Shunting Accident

Executive summary

At approximately 1317 Central Summer Time¹ (CSuT) on Wednesday 2 February 2005, a Specialised Container Transport² (SCT) employee was seriously injured whilst undertaking shunting operations at the SCT Rail Yards, Regency Park, South Australia. On the day of the accident, he was directing the shunting activities of locomotive T345.

At the time of the accident, locomotive T345 was propelling³ a rake of nine wagons. Towards the conclusion of this movement, approximately 1319, the driver of T345 called the shunter using his hand held radio to establish his whereabouts. When the shunter failed to respond to several radio calls, the driver decided to stop the train, leave the cab and look for the shunter. As the driver left the cab he saw the shunter lying face down, parallel to the track, within the ‘four foot’⁴, the right hand side of his body was partly straddled across the rail lines. The shunter had sustained serious injuries.

SCT staff and emergency services personnel reacted quickly and efficiently to the accident.

Based on the analysis of available evidence it is concluded that it is likely that either:

• the shunter fell from the end step of the leading container flat wagon  CQMY 3008N, whilst locomotive T345 was propelling a rake of wagons in  a northerly direction, heading out of the SCT marshalling loop; or

• the shunter was run over by CQMY 3008N just before or as the shunter  attempted to board the end step.

The investigation found that work procedures in the Regency Park rail yard allowed a shunter to ride on the end step of a wagon while being shunted and did not require that the driver confirm that the shunter was safe and/or in a safe position before starting a shunt movement.

In the lead-up to and post accident, SCT was conducting a review of their shunting procedures at its various intermodal sites. This included the Regency Park site in South Australia. They have subsequently modified shunting arrangements to incorporate the use of a small ‘All Terrain’ vehicle by shunters and the riding of wagons is no longer permitted. SCT has also enhanced its radio communications on T345 by providing a fixed radio with an external speaker as well as an on board CCTV system to assist with driver peripheral vision. Although these new initiatives are likely to prevent a similar accident, the investigation has identified further opportunities to improve railway operational safety.

The ATSB recommends that SCT:

1. develop arrangements that do not require employees to ride a locomotive/wagon whilst it is being shunted, this should be done without compromising the safety of shunt movements; or if not feasible develop a restraint mechanism/workstation to protect a shunter from falling from a locomotive/wagon whilst carrying out a shunt movement.

2. develop procedures that ensure a driver validates the position of a shunter, before proceeding with a shunt movement, and procedures that also regularly validate the wellbeing/whereabouts of a shunter whilst undertaking shunting activities.

3. undertake a thorough risk assessment of its shunting activities, including communication protocols. Translate this into a comprehensive safe working procedure and develop/provide an associated and accredited training program. Provide regular retraining of employees with respect to safety critical activities.

4. remind employees of their Occupational Health and Safety (OHS) responsibilities with respect to their personal safety, which includes a requirement to regularly check/replace worn personal protective equipment (PPE) such as safety boots/shoes and compliance with prescribed safety policies.
5. undertake/record results of regular audits of employees working practices to ensure that they are complying with documented safe working procedures and training directives.
6. ensure mandated medical instructions/restrictions are implemented. If the intent of a medical directive cannot be fully achieved consult with the medical practitioner to ensure any proposed alternative is effective.

The ATSB recommends that the South Australian Railway Safety Regulator:

1. Actively monitor the actions initiated by SCT in response to this investigation.

2. Recognise that the findings of this investigation may be relevant to other organisations, and take the appropriate actions to ensure they are advised accordingly.

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1. All times throughout this report is Central Summer Time (CSuT). However as times from various sources differ marginally, all times have been referenced to the Hasler clock roll (locomotive data logger) from T345.
2. Throughout the report, Specialised Container Transport (SCT) refers to ‘Twentieth Superpace Nominees Pty Ltd, trading as SCT Logistics.
3. ‘propelling’ - any reversing movement other than setting back at a platform after a partial overrun. (Source: Glossary for the National Codes of Practice and Dictionary of Railway Terminology).
4. ‘four foot’ – the area between the rails of a standard gauge railway. (Source: Glossary for the National Codes of Practice and Dictionary of Railway Terminology)