Overrun of authority involving train 6MP5, at Blamey, Western Australia, on 14 July 2013

RO-2013-019

Final report

Safety summary

What happened

At about 2121 on 14 July 2013, Pacific National intermodal freight train 6MP5 overran the limit of its authority at Blamey, Western Australia. The train travelled 23 km into the Blamey to Curtin section before the crew realised the overrun had occurred and stopped the train.

The crew did not immediately report the overrun to the Network Control Officer as required. Instead, they provided misleading information about the train’s location and that they were having problems with the on board communication systems. Unaware of the authority overrun, the Network Control Officer issued a Train Authority for train 6MP5 to proceed from Blamey to Parkeston.

The train crew signed off duty at Parkeston and after reflecting on their actions reported the occurrence to the Pacific National Kalgoorlie Depot Manager the following day.

What the ATSB found

The ATSB found that during the safety critical period approaching the limit of authority at Blamey, the train crew had focused their attention on planning for the upcoming refuelling at Parkeston. As a result, they were distracted from the primary task of driving the train and missed vital cues and information that identified the limit of the current train authority.

The investigation also found that there were inconsistencies in the instructions contained in the various Pacific National procedural documents relating to refuelling at Parkeston.

What's been done as a result

Pacific National has amended procedures related to the arrangements for refuelling trains at Parkeston to remove inconsistencies and ensure that ancillary tasks do not have the potential to distract train crews from undertaking safety critical work.

Safety message

Train crews must be cognisant of and apply the operational procedures intended to prevent or control the consequence that may arise from an overrun of authority.

Rail transport operators should ensure that any ancillary tasks undertaken by a train crew do not have the potential to divert attention away from the safe operation of a train.

Occurrence summary

Investigation number RO-2013-019
Occurrence date 14/07/2013
Location Blamey
State Western Australia
Report release date 07/07/2014
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Rail
Rail occurrence category Proceed Authority Exceeded
Occurrence class Incident
Highest injury level None

Train details

Train operator Pacific National
Train number 6MP5
Type of operation Interstate intermodal freight
Departure point Cook, SA
Destination Parkeston, WA
Train damage Nil