Rail safety investigations & reports

Derailment of train 7MP7 at Coonana, Western Australia on 19 August 2018

Investigation number:
RO-2018-012
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

At about 1040 on 19 August 2018, the train crew of Pacific National train 7MP7, travelling from Cook, South Australia to Parkeston near Kalgoorlie in Western Australia approached the points located at the eastern end of the Coonana train order location. Around 4 hours earlier, the trackside interlocking at Coonana detected that the point machine at the eastern end had not set correctly for the main line following the passage of a previous train. The colour light indicator (enhancer) situated adjacent to the point machine displayed a red light (stop indication) to approaching train crew of 7MP7.

During the approach to Coonana, the train crew of 7MP7 maintained track speed while looking for the light displayed by the enhancer ahead. When they realised that they could not see the enhancer, they braked but were unable to stop train 7MP7 before it traversed the eastern point machine travelling at 44 km/h and derailed. The two lead locomotives, unoccupied crew car and first two platforms of the lead wagon derailed, destroying around 200 m of the main and crossing loop tracks. The train crew were uninjured.

What the ATSB found

Point machines at each end of Coonana crossing loop would normally be set to allow travel along the main line. An incorrectly stored locking pin from a point clamp dislodged and caught in a mechanical pivot mechanism attached to the eastern point machine, preventing the correct movement of the points to reset for the main line after the departure of the previous train.

The ATSB found that during the approach to Coonana the train crew sought to identify and confirm the light displayed on the enhancer. While doing so, the speed of 7MP7 was not sufficiently reduced at the Location Ahead sign to ensure the train could be stopped before the facing points should the light indicator not display a green aspect. Additionally, a breakdown in verbal communication between the supervising and trainee driver resulted in a misunderstanding of the significance of not sighting the enhancer indication when predicted, and the urgency of the intended action to brake the train. Consequently, train 7MP7 approached the eastern end of Coonana at a speed where it was unable to stop before the open points.

The subsequent manipulation of locomotive control inputs in response to the situation highlighted how the on-the-job component of the Pacific National driver competency program did not adequately prepare the trainee driver to control the train in response to an emergency.

What's been done as a result

Post the derailment of 7MP7, the Australian Rail Track Corporation (ATRC) removed all point clamps from the point indicator stands and relocated them to the adjacent equipment huts at each location between Malbooma (South Australia) and Parkeston (Western Australia). Additionally ARTC have replaced all K3 searchlight units with long-range LED luminaire type units between Malbooma and Parkeston.

Pacific National (PN) introduced a SPAD reduction program and reinforced that train crews reduce speed in preparation for stopping short of facing points, until both drivers confirm recognition and understanding of indicator aspects. Additionally PN discussed with ARTC the implementation of improvements to point indicators between Kalgoorlie (Western Australia) and Cook (South Australia).

Safety message

The practice of maintaining momentum approaching a train order location, before confirming the enhancer indication, is an issue that probably affects multiple operators. The variability in the distance for the effective sighting of enhancers and targets at these safety critical locations means the available distance when an indication is sighted may be less than the effective braking distance of the train, which represents a physical gap or limitation in the system. This gap/limitation places the onus on train crews to implement a rule-based procedure to reduce speed at defined locations repeatedly, in preparation for an anomalous event where the enhancer might display a red light (stop indication).

Download final report
[Download  PDF: 1.84MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

General details
Date: 19 August 2018   Investigation status: Completed  
Time: 1045 AWST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Coonana (about 170 track km east of Kalgoorlie)   Investigation phase: Final report: Dissemination  
State: Western Australia    
Release date: 10 June 2020   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Australian Rail Track Corporation (ARTC)  
Train operator Pacific National  
Train registration 7MP7  
Type of operation Intermodal freight  
Sector Freight  
Damage to train Substantial  
Departure point Melbourne, Victoria  
Destination Perth, Western Australia  
Last update 10 June 2020