Unsecured locomotive hatch exceeded rolling stock outline prior to collision with train on adjacent track

Unsecured locomotive hatch

The collision of a passenger train with the open hatch of an adjacent locomotive emphasises the need for appropriate risk controls to prevent hatches from opening during service, a safety investigation has concluded.

On the evening of 21 July 2020, a passenger train bound for Kiama collided with the air filter hatch of a stationary Pacific National NR locomotive near Loftus station, on Sydney Trains’ Illawarra line.

There were no injuries reported, but the guard’s windscreen and passenger doors on the lead carriage of the passenger train were damaged in the collision.

An investigation into the incident was undertaken by the Office of Transport Safety Investigations (OTSI), which conducts rail safety investigations in NSW on behalf of the ATSB.

It concluded the air filter hatch was likely not properly secured during recent maintenance. This was then missed during roll-by inspections, as the design of the hatch and locks meant that the hatch could appear visibly closed and locked without it being secured correctly.

Open, and able to swing perpendicular to the train, the hatch exceeded the rolling stock outline*, thus becoming out of gauge. This allowed the hatch to infringe on the outline of the oncoming passenger train on the adjacent track.

The Australian Standard for Rolling Stock Outlines (AS 7507:2017) specifies external hatches should be designed such that when open they do not protrude from the kinematic envelope (i.e. outline) of the rolling stock.

“If this cannot be achieved, the Australian Standard suggests a range of secondary measures that can prevent an incident like this one occurring,” said OTSI Chief Investigator and CEO Dr Natalie Pelham.

“While not mandatory, the Standard provides industry with guidance on recommended practices that can reduce the risk of an incident occurring and improve safety for everyone using the network.

“Rail transport operators should review their rolling stock to ensure that appropriate risk controls are in place to prevent hatches from opening while in service and becoming out of gauge.”

Following the incident, Pacific National and its maintenance provider United Group Limited (UGL) conducted an assessment of the NR locomotive fleet, which identified the locomotives’ CA10 communications cabinets featured a hatch which could also exceed the rolling stock outline if not properly secured.

As a result, Pacific National and UGL have released a modification to fit a secondary latch to the air filter and CA10 hatches on all NR locomotives.

The intent of the modification is to prevent a hatch from exceeding the rolling stock outline if it was not properly secured or the lock was to fail.

Pacific National and UGL also issued a bulletin to maintenance staff in November 2020, detailing the correct procedure for securing hatches, and conducted an inspection to check the integrity of locks and hinges on air filter hatches across the NR locomotive fleet.

* The maximum permissible dimension a train must remain within to maintain acceptable clearances between rolling stock, structures and passing trains.

Read the report: RO-2020-012 Collision between out of gauge freight train 3WB3 and passenger train C181, Loftus, New South Wales on 21 July 2020.

 

 

Last update 21 July 2021

Final report

Collision between out of gauge freight train 3WB3 and passenger train C181, Loftus, New South Wales on 21 July 2020