worksite near Rinadeena Station on the West Coast Wilderness Railway, Tasmania, when the vehicle unexpectedly started to roll backwards down a 1:20 grade. The driver was unable to slow the vehicle, so he and the passenger jumped clear, sustaining minor injuries.

The now unmanned out-of-control vehicle continued to accelerate down the steep grade, heading towards a second road-rail vehicle containing four track workers. Two passengers of the second vehicle jumped clear, sustaining minor injuries, but a third passenger and the driver were still inside when the unmanned road-rail vehicle collided with theirs.

The passenger sustained minor injuries but the driver was trapped and seriously injured in the collision. He was subsequently removed from the vehicle and air lifted to hospital. Both road-rail vehicles were extensively damaged.

What the ATSB found

The ATSB found that the vehicle’s rear road tyres were lifted from the track to examine a suspected problem with the rear rail guidance wheels. As a result, the braking force provided by the rear road wheels was lost and the vehicle began to roll down the incline. The rail guidance wheel electric brake controller had not yet been set correctly and, as a result, little braking effort was applied through the rail guidance wheels.

The investigation also found that the West Coast Wilderness Railway had not considered all of the risks associated with the operation of road-rail vehicles on the steep railway. As a result, documented operational procedures had not been developed and locations where vehicles could be safely on and off railed had not been defined.

Other findings related to the effectiveness of the training provided to the road-rail vehicle operators, road-rail vehicle procurement standards, acceptance testing and commissioning of road-rail vehicles, reliability of the very high frequency (VHF) radio network in the Rinadeena area and radio communication protocols.

What's been done as a result

West Coast Wilderness Railway has reviewed its risk register and implemented operational procedures covering the safe operation of road-rail vehicles on the network. This has led to the development and implementation of an updated training package, procurement specifications and documented on/off tracking points. The company has also taken action to improve radio reception in the Rinadeena area and to ensure reliable communications at the station.

Safety message

All organisations operating road-rail vehicles should consider the risks associated with operating the vehicles on their networks. Information on the risk of operating road-rail vehicles can be found at the Office of National Rail Safety Regulator website.

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Preliminary report released 15 August 2013

What happened

On 4 June 2013, track workers were preparing a road rail vehicle to travel to a worksite near Rinadeena Station on the West Coast Wilderness Railway, Tasmania, when the vehicle unexpectedly started to roll backwards down a 1:20 grade. The driver was unable to slow the vehicle, so he and the passenger jumped clear, sustaining minor injuries.

The now unmanned out-of-control vehicle continued to accelerate down the steep grade, heading towards a second road rail vehicle containing four track workers. Two passengers of the second vehicle jumped clear, sustaining minor injuries, but a third passenger and the driver were still inside when the unmanned road rail vehicle collided with theirs. The passenger sustained minor injuries but the driver was trapped and seriously injured in the collision. He was subsequently removed from the vehicle and air lifted to hospital. Both road rail vehicles were extensively damaged.

What the ATSB has found so far

The preliminary ATSB investigation has found that the vehicle’s rear road-going tyres were lifted from the track during an inspection of the rear rail guidance wheels. As a result, the braking force provided by them was lost and the vehicle began to roll down the grade.

The investigation has also found that West Coast Wilderness Railway had not considered all of the risks associated with operating road rail vehicles on the steep railway.

What's been done as a result

Immediately after the incident, West Coast Wilderness Railway suspended all road rail operations and initiated a full review of its management of the safety of these vehicles. This has led to the development of updated procedures and training and a review of suitable on/off tracking points.

Safety message

All rail organisations operating road rail equipment should consider the advice in safety alert RISN Number 7/2012 Risk associated with Hirail Operations (issued by the Department of Infrastructure, Energy & Resources, Tasmania) and review their management of the risks associated with these operations.

 

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Safety issues

RO-2013-014-SI-01 - RO-2013-014-SI-04 - RO-2013-014-SI-05 - RO-2013-014-SI-08 - RO-2013-014-SI-06 - RO-2013-014-SI-07 -  

Risk assessment, procedure and guidelines

West Coast Wilderness Railway had not considered all of the risks associated with the operation of road-rail vehicles on the steep railway. As a result, documented operational procedures had not been developed and locations where vehicles could be safely on/off railed had not been defined.

Safety issue details
Issue number:RO-2013-014-SI-01
Who it affects:All owners and operators of road rail vehicles
Status:Adequately addressed


 

Training

The training provided to the West Coast Wilderness Railway road-rail vehicle operators did not identify and incorporate local specific training requirements, such as operating on very steep grades and the use of radios.

Safety issue details
Issue number:RO-2013-014-SI-04
Who it affects:All owners and operators of road-rail vehicles
Status:Adequately addressed


 

Radio communications

Rinadeena Station was the only emergency meeting point between Queenstown and Strahan and the only road access point on the rack between Halls Creek and Dubbil Barril. However, the Rinadeena Station radio was not maintained in a serviceable state at all times.

Safety issue details
Issue number:RO-2013-014-SI-05
Who it affects:All track managers
Status:Adequately addressed


 

Radio procedures and protocols

The West Coast Wilderness Railway did not have documented radio communication procedures and their staff were not trained in the use of radios. As a result, radio protocols were not formalised and communications were ad hoc and casual in nature.

Safety issue details
Issue number:RO-2013-014-SI-08
Who it affects:All track managers
Status:Adequately addressed


 

Hirail 3 testing and acceptance

West Coast Wilderness Railway had not developed and implemented a specification for the design, fitment and safety performance of road-rail vehicle rail guidance equipment.

Safety issue details
Issue number:RO-2013-014-SI-06
Who it affects:All owners and operators of road-rail vehicles
Status:Adequately addressed


 

Documented process for the testing of RRV’s

The West Coast Wilderness Railway did not have a documented process of testing road-rail vehicles.

Safety issue details
Issue number:RO-2013-014-SI-07
Who it affects:All owners and operators of road-rail vehicles
Status:Adequately addressed

 
General details
Date: 04 June 2013 Investigation status: Completed 
Time: 1130 EST Investigation type: Occurrence Investigation 
Location   (show map):near Rinadeena  
State: Tasmania  
Release date: 11 June 2014 Occurrence category: Serious Incident 
Report status: Final Highest injury level: Serious 
 
Train 1 details
Train registration: 1995 Mazda T4600 truck 
Type of operation: Road-rail vehicle 
Damage to train: Destroyed 
Departure point:Queenstown, TAS
Destination:near Rinadeena, TAS
Train 2 details
Train registration: Mitsubishi Fuso Canter 4.0 FE85 
Type of operation: Road-rail vehicle 
Damage to train: Substantial 
Departure point:Queenstown, TAS
Destination:near Rinadeena
 
 
 
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Last update 25 February 2015