Rail safety investigations & reports

Runaway and derailment of TasRail freight train in Devonport, Tasmania on 21 September 2018

Investigation number:
RO-2018-014
Status: Active
Investigation in progress

Preliminary report

Preliminary report published: 9 November 2018

Overview

At approximately 0846[1] on 21 September 2018, a TasRail freight train rolled away from a loading facility at Railton, Tasmania. There was no train crew on board the freight train at the time. The train travelled for about 21 km before being routed into a dead-end siding in Devonport.

At about 0909, the train collided with the end of a dead-end siding, destroyed a fence line and travelled in a derailed state for about 60 m into a public area (Figure 1). Two pedestrians within the public area received minor injuries from fence debris.

Figure 1: Derailment site in Devonport, Tasmania

Figure 1: Derailment site in Devonport, Tasmania. Image shows location of injured pedestrians at time of collision and derailment, as well as the configuration of the cement train consist at the derailment site in Devonport on 22 September 2018. Annotated by ATSB

Image shows location of injured pedestrians at time of collision and derailment, as well as the configuration of the cement train consist at the derailment site in Devonport on 22 September 2018.

Source: ATSB

Train and track information

The freight train weighed approximately 1132 t and was 220 m long. It consisted of a TR class locomotive (TR11), 16 THFY class bulk cement wagons and a trailing driver’s van (DV1[2]). The freight train was a regular TasRail bulk cement service that operated between the loading facility in Railton and an unloading facility in Devonport (Figure 2).

The track from Railton descends from an elevation of about 58 m (above mean sea level) towards Devonport. Devonport is located on the northern coast of Tasmania and is a shipping port with an elevation of 3 m (Figure 2).

Figure 2: Map of TasRail Network

Figure 2: Map of TasRail Network. Image shows location of Railton with respect to Devonport within the TasRail network. 
Source: TasRail and ARA Railways of Australia 2014, annotated by ATSB.

Image shows location of Railton with respect to Devonport within the TasRail network.
Source: TasRail and ARA Railways of Australia 2014, annotated by ATSB.

The TasRail bulk cement service is operated as a driver-alone operation[3] in a push-pull configuration with motive power provided from one locomotive.

To facilitate this push-pull configuration, a portable remote control system is used to control the locomotive. The portable remote control system can be used both from outside of the train driver’s cabin during loading or unloading operations, and from within the leading driver’s cabin when travelling in either direction between Railton and Devonport. The leading driver’s cabin is dependent on direction of travel and can be either from the driver’s cabin in the powered locomotive (TR11), or the driver’s van (DV1) (Figure 1).

Sequence of events

On the morning of 21 September 2018, the train was being loaded at Railton. The driver was situated within the cement loading facility, and was remotely controlling the train to align wagons to the loading chutes. While the last pair of wagons were being aligned, the train came to a stop past the intended stop location.

The driver recalled that, at approximately 0842, he selected reverse to re-align the final two wagons with the loading chutes. However, after selecting reverse, the train became unresponsive to his remote commands.

The driver stated that he attempted multiple times to reset the remote control equipment with the portable remote transmitter. After allowing time for the remote control system to recover, the locomotive continued to be unresponsive to his commands.

The driver decided to walk to the lead locomotive TR11 to undertake a cold restart of the remote control system at the receiver located on the rear of the locomotive. Before he started to walk, at about 0846, the train slowly began rolling away towards Devonport. The driver recalled trying to activate the emergency stop features of the remote system by removing power to the portable remote control system’s transmitter. However, the train did not respond to these commands and gradually gained speed as it rolled away from the loading facility.

At 0848, the driver placed an emergency phone call to TasRail Train Control. He reported the runaway of the cement train to the train controller, who then contacted emergency services.

The Network Access Manager in TasRail Train Control, with the assistance of the TasRail Rolling Stock Assets Manager, were able to monitor the progress of the train using the real time locomotive performance monitoring system. The Network Access Manager communicated this information to the police during the runaway. The police used this information to coordinate their resources to the area ahead of the runaway train. The police concentrated on stopping vehicles and pedestrian traffic at level crossings and about the railway corridor.

During the runaway response, a decision to route the runaway train into the dead-end siding at Devonport was actioned (Figure 3).

Figure 3: Devonport Rail Yard Layout

Figure 3: Devonport Rail Yard Layout. Image shows route taken by runaway train, and dead-end siding. 
Source: TasRail, annotated by ATSB.

Image shows route taken by runaway train, and dead-end siding.
Source: TasRail, annotated by ATSB.

At about 0909, the runaway train collided with a concrete footing and wooden fence line at the end of the dead-end siding in Devonport. As a result of the derailment and collision, two pedestrians received non-life threatening injuries from fence debris. The locomotive and eight THFY class wagons were significantly damaged.

Post Incident

TasRail advised that its bulk cement service between Railton and Devonport was the only service that used a locomotive remote control system. Following the accident on 21 September 2018, TasRail suspended all use of the remote control system from its operations, pending the conclusion of investigations.

Continuing investigation

The ATSB investigation has conducted interviews with the incident driver, the driver of the train’s previous trip, the rolling stock manager, the injured pedestrians, and the train controller and manager. The ATSB has also gathered documentation about the train, the remote control system and the train network.

Following the accident, a series of tests were organised by TasRail on the locomotive and remote control system. The ATSB were present for a number of these tests.

The ATSB investigation is continuing, and will include consideration of the following:

  • serviceability of the locomotive, wagons, remote control system, and the interface between them at time of the accident
  • remote control system and locomotive braking operational inspection and testing arrangements
  • design and compatibility of the locomotive, remote control system, and the interface between them
  • implementation management and on-going monitoring of remote control system and locomotive
  • driver qualifications, experience and medical information
  • recovery controls:
    • runaway protection at Railton
    • detection of unauthorised train access to main line from yard
    • effectiveness of emergency response systems.

____________

The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this update. As such, no analysis or findings are included in this update.

 

__________

  1. EST, Eastern Standard Time.
  2. DV1 was a reclaimed Y class locomotive with no engine or traction motors, and was solely used for a driver to control a pushing locomotive with a portable remote control system when the powered locomotive was trailing the train.
  3. Driver-Alone Operation – Operations in which one rail safety worker has the responsibility for the control, operations and procedures of a train. Source: RISSB Glossary of Railway Terminology – Guideline, Version 1.0, 3 December 2010

Initial summary

Published: 21 October 2018

The ATSB is investigating the derailment of a freight train in Devonport, Tasmania on 21 September 2018.

At approximately 0900 on 21 September 2018, a freight train operated by TasRail was being loaded with cement, the train departed without any command from the remote driver. The operator alerted the relevant authorities immediately, and they intentionally directed it into a dead-end siding in Devonport. Once it arrived at the stops of the siding, the train derailed. Two members of the public sustained injuries.

As part of the investigation, the ATSB will examine the locomotive and wagons, interview witnesses, and obtain any available recorded data for analysis.

A final report will be released at the end of the investigation.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

Media

Download VIDEO: Prelim_Devonport_derailment_Nat_Nagy_ATSB [MP4 289.13MB]

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General details
Date: 21 September 2018   Investigation status: Active  
Time: 0909 EST   Investigation phase: Evidence collection  
Location   (show map): Devonport   Investigation type: Occurrence Investigation  
State: Tasmania    
Release date: 09 November 2018    
Report status: Preliminary   Occurrence category: Accident  
Expected completion: 3rd Quarter 2019   Highest injury level: Minor  

Train details

Train details
Line operator TasRail  
Train operator TasRail  
Train registration 604  
Type of operation Freight  
Sector Freight  
Damage to train Substantial  
Departure point Railton, Tas.  
Destination Devonport, Tas.  
Last update 21 November 2018