Rail safety investigations & reports

Near hit with detrained passengers on track at Kilbride, New South Wales, on 22 May 2014

Investigation number:
RO-2014-009
Status: Completed
Investigation completed

Final Report

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What happened

At 1137 on 22 May 2014, NSW Trains XPT passenger service NT33 departed Paterson towards Kilbride when the driver observed a bus at the Mirari road level crossing and people walking on the track ahead. The driver immediately made an emergency brake application and brought the train to a stand approximately 80 m short of the people.

There were no reported injuries as a result of the incident.

What the ATSB found

A disabled coal train SF630 had initially delayed NSW Trains’ passenger service V938. A decision was made to evacuate V938 and provide the passengers with alternative road transport.

The train crew of V938 did not comply with the Australian Rail Track Corporation (ARTC) network rules when detraining passengers from their train and unknowingly placed the passengers in the path of NT33.

The NSW Trains procedure for detrainment did not preference the option of moving to a designated platform when available and would have required approval from the network owner ARTC. This option was also absent from ARTC’s Network Rules and Procedures.

Key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority. This misunderstanding of roles, responsibilities and limits of authority by operational employees likely contributed to inadequate communication between critical safe working positions.

What's been done as a result

NSW Trains has informed the ATSB they had commenced an immediate review of procedures for detraining passengers when a train is not at a designated station. It has also informed the ATSB that the procedures had also been amended to clarify how passenger safety, their wellbeing and track protection will be managed when detraining.

Safety message

This incident illustrates the importance for train crews to strictly adhere to recognised detraining and track protection procedures when transferring passengers from a stranded train to a safe place.

It is essential that train crew and network control implement an appropriate level of protection and confirm that the protection is in place before detraining passengers.

When the option is available, preference should be given to detraining at a recognised platform before electing to detrain passengers into the rail corridor.

Operators must confirm and ensure roles, responsibilities and limits of authority are clearly understood during organisational change.

 

Mirari Road level crossing Kilbride
Mirari Road level crossing Kilbride

Download final report
[Download  PDF: 1.82MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issues

Go to RO-2014-009-SI-01 - Go to RO-2014-009-SI-02 - Go to RO-2014-009-SI-03 - Go to RO-2014-009-SI-04 -

Train protection

The crew of V938 detrained passengers onto the track near Kilbride without having arranged the required train protection with the ARTC Network Controller in accordance with the ARTC Network rules and procedures.

Safety issue details
Issue number: RO-2014-009-SI-01
Who it affects: All rail operations
Status: Adequately addressed

Management of change

Key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority.

Safety issue details
Issue number: RO-2014-009-SI-02
Who it affects: All rail operations
Status: Adequately addressed

Unclear purpose of communication

The purpose of communication between key operational people was not always clearly stated nor understood leading to misunderstandings between people.

Safety issue details
Issue number: RO-2014-009-SI-03
Who it affects: All rail operations
Status: Adequately addressed

Processes for evacuating trains

Rules and procedures for detrainment do not consider a priority option of moving the train to a station or platform.

Safety issue details
Issue number: RO-2014-009-SI-04
Who it affects: All rail operations
Status: Adequately addressed
General details
Date: 22 May 2014   Investigation status: Completed  
Time: 1137 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Between Kilbride and Paterson    
State: New South Wales    
Release date: 17 January 2018   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Australian Rail Track Corporation (ARTC)  
Train operator NSW Trains  
Train registration V938  
Type of operation Passenger  
Sector Passenger - regional  
Damage to train Nil  
Departure point Dungog, NSW  
Destination Newcastle, NSW  
Last update 14 November 2018