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Final Report

Summary

What happened

On 25 July 2013, Pacific National locomotive 8122 was undertaking shunt operations in the Melbourne Freight Terminal (MFT) and onto areas of the main line controlled by signal DYN150. During one of the shunt movements, the locomotive stopped slightly forward of signal DYN150, in a position where indication on the signal was not visible to the driver. The signalling system should have detected the locomotive still occupied the track section forward of the signal, but in this instance, the system registered the train had cleared the section. The system then allowed points 143 ahead of signal DYN150 to change position for the passage of another train.

Unaware of the change in points 143, the driver continued with shunt operations by moving the locomotive forward. A Signal Passed at Danger (SPAD) alarm was generated and displayed to the Network Control Officer (NCO) who then contacted the MFT shunt planner. Meanwhile, the driver continued forward before stopping just after the lead bogie of locomotive 8122 had run through points 143, which were now set in the incorrect position for the move being undertaken.

Unaware that the points had been run through, the driver then reversed direction for the next shunt movement. This manoeuvre resulted in the lead bogie of the locomotive diverging onto a different track, causing all wheels of the locomotive and one bogie of the first wagon coupled to the locomotive to derail. At no point in time did a conversation occur between the NCO and the locomotive driver, and almost 30 minutes passed before the NCO and the shunt planner became aware of (and confirmed) the derailment at points 143.

What the ATSB found

The ATSB found that the location of the insulated rail joints adjacent signal DYN150 were incorrect. Consequently, the track section past the signal could be detected as unoccupied, even though the locomotive (and drivers cab) was positioned past the signal.

The ATSB also found that procedures specific to shunting in and about the MFT had not been implemented in this instance. It was evident that communication in response to the preceding SPAD alarm had been ineffective – allowing shunt operations to continue and locomotive 8122 to derail. Furthermore, significant time passed before the network control officer and the MFT shunt planner became fully aware of the derailment.

What's been done as a result

The Australian Rail Track Corporation initiated actions to verify (within Victoria) the position of insulated joints relative to the respective signals and develop a prioritised remediation plan for any non-conforming arrangements.

Pacific National and the Australian Rail Track Corporation have taken action to ensure all parties adhere to the documented process for shunting in and about the MFT. In addition, Pacific National has advised their drivers and shunt planners that communication regarding any issues related to the shunting movements must occur directly between the network controller and the locomotive driver.

Safety message

Rail transport operators must ensure that local communication practices are not substituted for, or do not influence required communication protocols in an emergency.

 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

 
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