Rail safety investigations & reports

Runaway and collision between 'J' class and 'Nagasaki’ class trams, Sydney Tramway Museum, Loftus, NSW, on 15 May 2016

Investigation number:
RO-2016-006
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 3.2MB]
 

What happened

On 15 May 2016, at approximately 1056 Australian Eastern Standard Time (AEST), an unmanned ‘675 J class’ tram (‘J’ class) collided with a ‘1054 Nagasaki’ tram (Nagasaki) at Sydney Tramway Museum (STM) in Loftus, New South Wales. The Nagasaki was approaching Loftus after completing a tourist operation between Sutherland and Loftus, when the crew noticed the unmanned ‘J’ class moving towards them on the same track. The crew responded by stopping the Nagasaki and evacuated all 16 passengers safely before the collision occurred.

What the ATSB found

The ATSB found that the ‘J’ class was parked on a downhill gradient towards Sutherland prior to the runaway and collision. It was also found that the tram’s handbrake had not been applied and instead, a hardwood wheel chock had been placed under the tram’s front wheel to restrain the vehicle’s movement.

What's been done as a result

Since the incident, STM has adopted a number of changes to manage the risk of tram runaway. These include but are not limited to the following:

  • STM has made the application of handbrakes mandatory.
  • STM’s Safety Management System (SMS) now requires trams to be stabled on level track.
  • STM has included yellow markings to delineate level track from a descending gradient.
  • STM has stopped using hardwood wheel chocks to stable its trams.

Safety message

Rolling Stock Operators need to consider the limitations of rolling stock brake systems, including brake retention times, when designing stabling procedures and locations to park rolling stock.

The risk of rolling stock runaway should be assessed, taking into account the context of the organisations railway operations, and should examine all existing and available risk controls.

Additionally, any changes made to a risk control should follow a change management process to ensure that the change does not reduce the risk control’s effectiveness.

Figure 1: 675 ‘J’ class and 1054 ‘Nagasaki’ class tram collision

Figure 1: 675 ‘J’ class and 1054 ‘Nagasaki’ class tram collision. Source:   ATSB

Source:   ATSB

Download final report
[Download  PDF: 3.2MB]
 
 
 

The occurrence

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issues

Go to RO-2016-006-SI-02 - Go to RO-2016-006-SI-03 - Go to RO-2016-006-SI-04 -

Change management process implementation for safety critical changes

STM did not follow its change management process for adopting the new hardwood chock type. Subsequently, the hardwood chock could not be applied reliably under the ‘J’ class wheel and could not restrict its movement.

Safety issue details
Issue number: RO-2016-006-SI-02
Who it affects: Rolling Stock Operators
Status: Adequately addressed

Attending parked trams

STM did not comply with its risk control in ensuring that trams were attended when parked.

Safety issue details
Issue number: RO-2016-006-SI-03
Who it affects: Sydney Tramway Museum
Status: Adequately addressed

Use of all available and reasonably practicable risk controls when parking trams

STM did not require the application of all available and reasonably practicable risk controls when parking trams with respect to their location and handbrake application.

Safety issue details
Issue number: RO-2016-006-SI-04
Who it affects: Rolling Stock Operators
Status: Adequately addressed
General details
Date: 15 May 2016   Investigation status: Completed  
Time: 1057 AEST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Loftus, Sydney   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 17 May 2019   Occurrence category: Incident  
Report status: Final   Highest injury level: Minor  

Train 1 details

Train 1 details
Line operator Sydney Tramway Museum  
Train operator Sydney Tramway Museum  
Train registration 'Nagasaki' class tram 1054  
Type of operation Passenger  
Sector Other  
Damage to train Minor  
Departure point Loftus, NSW  

Train 2 details

Train 2 details
Line operator Sydney Tramway Museum  
Train operator Sydney Tramway Museum  
Train registration ‘J’ class tram 675  
Type of operation Tramway Museum  
Sector Other  
Damage to train Substantial  
Departure point Loftus, NSW  

Train 3 details

Train 3 details
Line operator Sydney Tramway Museum  
Train operator Sydney Tramway Museum  
Train registration ‘Y’ class tram 1  
Type of operation Tramway Museum  
Sector Other  
Damage to train Nil  
Departure point Loftus, NSW  
Last update 17 May 2019