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What happened

On 10 July 2013, a pre-planned and advertised Local Possession Authority (LPA) was implemented on the Up Main line between Revesby and Turrella.

Approximately 30 minutes after the LPA was implemented, passenger train 709C entered the limits of the possession area and immediately ran over railway track signals (detonators) and was brought to a stand. There were no injuries or damage.

What the ATSB found

The ATSB’s investigation found that an LPA was an appropriate method of authorising the work to be performed. However, a combination of individual actions and systemic issues contributed to the incident. Two Special Train Notices (STNs) were published, one highlighting the limits of the LPA (called the proforma) and the other advising of altered train running (or pathing) arrangements. When implementing the LPA, two Sydney Trains area controllers working the Revesby control panel incorrectly assumed the limits of the LPA were at the city end of Revesby (clear of 51 points) rather than the country end (clear of 55 points). As a result blocking facilities were applied at the wrong location. These actions were partly influenced by a deficiency in the train pathing STN, which routed city-bound trains via 51 points. A final amendment to the proforma STN, extending the possession limit to 55 points, was not accounted for in the pathing STN, resulting in the two STNs being incompatible and contrary to engineering and pathing requirements when implemented.

A number of Sydney Trains’ procedures were examined to determine if any area of the planning, advertising and implementation of the LPA contributed to the incident. The ATSB found that the key parties involved in the implementation of the LPA did not come to a mutual understanding of the possession limits and other potential entry points or impact to train running arrangements. Documented procedures were not accurately followed and critical safety information was not confirmed by train control. The ATSB also found that there was an over-reliance on informal and verbal handover procedures amongst area controllers.

What's been done as a result

As a result of the incident, Sydney Trains implemented changes to STN production and validation processes. Sydney Trains also updated the signal box phone list and the Protection Officers Handbook which were published on their RailSafe website. Sydney Trains proposes to undertake targeted assurance in relation to adherence to safety critical communications protocols in LPAs in order to determine whether the non-compliances revealed in this investigation represent a systemic failure.

Safety message

In order to minimise errors prior to implementing LPAs, key parties should come to a mutual understanding of the possession limits and impact on train running, and ensure that altered train running (pathing) is compatible with the advertised possession limits. Rail operators should also recognise that handovers leading up to or during the implementation of an LPA increase exposure to the possibility of error and that this risk can be mitigated if train controllers, signallers and protection officers comply with documented procedures, protect all entry points and repeat back safety critical information.

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Safety issues

RO-2013-017-SI-02 - RO-2013-017-SI-03 -  

Non-compliance with repeat back provisions

There were non-compliances to the repeat back provision because it was viewed as onerous under certain Local Possession Authorities (LPAs). An opportunity exists to review rule non-conformance with the implementation of LPAs.

Safety issue details
Issue number:RO-2013-017-SI-02
Who it affects:All rail operators
Status:Adequately addressed


 

Production, validation, customer review and distribution of STNs

Sydney Trains validation processes were not effective in detecting errors in Special Train Notice (STN) 1004 prior to the Local Possession Authority (LPA) implementation.

Safety issue details
Issue number:RO-2013-017-SI-03
Who it affects:All rail operators
Status:Adequately addressed

 
General details
Date: 10 July 2013 Investigation status: Completed 
Time: 1049 EST Investigation type: Occurrence Investigation 
Location   (show map):Revesby  
State: New South Wales  
Release date: 19 September 2014 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Train 1 details
Train registration: 707D 
Type of operation: Passenger 
Damage to train: Nil 
Departure point:Macarthur, NSW
Destination:Circular Quay (via East Hills), NSW
Train 2 details
Train registration: 709D 
Type of operation: Passenger 
Damage to train: Nil 
Departure point:Macarthur, NSW
Destination:Circular Quay (via East Hills), NSW
 
 
 
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Last update 22 October 2015