At about 2121 on 14 July 2013, Pacific National intermodal freight train 6MP5 overran the limit of its authority at Blamey, Western Australia. The train travelled 23 km into the Blamey to Curtin section before the crew realised the overrun had occurred and stopped the train.
The crew did not immediately report the overrun to the Network Control Officer as required. Instead, they provided misleading information about the train’s location and that they were having problems with the on board communication systems. Unaware of the authority overrun, the Network Control Officer issued a Train Authority for train 6MP5 to proceed from Blamey to Parkeston.
The train crew signed off duty at Parkeston and after reflecting on their actions reported the occurrence to the Pacific National Kalgoorlie Depot Manager the following day.
What the ATSB found
The ATSB found that during the safety critical period approaching the limit of authority at Blamey, the train crew had focused their attention on planning for the upcoming refuelling at Parkeston. As a result, they were distracted from the primary task of driving the train and missed vital cues and information that identified the limit of the current train authority.
The investigation also found that there were inconsistencies in the instructions contained in the various Pacific National procedural documents relating to refuelling at Parkeston.
What's been done as a result
Pacific National has amended procedures related to the arrangements for refuelling trains at Parkeston to remove inconsistencies and ensure that ancillary tasks do not have the potential to distract train crews from undertaking safety critical work.
Train crews must be cognisant of and apply the operational procedures intended to prevent or control the consequence that may arise from an overrun of authority.
Rail transport operators should ensure that any ancillary tasks undertaken by a train crew do not have the potential to divert attention away from the safe operation of a train.
The instructions relating to the arranging of refuelling at Parkeston contained in the Pacific National train management plan and the intermodal procedures manual were inconsistent.
|Who it affects:||All rail safety workers and rolling stock operators|
|Date:||14 July 2013||Investigation status:||Completed|
|Time:||2121 WST||Investigation level:||Complex - click for an explanation of investigation levels|
|Release date:||07 July 2014||Occurrence category:||Incident|
|Report status:||Final||Highest injury level:||None|
|Line operator||Aust Rail Track Corp.|
|Train operator||Pacific National|
|Type of operation||Interstate intermodal freight|
|Damage to train||Nil|
|Departure point||Cook, SA|