Final Report


What happened

On 29 September 2015, train 3K26 loaded with bulk grain was travelling from Avon Yard to the port at Kwinana in Western Australia, when it exceeded its limit of authority. On that day, track re-railing works were in progress along the route requiring the closure of the Up Main line between Moondyne and Jumperkine. The closure resulted in the diversion of train movements to the adjacent track and the implementation of single line block working under the rules applicable to train order working.

The crew of train 3K26 received a train order to proceed from Moondyne to the station limits board at the 48 km location where they were to stop. Attached to the train order was an additional instruction relating to tasks required when approaching the worksite beyond the 48 km location. After accepting the train order and departing Moondyne, the train crew continued to discuss the additional instructions relating to the tasks required when passing the worksite.

As the train approached the 48 km location, the train crew observed a station limits board and a track closed warning device that marked the limit of the authority. With little time to respond, the driver applied an emergency brake application. The train collided with the track closed warning device before coming to a stop approximately 400 metres past the limit of authority. There was no imminent risk of collision with people or other rail traffic as the distance separating the train and the worksite was approximately 4 km.

What the ATSB found

The ATSB found that the additional instructions attached to the train order distracted the crew from their principal task, which was to stop at the 48 km location. The ATSB also found that there were no visual cues to alert train crew that they were approaching the limit of their authority.

What's been done as a result

Brookfield Rail erected non-crossing indicator boards on each approach to the station limits board. Additionally, safeguards to protect the worksite were increased to include extra infield protection at either end of the closed section of track.

In March 2016, Brookfield Rail introduced a new suite of safe working rules and procedures consistent with the Australian Network Rules & Procedures.

Safety message

Communication of information through non-standard practices and/or the addition of information irrelevant to the intended task may reduce clarity and introduce a source of distraction.

In an operational environment, effective communication, crosschecking and shared understanding by train crew, together with appropriate environmental cues contribute to ensuring the effective performance of tasks.

The occurrence

Safety analysis


Safety actions

Sources and submissions