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Final Report

Summary

What happened

On 23 September 2015, two Pacific National terminal operators and the train crew were completing a shunt of train 4MW2 at the Sydney Freight Terminal. After detaching the remaining wagons, the train crew moved the five locomotives toward the end of the stabling road, where a shunt driver was waiting trackside to take over. After stopping, the train crew exited the cab and alighted from the lead locomotive. The train crew had left the locomotive independent brake handle fully applied but did not operate the park brake prior to leaving the cab.

The shunt plan required two of the five locomotives to be uncoupled and stabled. In readiness to uncouple, one of the terminal operators entered between the locomotives and isolated the air taps, disconnected the train hoses and lifted the coupling pin to the two trailing locomotives. Neither the train crew nor shunt driver realised that the rear two locomotives had been uncoupled. Shortly after, the shunt driver boarded the lead locomotive and in conjunction with the other terminal operator moved the front three locomotives to another area of the terminal. The two trailing locomotives remained at the end of the road, unattended by a qualified worker.

Shortly before 1751, sufficient air had bled from the brake cylinders to allow locomotives NR24 and NR12 to begin to roll away. The locomotives continued to roll uncontrolled through the Sydney Freight Terminal before exiting into the Australian Rail Track Corporation network. The locomotives travelled a short distance on the Down South Fork before coming to rest at Chullora West Junction. There were no injuries or damage due to the run away.

What the ATSB found

The ATSB found that a combination of individual action and ambiguous radio communications resulted in a breakdown of controls to prevent an uncontrolled movement of rolling stock. The interface coordination arrangements at the eastern interface between Pacific National and the Australian Rail Track Corporation were ineffective in capturing an uncontrolled movement before exiting the Sydney Freight Terminal.

What's been done as a result

The Australian Rail Track Corporation have issued instructions for the restoration of points at the interface following each movement and commenced investigation into the feasibility of automatic resetting of the points at that location.

Pacific National undertook toolbox briefings and issued Business Safety Notices restricting terminal operators from uncoupling locomotives and reinforcing the importance of applying communications and shunting procedures.

Safety message

Rail transport operators and rail safety workers must ensure the correct and consistent application of communication protocols and procedures when undertaking safety critical work, such as detaching and securing unattended locomotives.

The occurrence

Context

Safety analysis

Findings

Safety actions

Sources and submissions

 
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