Summary
Updated: 28 February 2020
The investigation into the circumstances that led to the Pacific National grain train 5KC3 passing a series of signals passed at danger near Wagga Wagga, NSW on 1 March 2019 is continuing.
The report from the investigation is currently in the ‘Examination and analysis’ phase. During this phase, evidence is reviewed and evaluated to determine its relevance, validity, credibility and relationship to other evidence and to the occurrence.
ATSB investigators have so far gathered and analysed numerous information sources including:
- Signalling system reports and logs
- Recorded audio exchanges between the Network Control Officer and train crews
- Post-incident signal sighting reports
- Interviews with the crews involved
- Meetings with the various rollingstock operators involved directly and indirectly in this occurrence
- Independent review of the report from the involved rollingstock operator including circumstances prior to and immediately post-occurrence
- Independent review of the crew shift patterns in place by the rollingstock operator at the time of the occurrence.
Initial summary: 1 March 2019
The ATSB is investigating the circumstances that led to the Pacific National grain train 5KC3 passing a series of signals passed at danger near Wagga Wagga, NSW on 1 March 2019.
This investigation is being led by the New South Wales Office of Transport Safety Investigations (OTSI). OTSI conducts rail investigations in NSW on behalf of the ATSB under the Transport Safety Investigation Act 2003.
At 0505 AEDT, grain train 5KC3 travelling in the up direction passed signal 04-26 at danger. The train continued for approximately 1 km and passed signals 04-32 and 04-30 at danger. Train 5KC3 came to a halt after the Australian Rail Track Corporation Junee train controller advised the crew that they had passed the signals at danger. Train 5KC3 came to a halt approximately 3 km from train 5BM9 which was travelling in the down direction on the same line.
As part of the investigation, the ATSB will obtain details from both rolling stock operators as well as the infrastructure manager including but not limited to confirmation of signal aspect operation, train driver interviews and other factors which may have contributed to the incident.
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.
Discontinuation
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Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the ATSB to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation. This statement is published as a report in accordance with section 25 of the TSI Act, capturing information from the investigation up to the time of discontinuance. |
Overview of the investigation
At 0504 Eastern Daylight-Saving Time on Friday 1 March 2019, Pacific National (PN) grain train 5KC3 passed signal 04 26 at stop at Wagga Wagga while on a journey from Ararat, Victoria to Cootamundra, New South Wales. The train continued its journey north, passed another two signals at stop and through a set of points in Wagga Wagga yard. The train was stopped after the Australian Rail Track Corporation (ARTC) Network Controller contacted the train crew by radio and informed them of the signals passed at danger events. The train crew consisted of two persons, driver 1 and driver 2.
Train 4BM9 had departed Bomen and was heading towards Wagga Wagga to cross train 5KC3 when train 5KC3 passed the signals at stop. Train 5KC3 passed the up direction starting signal for the Wagga Wagga to Bomen section and was heading into a potential collision with train 4BM9. The two trains were around 2.5 km apart by the time they were both brought to a stand.
The investigation found that the crew of train 5KC3 did not react to the signal indications within Wagga Wagga yard limits that were set, at first to restrictive indications, and then stop indications. These signals were set to cross train 4BM9 at Wagga Wagga. The reason for the crew of train 5KC3 not responding to the signal indications could not be conclusively determined.
The data logger of the leading locomotive of train 5KC3 indicated the driver was successfully responding to the demands of the vigilance control system.
There was no evidence either of the crew of 5KC3 were affected by any medical or other health episode. Neither of the crew members can recall their journey beyond the southern entrance to Wagga Wagga yard limits until the notification of the signal passed at danger (SPAD) events by the ARTC Network Controller. Both crew members commenced their shifts at about 2000 the previous evening and their recent shifts were not regarded as being outside the normal rostering parameters for the operator.
The reasons for the train crew not responding to the signals may have been determined if the driver’s cab was fitted with an inward-facing camera recording the actions of the train crew. The video may have shown what the train crew were doing leading up to the SPAD. The presence of a camera would not have prevented the SPAD but may have assisted in the post-incident analysis. An audio recording, synchronised with the camera, may have also provided additional information about the train crew’s actions, and possible alarms or sounds inside the cab. Having audio and video recording allows investigators to eliminate potential contributory factors early in the investigation.
The Office of National Rail Safety Regulator (ONRSR) has consulted with key stakeholders regarding a requirement for Australian rail operators to install in-cab audio and video recorders in driver’s compartments. The finalisation of this process would be beneficial to the understanding of in-cab interactions of train crew and may lead to the development of new or improved risk mitigation measures.
Another ATSB investigation, involving a collision between freight trains 7MP5 and 2K66, at Jumperkine, Western Australia, on 24 December 2019, is currently examining vigilance control activation issues. In that investigation, the driver of 7MP5, operated by Pacific National, continued towards Jumperkine, without appearing to undertake any driver control changes that would have reset the vigilance time count. This investigation is expected to be completed in Quarter 4 2021.
The issue of drivers’ being unresponsive to signals while continuing to acknowledge vigilance alerts has been identified in previous rail investigations including Beresfield[1] and Hurlstone Park.[2] It may be beneficial if the effectiveness of vigilance control systems is explored as part of a separate safety study, and this is currently being considered by the ATSB.
Reasons for the discontinuation
The contributing factors to this SPAD highlight the need for a positive train control system to provide additional control in the prevention of SPAD events and their subsequent consequences.
In response to the investigation, ARTC has advised their Advanced Train Management System (ATMS) is a project underway that will provide additional protection from the risk of SPAD. The ATMS can detect and intervene when a train is not being managed in accordance with speed and proceed authority instructions.
According to the ARTC, the ATMS provides the following features:
- increased rail capacity, by allowing operations with smaller inter-train distances
- increased safety, through limit of authority and speed limit enforcement and protection for trackside workers
- improved reliability, through better on-time performance
- improved efficiency and flexibility in network use
- reduced operation and maintenance cost for trackside infrastructure
- a modern platform capable of extension to meet future demand.
Based on this information, it was considered unlikely that further investigation would identify any systemic safety issues or additional opportunity for the enhancement of transport safety beyond the introduction of a positive train control system. Consequently, the investigation is discontinued.
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Occurrence summary
| Investigation number | RO-2019-007 |
|---|---|
| Occurrence date | 01/03/2019 |
| Location | near Wagga Wagga |
| State | New South Wales |
| Report release date | 20/04/2021 |
| Report status | Discontinued |
| Investigation level | Defined |
| Investigation type | Occurrence Investigation |
| Investigation phase | Final report: Dissemination |
| Investigation status | Discontinued |
| Mode of transport | Rail |
| Rail occurrence category | SPAD (signal passed at danger) |
| Occurrence class | Serious Incident |
| Highest injury level | None |
Train details
| Train operator | Pacific National |
|---|---|
| Train number | 5KC3 |
| Type of operation | Grain train |
| Destination | Carrington, NSW |
| Train damage | Nil |
Train details
| Train number | 5BM9 |
|---|---|
| Type of operation | Goods train |
| Departure point | Brisbane, Queensland |
| Destination | Melbourne, Vistoria |
| Train damage | Nil |