Maintenance worker near miss on Skitube Alpine Railway

Skitube Alpine Railway’s Bollocks Flat Terminal

Key points:

  • Duty controller granted track access to maintenance electrician during shunting
  • Required protection flags were not placed on the train
  • Elements of the operator’s safety management system had little scope to recover once human or procedural error occurred

 

A maintenance electrician was inadvertently briefly beneath a moving train wagon during a shunting operation at the Skitube Alpine Railway’s Bullocks Flat Terminal, a new ATSB investigation report details.

The electrician was uninjured during the 3 July 2019 incident, which occurred during a scheduled de-coupling of a four carriage Skitube train set into two two-carriage sets at the Bullocks Flat Terminal, New South Wales. Just before the carriage started moving the electrician heard the brakes release and moved against the wall under the platform, clear of the train, the report details.

The transport safety investigation into the incident, which was classified as a ‘near miss’, was carried out by the Office of Transport Safety Investigations (OTSI), which conducts rail incident investigations in New South Wales on behalf of the ATSB, found that the duty controller had granted access to the electrician during shunting activity on the track. 

“It is likely that the duty controller did not connect that the shunting operation and the electrician accessing the track was occurring at the same time, due to other activities occurring in the control room, including the visit of an off-duty controller,” noted acting OTSI Chief Investigator, Mick Quinn.

“In addition, the electrician did not apply the required protection flags to the train set to indicate that work was being conducted on the train.”

The investigation also found that Skitube’s safety management system was reliant on procedures being followed to manage safety risks and that there was little scope for the system to recover once there had been a human or procedural error.

“In this instance, the operator’s safety management system did consider the likelihood of the duty controller making an error and provided two secondary layers of control, the control room logbook and the temporary access track form, however these did not provide any  greater awareness of a pending conflict for the controller,” Mr Quinn continued.

“Also, the placement of protection flags does not ensure energy to a train is isolated and that the train cannot be moved while it is being worked on.” 

The investigation highlights the importance of workers ensuring they are protected and that they follow safety procedures before entering the danger zone or when interacting with trains, Mr Quinn said.

“Safety management systems also need to identify when conflicting activities take place that increase the risk to workers, and organisations should asses their risk controls to ensure their safety systems are error-tolerant and have a second line of defence to protect workers,” he said.

Since the near miss, Skitube updated its temporary track access procedures. That included its red flag procedure – including lowering the pantograph, applying the brakes, removing keys and locking the driver’s cab, and placing a “Do Not Operate” tag on all driver’s cabs when a person is required to be in close proximity to a stationary train – which was formalised and documented as a discrete procedure.

Read the investigation report RO-2019-014: Near miss with maintenance worker on the Skitube Alpine Railway at Bullocks Flat, New South Wales, on 3 July 2019

Last update 19 November 2020

Final report

RO-2019-014: Near miss with maintenance worker on the Skitube Alpine Railway at Bullocks Flat, New South Wales, on 3 July 2019