Safety summary

What happened

On 31 July 2017, a team of Sydney Trains’^[1] infrastructure maintainers were conducting a series of inspections and measurements along the Up and Down^[2] Illawarra Main and Up and Down Illawarra Local lines, Tempe. The workgroup were located between 746 points and 748 points when a passenger service 59-J travelling on the Down Illawarra Local line towards Tempe Station narrowly missed the workgroup as it passed their worksite. There were no injuries or damage.

What the ATSB found

The workgroup had relied on lookout working (LOW) as the method of worksite protection. Two workers were positioned as lookouts for oncoming trains; one trackside watching for the approach of Down trains, using track warning lights^[3] (Down lookout), the other positioned at Tempe^[4] Station footbridge watching for the approach of Up trains (Up lookout). The Down lookout had diverted his attention away from the warning lights to acknowledge an Up train. When he re-focussed on the warning lights, he realised a warning light for approaching Down trains had extinguished. He was not able to sound a warning to the workgroup and give them sufficient time to clear the danger zone to a safe location, before 59-J approached their location.

Additionally, the ATSB found the location of the worksite was considered unsuitable for LOW according to Sydney Trains’ Worksite Protection and Hazardous Locations Register (WPHLR).

What's been done as a result

On 12 November 2017, Sydney Trains made changes to NPR 711 Using Lookouts^[5]. Instructions mandated that warning lights must not be used to provide warning of approaching rail traffic when using lookouts. Further, this instruction applied to all tracks in the Sydney Trains Network unless specifically exempted in the Network Local Appendices.

Sydney Trains is also reviewing the WPHLR with a view to simplifying the document by only including locations where LOW is specifically prohibited.

Safety message

Compared to the other worksite protection methods, Lookout Working (LOW) does not warn, or restrict trains from approaching, or entering a work location. Where practicable, rail transport operators (RTOs) must require track workers to continually re-assess the site risks, add/combine safety measures (like Automatic Track Warning System, or audible warning devices), or implement a higher form of protection.

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1. All trains, employees, roles, Network Rules, Network Procedures and maintenance responsibilities referred to in this report were under the control of Sydney Trains.
2. Trains that travel away from Sydney are Down trains. The lines that carry them are Down lines. Trains that travel towards Sydney are Up trains. The lines that carry them are Up lines, e.g., ‘Up and Down Main’ Lines.
3. A track warning light is defined as an illuminated white or orange warning light provided at locations where workers on track have a restricted view of approaching rail traffic. If rail traffic approaches, the light goes out, giving time for workers to move to, or remain in, a safe place (Network Rule NSG 604).
4. The rail kilometrage for Tempe Station is 6.770 km by rail South of Central railway station. This was referenced from Network Local Appendices NLA 402.
5. These changes were advertised on the RailSafe website and cited Safe Notice 1042-2017 (which outlined the specific change to NPR 711 Using Lookouts) and SafeTracks 3 November 2017 (which provided more information about the changes). Refer to www.railsafe.org.au/

The occurrence

What happened

On the morning of 31 July 2017, a team of four Sydney Trains infrastructure maintainers from their Sydenham Network Base gathered to conduct a series of regular inspections and measurements at several points along the Up and Down Illawarra Main and Up and Down Illawarra Local lines, Tempe. The work involved four sets of points, with the incident occurring between 746 points and 748 points (see Figure 1).

Figure 1: Incident location – Tempe, NSW

Source: ATSB

Two workers forming an inspection team, entered the danger zone and accessed the track in accordance with procedures for the protection of track workers using Network Rule NWT 310 Lookout Working. The rules stipulated that all workers and equipment were to be completely within a safe place a minimum of ten seconds before rail traffic entered a worksite (passed their location).

At approximately 1000, empty passenger service 59-J was travelling on the Down Illawarra Local line towards Tempe Station, when the driver observed the workgroup in the danger zone. The driver applied the train brakes, blew the horn and the workers began to move off the line towards a safe place, to the side of the track or ‘cess’ (see Figure 1). A review of CCTV footage from the train showed that the workers had nearly reached a safe place when the train passed the workers’ location (approximately seven seconds after the train first observed the work group). There were no injuries or damage.

The incident involving train 59-J occurred when the Down lookout responded to the horn from the approaching Up train. He turned away from the warning lights to provide an ‘all clear’^[6] hand signal to the driver of the Up train. He then waited for an acknowledgement from the driver of the Up train, before turning back to re-focus on the warning lights. He realised a warning light for approaching down trains had already extinguished. He was not able to sound the warning to the work group and give them sufficient time to clear the danger zone to a safe location, before 59-J approached their location.

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6. Drivers or Track Vehicle Operators must sound the whistle to acknowledge an ALL CLEAR handsignal given by a white light, or one hand held high (Network Rule NGE 202).

Context

Location

The incident location at Tempe is approximately 6.5 km from Sydney’s Central Station and is a multiple-track site consisting of the Up and Down Illawarra Main and Up and Down Illawarra Local lines.

Figure 2: Location of Tempe Station, NSW

Source: Google Maps

Worksite protection

Network Rule NWT 300 Planning Work in the Rail Corridor requires work in the danger zone to be planned and carried out using one of five methods of worksite protection^[7]. The different methods of worksite protection are implemented according to the risk involved with the work task.

LOW is relatively expedient to implement compared to other worksite protection methods. This is because LOW does not prevent trains from entering the worksite. Protection of workers under LOW is reliant on positive outcomes from human performance and compliance to procedures.

To minimise risk, the Network Rules encourage track workers to assess and reassess the risks at each location, apply additional safety measures, or implement a higher form of protection, where practicable. NWT 300 states that Local Possession Authorities (LPAs) and Track Occupancy Authorities (TOAs) are the preferred methods of working on track, mainly as they authorise closure, or exclusive occupation of the track. The LOW rule, NWT 310, reinforces this philosophy when it states:

‘If Absolute Signal Blocking (ASB) is available, it is preferred over Lookout Working’.

Some considerations in reducing risk when using LOW are to add, or combine, additional safety measures like Automatic Track Warning System (ATWS), or audible warning devices.

LOW network procedure

Lookouts are responsible for maintaining minimum allowable sighting distance, remaining vigilant for and detecting the approach of trains, and for warning workers in the danger zone of an approaching train.

The LOW Network Procedure NPR 711 states lookouts must:

1. Agree with the Protection Officer on how workers will be warned about the approach of rail traffic.
2. Stand in a safe place where you can see approaching rail traffic and be within sight and hearing of the workers. If you cannot do both of these safely, tell the Protection Officer.
3. Keep a continuous lookout for the approach of rail traffic.
4. When rail traffic approaches, warn the workers immediately.
5. Only if workers and their equipment are in a safe place, face the approaching train or track vehicle and give the ALL CLEAR handsignal to the Driver or Track Vehicle Operator.
6. Wait for the Driver or Track Vehicle Operator to acknowledge the ALL CLEAR handsignal.
7. Make sure that the line is clear before telling the Protection Officer that it is safe for work to resume.
8. Tell the Protection Officer if you need to move from your designated position. Do not move from your position until:
   - all workers and their equipment are in a safe place
   - a new Lookout is in position
9. Tell the Protection Officer if conditions such as visibility change.

The Network Rules do not stipulate any separate criteria for trains approaching from one direction or another direction.

Location of the Lookouts

The distance of the work group at 746 points from the Up lookout was approximately 350 metres. The distance of the work group from the Down lookout from 746 points was approximately 170 metres. At these locations the Down lookout was within sighting distance of the work group, however, the sighting distance to the Up lookout was obstructed by the overhead bridge stanchions.

Figure 3: View from the position of the Down lookout

Source: ATSB

Figure 4: View from the position of the Up lookout, looking towards the work group

Source: ATSB

Worksite Protection Hazardous Locations Register (WPHLR)

The Worksite Protection Hazardous Locations Register (WPHLR) identifies hazardous locations across the Sydney Trains rail network. Its purpose is to help users understand the hazards relating to worksite protection in these hazardous locations and provide recommendations for implementing appropriate worksite protection.

This section of track was included on the WPHLR and was considered an area inappropriate for using LOW. The Up Main and Down Local Illawarra lines were the two inside rail lines of the four rail line corridor. These tracks were identified to have some areas with inadequate sighting distance or no safe place. The recommended precautions were:

‘Unless a safe place can be created by taking an ASB on the adjacent track to which the worksite is to be set up, LOW is not permitted’

This WPHLR was available and was consulted by the Protection Officer (PO), who considered the WPHLR as a guide only. The protection plan was put to the Network Controller and was accepted, confirming the PO’s thoughts on the WPHLR.

Warning lights

In the network rule NSG 604 Indicators and signs, warning lights are described as;

Illuminated white or orange warning lights are provided at locations where workers on track have a restricted view of approaching rail traffic. If rail traffic approaches, the lights go out.

These lights can provide a warning to workers of approaching rail traffic. On detection of approaching rail traffic, the warning lights extinguish. This is intended to provide a fail-safe operation such that, if the light fails, or is observed to be extinguished, it must be assumed that a train is approaching.

The warning lights used by the Down lookout were illuminated white with a configuration of the example warning light in Figure 5.

Figure 5: Example of Warning light

Source: Sydney Trains
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7. The five include Local Possession Authority (LPA), Track Occupancy Authority (TOA), Track Work Authority (TWA), Absolute Signal Blocking (ASB) and Lookout Working (LOW).

Safety analysis

Mobile worksite and re-assessment of risk

Although the work itself was considered routine, the worksite area was mobile; that is, it was progressing along the rail corridor/tracks in the danger zone. The constantly changing terrain required the workers to be on both Up and Down tracks simultaneously and on multiple occasions. Both Up and Down lookouts were equipped with the same audible devices (horn and whistle) to warn the work group. In some cases, as in this incident, the position of the work group changed, whilst the position of the lookouts remained static.

In this incident, there were occasions when the workers passed through locations where there was restricted sighting (due to structures) and/or an absence of a safe place. It was likely that the ability of the lookouts to maintain sighting distance and provide timely warnings over the entire worksite area was impacted by the mobility of the work group conducting their inspection tasks.

Network Rule NWT 310 requires POs to reassess safety measures if conditions such as visibility, or work locations change. Additionally, if worksites are established over a large area, minimum warning times (MWTs) must be continually reassessed.

While the nature of the task required the workgroup to move over a large area and potentially affect MWT for the workgroup, there was no evidence of the PO reassessing MWTs.

The PO and Down lookout took on their respective roles at short notice, as other staff to fulfil these roles were not available. The PO also acted as the worksite supervisor and accompanied the inspection worker in the danger zone. The PO was satisfied that these additional duties did not interfere with his primary duty as a PO.

When interviewed, the PO explained his understanding of LOW and safe places. He expressed that when LOW was implemented over multiple rail tracks, safe places were created on adjacent clear rail tracks when a train approached on the same rail track as the workers.

The PO’s understanding of a safe place is not consistent with the definition of a safe place as defined in the RailSafe Glossary which states a safe place to be;

‘A place where workers and equipment cannot be struck by rail traffic.’

When a worker is on a live rail track there is a possibility of the worker being struck by rail traffic. Although the PO had been in the rail industry for 24 years and had worked as a qualified PO for 16 years, his understanding of a safe place in the rail corridor was no longer consistent with the definition.

The two lookouts and the inspection worker all agreed to the worksite protection plan and agreed with the PO on what constituted a safe place. It is likely the understanding of what constituted a safe place amongst all these workers increased the risk to the workers in the danger zone of being struck by rail traffic.

Responsibilities of the lookout

At Tempe, the Down lookout focused on acknowledging, by giving an ‘all clear’ hand signal and waiting for acknowledgement from an Up train. The Up train did not pose an immediate risk to the work group. The Down lookout focusing on acknowledging an Up train increased the risk to the work group of being struck by the Down train.

Where a lookout is required to remain vigilant for trains coming from a specific direction and provide adequate warning to people to get off the track, any distraction from this task increases the risk to the workgroup. NPR 711 stipulates that the lookout can only do this when workers and equipment are in a safe place, the ability for any lookout to perform this task effectively is questionable as the lookout must be able to establish the workgroup is clear of the track and will remain clear of the track before acknowledging the oncoming rail traffic.

There is limited time for a lookout to be satisfied of this when communication between the lookout and the workgroup is limited to non-verbal and visual communications. The act of acknowledging the oncoming train requires the lookout to face away from the workgroup and focus their attention on the oncoming train. The lookout cannot be sure members of the workgroup are clear and will remain clear when they turn away to acknowledge an oncoming train.

The Down lookout had the necessary competencies and experience to fulfil the role of a lookout. When interviewed, the Down lookout readily recalled the key responsibilities of that role and how they applied to the Tempe location. Notably, he explained that his decision to react to a train horn and provide an ‘all clear’ towards an Up train, was based on his interpretation and understanding of Network Rule NPR711 and from his practical experience. He reiterated that he reacted the same way to any train driver that sounded their train horn. This had been reinforced during his many years of track work experience, where he had personally received adverse reactions from drivers when they were not in receipt of an appropriate ‘all clear’ hand signal from lookouts.

Location of the Lookouts

The distance of the work group at 746 points from the Up lookout was approximately 350 metres. The distance of the work group from the Down lookout from 746 points was approximately 170 metres. At these locations the Down lookout was within sighting distance of the work group, however, the sighting distance to the Up lookout was obstructed by the overhead bridge stanchions.

The location and distance of the Up lookout from the work group would have made it difficult for the work group to hear the audible warning devices during their first two point inspections of 746 points and 748 points (see Figure 4).

Other ambient noise in closer proximity to the work group may have masked the sound of the horn and/or whistle which were the agreed audible devices used by the lookouts. Additionally, the overhead bridge between the Up lookout and the workgroup may have buffered the sound of the horn and whistle, making it harder for the work group to hear the audible warning. It is likely the audible warning devices would have been heard from the Down lookout.

The Down lookout was on the Up side of the work group during the inspections of 746 and 748 points. It is possible the Down lookout’s audible alarm coming from the Up side of the work group could have confused workers and delayed their evacuation from the danger zone. In most cases, Lookouts are on the extremities of the workgroup, so audible warnings from a lookout generally come from the direction the train is coming from.

Worksite Protection Hazardous Locations Register (WPHLR)

Had the WPHLR been a document that required strict adherence, then the Network Controller should have informed the PO and an alternate protection method would have been sought.

Reference and adherence to the WPHLR is not apparent in the Network Rules and Procedures. Having a reference such as this is useful, but only if relevant people are aware of and are required to use it when planning work site protection.

Use of warning lights

From the approaches to the worksite at Tempe, there are a number of obstructions affecting visibility of the workers from an approaching train. From the down direction, these include an overbridge, stanchions and track curvature towards the Sydney end. Due to the restricted sighting on these track approaches, two illuminated white warning lights were provided for the Down Illawarra and Down Illawarra Local lines near Tempe to assist lookouts.

This warning light system, which relied on a lookout maintaining active observation, was utilised by the Down lookout as the Protection Officer considered the risk associated with using LOW had been successfully mitigated by using the warning lights. The warning lights are not designed with backup mechanisms (such as audible alarms, additional lights) to alert persons in the vicinity that the light/s in fact had extinguished and warned of an approaching train. However, while the purpose of warning lights is included in the Network Rules (NSG 604), they do not stipulate their application to specific worksite protection methods, like LOW. The warning lights at this location were not shown on older diagrams/network maps, worksite protection planning diagrams (WPPDs)^[8], or Drivers Route Knowledge Diagrams (DRKDs).^[9] The PO used DRKDs when implementing LOW.

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8. The RailSafe website stated that Worksite Protection Planning Diagrams (WPPD) were established to support the Rail Corridor Safety Program and were generated from the Sydney Trains Infrastructure GIS (Geospatial Information System). These were organised into books with each book covering a part of the Sydney Trains Infrastructure Network. These were uncontrolled documents and all information should be verified in the field. Refer to www.railsafe.org.au/diagrams
9. The RailSafe website stated that Drivers Route Knowledge Diagrams (DRKD) were a stylised diagram showing the layout of major infrastructure in the Sydney Trains Network approved for train crew knowledge only. These were uncontrolled documents and all information should be verified in the field. Refer to www.railsafe.org.au/diagrams

Findings

These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

• The incident involving train 59-J occurred during lookout working, when the Down lookout faced an approaching Up train to provide an ‘all clear’ hand signal to the train driver. At this time the Down lookout missed the change in aspect of the warning light indicating the approach of train service 59-J and could not provide adequate warning to the work group.
• The Workgroup’s understanding and establishment of a safe place increased their risk of being struck by rail traffic.
• The Down lookout’s interpretation and understanding of NPR711 contributed to his acknowledgment of the Up train.
• The location and distance of the Up lookout from the work group may have made it difficult for the work group to hear the audible warning devices during their first two point inspections of 746 points and 748 points.
• The location of the Down lookout presented a possibility of work group members being confused and delayed in responding to an audible warning.
• Lookout Working (LOW) was implemented in an area deemed unsuitable for LOW on the Sydney Trains Worksite Protection Hazardous Locations Register (WPHLR). This is likely due to the WPHLR not being clearly stated as a reference with specific requirements that must be adhered to. [Safety issue]
• Warning lights were utilised at Tempe to overcome sighting hazards and justify the use of LOW. Warning lights rely on lookouts maintaining continuous observation and their use were not specifically referenced in the LOW Network Rules. [Safety issue].

Safety issues and actions

The safety issues identified during this investigation are listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

Depending on the level of risk of the safety issue, the extent of corrective action taken by the relevant organisation, or the desirability of directing a broad safety message to the rail industry, the ATSB may issue safety recommendations or safety advisory notices as part of the final report.

All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.

Descriptions of each safety issue, and any associated safety recommendations, are detailed below. Click the link to read the full safety issue description, including the issue status and any safety action/s taken. Safety issues and actions are updated on this website when safety issue owners provide further information concerning the implementation of safety action.

Use of warning lights

Safety issue number: RO-2017-009-SI-01

Safety issue description: Warning lights were utilised at Tempe to overcome sighting hazards and justify the use of Lookout Working (LOW). Warning lights rely on lookouts maintaining continuous observation and their use were not specifically referenced in the LOW Network Rules.

Single source of information for Lookout Working prohibition

Safety issue number: RO-2017-009-SI-02

Safety issue description: Lookout Working (LOW) was implemented in an area deemed unsuitable for LOW on the Sydney Trains Worksite Protection Hazardous Locations Register (WPHLR). This is likely due to the WPHLR not being clearly stated as a reference with specific requirements that must be adhered to.

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10. These changes were advertised on the RailSafe website and cited Safe Notice 1042-2017 (which outlined the specific change to NPR 711 Using Lookouts) and SafeTracks 03 November 2017 (which provided more information about the changes). Refer to www.railsafe.org.au/

ATSB SafetyWatch

Safe work on track

The ATSB has investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. Conducting work on or near a railway track can be dangerous if safeworking rules and procedures have not been correctly implemented to protect the worksite. Trains cannot stop quickly and any breakdown in the communication or management of a worksite can leave workers extremely vulnerable to dangerous situations.

What can you do

Operational safe working on track requires a high level of preparation and organisation. Whenever there is work taking place on or near a track, coordination and communication are essential to ensure adequate worksite protection is implemented. Before authority is granted to occupy or work near a track, it is essential that all information is clearly communicated and verified between the Protection Officer and the Network Control Officer.

An adequate briefing about the work site and effective communications equipment must be made available to the track workers. For track workers, it is vital to ensure that all levels of worksite protection have been fully implemented before commencing work on or near the track.

Similarly, before worksite protection is removed, it is essential that the Protection Officer and the Network Control Officer ensure all plant and workers have ceased operating and are positioned clear of the track.

ATSB comment

Safe work on track across Australia

The ATSB has also produced a safety issue investigation report, Safe work on track across Australia: Analysis of incident data, 2009 – 2014 (RI-2014-011), that is available from the ATSB website. This safety issue investigation reviews available data from across Australia of incidents and accidents relating to work on track. It is designed to provide industry with insights into the protection arrangements that are failing, and the reasons why, across many occurrences so that safety action can be designed to reduce future safe work on track occurrences.

To minimise risk, rail transport operators must ensure systems for safe work on track encourage workers accessing the rail corridor to communicate sufficient information to validate their worksite location, the adequacy of the protections in place, and their positioning in relation to any approaching train movements.

Purpose of safety investigations & publishing information

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2019 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

What happened

On 2 August 2017, a Gippsland Aeronautics GA-8 aircraft registered VH-MQI, was operated by Arnhem Land Community Airlines, as a charter passenger flight from Milingimbi, Northern Territory (NT) to Djamardi aeroplane landing area (ALA),^[1] NT. There was a pilot and five passengers on board.

At about 1225 Central Standard Time (CST), the aircraft joined the downwind leg of the circuit for runway 10 at Djamardi. The pilot observed the windsock indicating a light north-easterly wind.

Recorded data captured the incident approach, along with three previous approaches, conducted by VH-MQI to runway 10 during earlier flights to Djamardi. The data shows that on the incident approach, the aircraft turned onto the base leg of the circuit earlier than these three previous approaches (Figure 1).

After turning onto the base leg, the pilot believed the aircraft was becoming high on the desired approach path and reduced power to return to the desired path. After turning onto the final leg of the circuit, the pilot stabilised the aircraft at the selected approach speed of 65 kt with a rate of descent of about 500 feet per minute.

Figure 1: Representation of recorded data showing the tracks of four approaches, including the incident approach, made by VH-MQI to runway 10 at Djamardi ALA. The downwind, base and final legs of the circuit for runway 10 are also shown.

Source: Operator, annotated by ATSB

At about 1227 as the aircraft approached the runway at a height of about 50 ft, the pilot observed the airspeed reduce to 62 kt and lowered the nose to accelerate the aircraft. The pilot did not recall increasing power. Recorded data shows that at this time, the descent rate increased to 846 feet per minute. The pilot detected the increasing descent rate and flared the aircraft more positively than normal, however he was unable to arrest the rate of descent. The aircraft touched down hard on the main landing gear. The cargo pod (Figure 2) struck the runway.

After the aircraft touched down hard, the aircraft bounced and became airborne. The pilot then increased power to attempt to stabilise the aircraft and continue the landing. The aircraft then touched down a second time, on the nose landing gear first, and again bounced. The pilot further increased power, stabilised the aircraft, and landed.

The pilot and passengers were not injured in the incident, the aircraft sustained minor damage.

Figure 2: VH-MQI showing the cargo pod fitted to the aircraft (left) and damage sustained during the incident (right).

Source: Operator, annotated by ATSB

Pilot comments

The pilot of the aircraft made the following comments:

• In response to the reducing airspeed, instead of lowering the nose, power should have been increased.
• Prior to landing, the approach did not feel out of control, or overly unusual. Only when the aircraft landed hard did he realise that it was an abnormal situation.

Operator report

The operator of the aircraft conducted an investigation in to the incident and provided the following observations:

• The early base turn led to a steeper approach descent profile.
• A change in wind direction from a north-easterly, to a northerly as the aircraft approached the runway, combined with mechanical turbulence caused by trees, increased the aircraft descent rate.
• After the pilot detected the reducing approach speed, the technique used to accelerate the aircraft was incorrect. Engine power should have been immediately increased.
• The cargo pod, both main landing gear legs and the fairings where the landing gear legs enter the fuselage were damaged (Figure 3). The right main landing gear leg was also cracked.

Figure 3: Damage to left main landing gear leg (left), and damage to the right main landing gear leg and fairing (right).

Source: Operator, annotated by ATSB

Safety analysis

Late in the final approach, the pilot detected the airspeed reduce below the desired speed. In response, the pilot lowered the nose of the aircraft. This led to a high descent rate which could not be arrested prior to the hard landing.

The hard landing damaged the cargo pod, the main undercarriage legs and fairings.

Findings

These findings should not be read as apportioning blame or liability to any particular organisation or individual.

• The incorrect response to the reducing airspeed led to a high descent rate with insufficient height to recover. This resulted in the hard landing and aircraft damage.

Safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Aircraft operator

As a result of this occurrence, the aircraft operator has advised the ATSB that they are taking the following safety actions:

Flight crew training

• The pilot has received training in the correct technique to arrest a high rate of descent during approach and landing.

Guidance material

• The operator’s guidance material for Djamardi ALA has been updated to include a note advising of possible turbulence due to the surrounding trees.

Safety message

This incident highlights the importance of maintaining the correct approach descent profile and speed, and ensuring that pilots respond correctly to any deviations from the desired profile.

The United States Federal Aviation Administration (FAA) Airplane Flying Handbook, chapter eight, Approaches and Landings contains the following guidance for pilots when approach speed reduces below the desired speed:

On the final approach, when the airplane is flown at a slower than normal airspeed, the pilot’s judgment of the rate of sink (descent) and the height of round out is difficult.

Whenever a slow speed approach is noted, apply power to accelerate the airplane and increase the lift to reduce the sink rate and to prevent a stall. This is done while still at a high enough altitude to re-establish the correct approach airspeed and attitude. If too slow and too low, it is best to execute a go-around.

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2017 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

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1. Djamardi ALA can also be known as Jimarda ALA.

Safety summary

What happened

On the 18 July 2017, Pilatus PC‑12, registered VH-FDJ departed Alice Springs, Northern Territory for Adelaide, South Australia, on a routine single-pilot aeromedical patient transfer flight. During the approach into Adelaide, the pilot noted that the aircraft’s autopilot system failed to intercept the localiser for the Adelaide runway 23 instrument landing system (ILS) approach.

Unaware of why the autopilot did not intercept the localiser, the pilot then became focussed on determining the cause of the autopilot tracking issue while attempting to re-establish the aircraft back on the ILS to continue the approach. The pilot reported this resulted in high workload that was further increased by the tracking information displayed on the aircraft’s course deviation indicator not reflecting the position information being communicated by ATC.

The pilot continued the approach and commenced further descent after observing that the aircraft was close to becoming established on the localiser and that the glideslope was becoming active. Soon after, ATC notified the pilot that the aircraft was below the minimum permitted altitude for the aircraft’s position and instructed the pilot to climb the aircraft to a safe altitude. The pilot then conducted another ILS approach and landed.

What the ATSB found

The unexpected failure of the autoflight system to intercept and track the localiser resulted in the aircraft deviating from the surveyed instrument approach path and significantly increased the pilot’s workload.

The pilot’s focus on resolving the aircraft's lateral tracking and perceived autoflight issues during the localiser intercept decreased his attention on managing the aircraft’s approach profile. That led to the aircraft descending off-track below the minimum safe altitude.

Detection of the off‑track descent and subsequent intervention by the air traffic controller restored safe operation.

What's been done as a result

Following this incident, the operator amended their descent, arrival, and approach procedures, and training and checking procedures to be more prescriptive. In addition, the operator introduced dual global positioning systems, with moving map and chart overlay displays into their legacy aircraft, to improve pilot situation awareness.

Safety message

Adequate approach preparation, and management of aircraft flight profile and automation is vital to ensure pilots maintain manageable workloads and positional awareness during an approach. Additionally, pilots should not hesitate to conduct a go-around or a missed approach should the functionality of the aircraft’s automation, or the validity of positional information, be in doubt.

The occurrence

On the 18 July 2017 a Pilatus PC12, registered VH-FDJ, departed Alice Springs, Northern Territory, for a routine single-pilot aeromedical patient transfer flight to Adelaide, South Australia. The departure from Alice Springs and subsequent en-route phase of the flight was reported by the pilot to have proceeded normally.

Recorded data indicated that the aircraft reached the pilot’s calculated descent point from a cruise altitude of FL 250,^[1] at about 42 NM (78 km) to the north-west of Adelaide Airport.

Before descending, the pilot reported that he obtained the available weather for Adelaide Airport and prepared the aircraft’s autoflight system for the arrival. This included programming the standard arrival route (STAR)^[2] and instrument landing system (ILS)^[3] approach frequency. The pilot also reported reviewing the respective arrival and approach charts displayed on the electronic flight bag screen.

At about 1240 Central Standard Time,^[4] the aircraft left FL 250 to commence the Salty 1 STAR (Figure 1) and subsequently the runway 23^[5] ILS. The pilot reported that as he was unfamiliar with the Salty 1 STAR, he elected to utilise the aircraft’s autoflight system and the Garmin 430 avionics system for navigation and descent.

Figure 1: Extract from the Adelaide Standard Instrument Arrival

Source: Airservices Australia modified by the Australian Transport Safety Bureau

The pilot reported that, during the descent, he noted a higher-than-normal groundspeed due to the strong westerly tailwind, however this decreased as the approach progressed to lower altitudes. As the aircraft approached the GLOBE waypoint, the pilot crosschecked the aircraft’s profile using the global positioning system (GPS) unit’s calculated profile. Noting that the aircraft was slightly high at that position, the pilot increased the selected descent rate on the autoflight system.

Just after passing the ELIZA waypoint and prior to turning inbound to intercept the localiser at GULLY, the pilot changed the primary navigation source from GPS navigation mode to a heading mode. This autoflight mode change was required to enable the pilot to set the inbound course for the ILS, to facilitate an intercept of the localiser for the runway 23 ILS approach. The pilot then recalled changing the autoflight system back to navigation mode to continue navigation to the waypoint GULLY and armed the approach mode for the ILS intercept. The estimated time available to complete these tasks was less than two minutes.

The pilot reported that the aircraft overshot the required intercept at GULLY. In response, he manipulated the autoflight system by turning the aircraft in the control wheel steering mode in an attempt to re-capture the localiser. At about that time, air traffic control (ATC) advised the pilot that the aircraft had flown through the localiser, ATC issued altitude and heading instructions to assist with a re-intercept. The pilot reported that this required him to cancel the current autoflight selections, including approach mode, to enable a heading to be selected and flown. The workload at this time was reported by the pilot to have been high as he attempted to determine the functionality of the aircraft’s autoflight and navigation systems.

Soon after, ATC gave the pilot radar information that positioned the aircraft left of the localiser. A clearance to conduct the ILS approach was then communicated, with a further request for the pilot to confirm when he was established on the approach. The pilot recalled that at that time he was still trying to determine the issues with the autoflight system and why the course deviation indicator (CDI) was giving conflicting information, indicating the aircraft was slightly right of the localiser. There was no recorded communication from the pilot reporting that the aircraft was established on the approach.

While trying to re-establish the aircraft on the localiser, the pilot observed the glideslope becoming active. As he believed that the aircraft was close to intercepting the inbound track, the descent was continued.

Recorded information confirmed that a short time later, ATC issued an altitude alert to the pilot to check his altitude. This was followed with instructions to climb to a new cleared altitude, to maintain the required terrain clearance, and to fly a different heading in anticipation of conducting another ILS approach.

The pilot reported that he followed the ATC issued radar vectors back to the commencement of the runway 23 ILS approach, where an intercept of the localiser using the autoflight system was made. The second approach was flown without issue.

Pilot information

The pilot was appropriately qualified for the flight, holding a Commercial Pilot Licence (Aeroplane). He also held an instrument rating for both multi-engine and single-engine aeroplanes. The pilot’s logbook recorded a total aeronautical experience of about 6,250 hours.

The logbook indicated that the pilot had about 5,800 hours in command of single-engine aircraft, which included about 640 hours flying Pilatus PC12 (PC12) aircraft.

The pilot had reportedly used the Garmin 430 avionics system before and had previous experience flying the PC12 legacy aircraft (see the section titled Operations). The pilots training file noted the pilot appeared to have no difficulty using the Garmin 430.

The appropriate flight reviews and proficiency checks had been conducted and the pilot was deemed competent to conduct line flying operations by the operator on the 5 July 2017.

The pilot held a valid class 1 aviation medical certificate and reported that he was well-rested prior to the flight and was in good health.

Weather

The pilot reported experiencing a strong westerly tailwind of about 57 kt during the descent and that the approach was conducted in instrument meteorological conditions. However, he noted that as the aircraft descended, the wind decreased and cloud layers were observed.

During the time of the aircraft’s arrival, the trend forecast for Adelaide Airport indicated a cloud base of 1,800 ft with broken cloud at 6,200 ft and wind from 280° M at 19 kt. There were also expected periods of up to 30 minutes duration where the weather would deteriorate, with the wind at 270° M at 22 kt gusting to 38 kt and the visibility reducing to 3,000 m in showers of rain.

Operations

The operator conducted aeromedical services throughout most regions of South Australia and the Northern Territory. The Pilatus PC12 aircraft was the only aircraft type used by the operator. The operator had three variants of the PC12, namely the PC12/45, PC12/47 and PC12/47E. The older PC12/45 and PC12/47 (sometimes referred to as the ‘legacy’) had different avionics and operating characteristics to the newer PC12/47E (referred to as the ‘NG’).

The operator had a valid Air Operator’s Certificate that enabled the use of PC12 aircraft in the charter and aerial work categories, which included the conduct of ambulance functions. The operator also had approval to conduct training and proficiency checks in accordance with the Civil Aviation Safety Regulations 1998.

The operator’s PC12 flight training manual provided basic reference material that related to initial pilot training. The flight training manual included an outline of the training syllabus, checklists and some lesson plans to assist the instructor with training preparation. The flight training manual did not provide any guidance to pilots as to the procedures and operational considerations while flying the PC12.

The flying operations manual outlined the standard operating procedures (SOPs) for a descent and approach. It included that:

At an appropriate time, the pilot is to review the intended approach procedure, including where applicable:

a. instrument or visual approach,

b. airfield information from ERSA, Jeppesen or OPS28 Airfield Register,

c. If an instrument approach procedure is required:

- correct chart, aids and frequencies,
- airfield elevation and MSA [minimum sector altitude],
- initial approach altitude and entry procedure,
- approach procedure,
- visual procedure - restrictions, runway, aircraft configuration, and
- missed approach procedure.

Checklists used by pilots during flight listed that an ‘approach review’ was to be completed before transition. It was reported by the operator that in the case of longer flights, such as Alice Springs to Adelaide, an approach review and flight instrument setup actions should be completed before commencing the descent.

There was no guidance for pilots as to the operator’s expected flight instrument settings for the arrival. However, the operations manual highlighted the importance of pre-arrival planning and flight instrument set-up during the approach/landing phase. It included procedures for the conduct of a non-precision approach (other than area navigation^[6]), area navigation approach and precision approach. There was no guidance to pilots as to when an approach review/brief and flight instrument setup should occur.

The operators expected instrument setup for VH-FDJ (FDJ) differed from other PC12 aircraft in the operator’s fleet due to variation in FDJ’s avionics. The operations manual required that specific familiarisation training was required for pilots flying VH-FDJ due to the differences with all other aircraft in the fleet. The pilot had conducted in-flight training in FDJ prior to the incident.

It was reported by the operator that a pilot flying FDJ should ensure that the inbound course was set on the CDI prior to commencing the STAR. This would alleviate the requirement to change between navigation modes once the STAR had commenced. It would also reduce pilot workload during the descent and arrival.

Training

The operator conducted ground theory training, endorsements, and line training for pilots flying the PC12 variants. The PC12 fleet comprised nine of the newer (NG) type aircraft fitted with ‘glass cockpit’ avionics, and eight older (legacy) type aircraft, with different avionics and operating characteristics. Training provided pilots with familiarity of both types. The occurrence pilot had significant previous experience on the legacy PC12 so the major component of his in command under supervision (ICUS) training concentrated on the NG variant.

The operator’s flight training records identified that the pilot had successfully completed all components of the operators training syllabus. However, notes made during the training identified that the pilot had difficulty at times with profile management, and approach preparation. These issues were not apparent during the pilot’s final flight check for commencement of line operations.

The pilot completed about 96 hours of in-flight training before being approved to conduct line flying operations on the 5 July 2017. The training consisted of 28 training flights, which included 24 flights with the newer PC12 NG variant and four flights with the PC12 legacy aircraft.

Following this occurrence, the pilot completed six remedial flights, two of which were in legacy aircraft. Those flights identified that the pilot required additional training with approach preparation. This included conducting more thorough approach briefings and ensuring that the approach checks and setup were not left too late in order to avoid high workload situations. The pilot’s training notes also emphasised the importance of conducting a go-around if the approach became unstable. At the end of this training the pilot was re‑checked and resumed line flying operations.

Related occurrences

A database search identified a number of occurrences with aircraft descending below the minimum safe altitude. The occurrences have primarily involved aircraft on approach to land. They include situations where pilot(s) attention has been on other tasks during higher workload phases of flight, such as during the later stages of an instrument approach. The ATSB has published the following related safety investigation reports.

AO-2015-018: Flight path management and descent toward the lower limit of controlled airspace involving Airbus A320, VH-VND, on approach to Melbourne Airport, Victoria, on 11 February 2015

On 11 February 2015, an Airbus A320 aircraft, registered VH‑VND and operated by Tiger Airways, was conducting a scheduled passenger service from Hobart Airport, Tasmania to Melbourne Airport, Victoria.

At about 1750 Eastern Daylight-saving Time, about 9 NM (17 km) north of Melbourne Airport, and after the flight crew had been cleared by air traffic control to conduct a visual approach, the aircraft descended below the minimum safe altitude, though the aircraft remained in controlled airspace.

During the descent, both flight crew became preoccupied with other tasks inside the flight deck, which had the effect of increasing their workload and distracting them from monitoring the aircraft’s flight path and altitude. About two minutes after commencing descent on the visual approach, the flight crew levelled the aircraft after realising that it appeared to be low on profile. A safety alert issued by air traffic control soon followed and in response, the aircraft was climbed to intercept the recommended visual approach descent profile. The remainder of the flight was uneventful and the aircraft landed on runway 16 at Melbourne Airport.

AO-2016-012: Descent below segment minimum safe altitude during a non-precision instrument approach involving Airbus A320, PK-AXY, 17 km WSW Perth Airport, Western Australia on 19 February 2016

On the evening of 19 February 2016, an Airbus A320 aircraft, registered PK-AXY and operated by PT Indonesia AirAsia was on a scheduled passenger service from Denpasar, Indonesia to Perth, Australia. During cruise, the captain’s flight management and guidance computer (FMGC1) failed. Due to the failure, the flight crew elected to use the first officer’s duplicate systems. For the aircraft’s arrival in Perth there was moderate to severe turbulence forecast below 3,000 ft with reports of windshear. The crew commenced an ILS approach to runway 21.

During the approach, the flight crew made a number of flight mode changes and autopilot selections, normal for an ILS approach with all aircraft operating systems available. However, some of those flight modes and autopilot selections relied on data from the failed FMGC1 and the auto-thrust system commanded increased engine thrust. The crew did not expect this engine response and elected to conduct a go-around. With an increasing crosswind on runway 21, the crew accepted a change of runway, to conduct a non-precision instrument approach to runway 06.

With the time available, the first officer programmed the new approach into his FMGC and conducted the approach briefing. During this period, the captain hand flew the aircraft and manually controlled the thrust. During the approach to runway 06, the crew descended the aircraft earlier than normal, but believed that they were on the correct flight path profile.

While descending, both flight crew became concerned that they could not visually identify the runway, and focused their attention outside the aircraft. At about that time, the approach controller received a ‘below minimum safe altitude’ warning for the aircraft. The controller alerted the crew of their low altitude and instructed them to conduct a go-around. The crew then conducted another approach to runway 06 and landed.

__________

1. Flight level: at altitudes above 10,000 ft in Australia, an aircraft’s height above mean sea level is referred to as a flight level (FL). FL 370 equates to 37,000 ft.
2. Standard Instrument Arrival (STAR): A designated IFR arrival route linking a significant point, normally on an air traffic services route, with a point from which a published instrument approach procedure can be commenced.
3. Instrument Landing System (ILS): A precision instrument approach system which normally consists of the following electronic components: VHF Localiser, UHF Glideslope and VHF Marker Beacons.
4. Central Standard Time (CST): Coordinated Universal Time (UTC) + 9.5 hours.
5. Runway number: the number represents the magnetic heading of the runway.
6. Area navigation (RNAV): A method of navigation which permits aircraft operation on any desired flight path within the coverage of ground or spacebased navigation aids, or within the limits of the capability of selfcontained aids, or a combination of these.

Safety analysis

Approach preparation and management

A number of factors lead to the pilot not being fully prepared for the arrival and subsequent instrument landing system (ILS) approach to Adelaide Airport. Although the importance of early preparation and maintenance of an appropriate flight path profile was reinforced during the pilot’s line training, the impact of not fully configuring the aircraft’s instrumentation earlier in the approach was likely not recognised by the pilot. This, combined with the effect of a tailwind during the approach, reduced the available time for the pilot prepare for the localiser intercept.

While it could not be determined why the aircraft’s autoflight system did not capture and track the localiser, it was possible that a late setup of the inbound course and arming of the approach provided insufficient time for the autopilot to turn the aircraft. From the available evidence it was likely that the pilot had less than two minutes to setup the instrumentation, arm the approach and prepare for the intercept.

It is possible that during preparation for the approach, the pilot incorrectly set the reciprocal of the inbound course on the aircraft’s course deviation indicator (CDI), resulting in displayed tracking indications that were not in the command sense. That would account for the difference between the aircraft’s position, relative to the localiser, displayed to the pilot compared to that advised by air traffic control. That discrepancy created confusion over the aircraft’s actual position and, in combination with the unexpected overshoot of the localiser, significantly increased the pilot’s workload in managing the ILS approach.

The pilot became focussed on resolving the aircraft's lateral tracking and perceived autoflight issues during the localiser intercept. His recollection of being aware that the aircraft was descending but unaware of its specific altitude was consistent with decreased attention on managing the aircraft’s approach profile. That led to the aircraft descending off-track below the minimum safe altitude until identified and remedied by the positive actions of the controller.

Pilot workload

When the aircraft did not automatically intercept the localiser as expected the pilot’s workload started to increase.

Workload has been defined by Orlady & Orlady (1999) as ’reflecting the interaction between a specific individual and the demands imposed by a particular task. Workload represents the cost incurred by the human operator in achieving a particular level of performance’.

Each individual has a finite set of mental resources which allow them to process information and identify appropriate tasks. The set is a variable trait, and will vary with many factors including the experience, training, recency and familiarity with a situation, stress and fatigue. Harris (2011) stated ’High workload is associated with increased error rates (and hence an associated decrease in safety margins) as well as having the effect of reducing overall productivity and increasing occupational stress’.

When the workload gets too high for the available set of resources, an individual will start to task shed, initially systematically and eventually indiscriminately as the workload continues to increase. Green et al. (1996) identified, ‘as the demands of the task, or the workload, are increased, the standard of our performance is achieved. Any increase in workload after this point leads to an overall degradation in performance. At extremely high levels of workload (overload), important information may be missed due to the narrowing or focussing of attention onto only one aspect of the task.’

The United Kingdom Civil Aviation Authority publication CAP 737 (2016) states workload ‘is linked to almost all other areas within cognition and performance, particularly attention, vigilance, fatigue, skills, and multi-tasking.’

Approach and landing is a well-known period of high workload for pilots. In this occurrence, the following factors had the potential to increase the pilot’s workload:

• an increased ground speed
• limited recent experience with the autoflight system fitted to this aircraft type
• the high intrinsic workload of single-pilot IFR flight
• restrictions of the single-channel autoflight system in setting up the ILS instrumentation.

While the pilot had the correct intentions for the approach, once the error arose with the aircraft tracking, the pilot became unable to effectively monitor the approach while troubleshooting the situation. Following the intervention of air traffic control, the situation was resolved and the second approach was flown without issue.

Training

The pilot’s initial training with the operator appeared to address identified approach management issues by the time he was cleared to conduct line flying operations. Recognising that subsequent remedial training identified the need for closer study and briefing of instrument approaches, it is difficult to ascertain if more approach consolidation conducted prior to the incident would have prevented it.

Despite profile management and approach preparation being reinforced during the pilot’s training, the standard operating procedures outlined in the company operations manual did not give guidance to pilots as to when and how the aircraft was expected to be configured for the approach. Although an approach review was required, information pertaining to the expected cockpit and approach setup may have benefited the occurrence pilot. More generally, the absence of such guidance increases the likelihood of greater variation in how approaches are conducted.

Safety issues and actions

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Royal Flying Doctor Service Central Operations

Since this occurrence, the operator has implemented the following improvements:

• amended the descent, arrival and approach procedures to include more prescriptive requirements
• upgraded the legacy fleet to include dual global positioning system equipment with moving map and chart overlay displays to improve pilot situation awareness
• rewritten the Training and Checking manual to include more prescriptive training
• strengthened the Safety Management System, including the introduction of a phased implementation of a change management program
• changed the initial pilot training, which is now conducted by their recently approved Part 141 organisation.

Findings

From the evidence available, the following findings are made with respect to flight below the minimum permitted altitude involving Pilatus PC-12, registered VH-FDJ, that occurred about 19 km north‑east of Adelaide Airport, South Australia on 18 July 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors

• The unexpected failure of the autoflight system to intercept and track the localiser resulted in the aircraft deviating from the surveyed instrument approach path and significantly increased the pilot’s workload.
• The pilot’s focus on resolving the aircraft's lateral tracking and perceived autoflight issues during the localiser intercept decreased his attention on managing the aircraft’s approach profile. That led to the aircraft descending off-track below the minimum safe altitude.

Other factors that increased risk

• The pilot did not initiate a missed approach despite being uncertain of the displayed navigation system information and aircraft position. This limited the opportunity for the pilot to resolve any perceived navigation issues at a safe altitude and in a more controlled environment.
• Approach guidance in the operations manual did not include detail of the expected cockpit and approach setup preparation. That increased the risk that variation in the conduct of approaches may be introduced into operations.

Other findings

• Detection and intervention by the air traffic controller following the off‑track descent below the minimum permitted altitude restored safe operation.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• Airservices Australia
• Civil Aviation Safety Authority
• FlightAware
• the flight crew and operator.

References

Civil Aviation Authority, 2016, CAP737 – Flight-crew human factors handbook, Civil Aviation Authority, United Kingdom.

Green RG, Muir H, James M, Gradwell, D, Green RL (1996) Human Factors For Pilots, Second Edition, Ashgate, England.

Harris, D (2011) Human Performance on the Flight Deck, Ashgate, England.

Orlady H & Orlady LM (1999) Human Factors in Multi-Crew Flight Operations, Ashgate, England.

Submissions

Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the Australian Transport Safety Bureau (ATSB) may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.

A draft of this report was provided to Airservices Australia, the flight crew, the operator and the Civil Aviation Safety Authority.

A submission was received from the operator. The submission was reviewed and where considered appropriate, the text of the report was amended accordingly.

Purpose of safety investigations & publishing information

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through:  identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2018 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

On 10 July 2017, at about 1445 Coordinated Universal Time (UTC), an amateur-built Arion Lightning light sport aircraft, registered N273DB, fitted with a Jabiru 3300 engine, was substantially damaged during a forced landing following a partial loss of engine power near New River, Arizona, United States. The pilot, the sole occupant, received minor injuries.

As the accident occurred in the United States, the National Transportation Safety Board (NTSB) was responsible for investigating this occurrence. As part of its investigation, the NTSB notified the Australian Transport Safety Bureau (ATSB) as the state of manufacture of the engine. In accordance with clause 5.18 of Annex 13 to the Convention on International Civil Aviation, the ATSB appointed an accredited representative to liaise with the NTSB and initiated an investigation under the Australian Transport Safety Investigation Act 2003.

The ATSB has concluded its support of this investigation. On 9 August 2019, the NTSB released the final investigation report into this occurrence and it is available at www.ntsb.gov.

Any enquiries regarding the investigation and report should, in the first instance, be directed to the NTSB.

On 29 July 2017, the ATSB commenced an investigation into a collision with terrain involving a Zaklad Remontow I Produkeji Spreztu Lotnicz MDM-1P FOX-P glider, registered VH-GPT, at Lismore Airport, New South Wales.

The ATSB found that while conducting an aerobatic display, the glider impacted the ground heavily during the final manoeuvre. The pilot was seriously injured. Examination of the aircraft identified no mechanical issues or faults that may have contributed to the accident.

The Gliding Federation of Australia has conducted an investigation of this accident and the public report (S-1010) is availiable on their website.

The ATSB has also reviewed the safety and administrative procedures necessary to conduct air shows and found that, in this case, preparations were consistent with regulatory requirements. The ATSB investigation AO-2017-013, Mallard aircraft, Perth, January 2017 is examining a range of issues associated with air shows, including the suitability of the regulations, approval and oversight of air shows, and compliance with regulatory approvals during air shows.

In this case, the ATSB did not identify any organisational or systemic issues that contributed to the development of the accident or that might adversely affect the future safety of aviation operations. The ATSB assessed that no safety issues would be identified through further investigation. On that basis, the ATSB will discontinue this investigation.

Safety summary

What happened

At about 0617 on 28 July 2017, a Bowmans Intermodal containerised ore train (1501S) travelling empty from Port Flat, South Australia (SA) stopped at Dry Creek South in SA. The driver felt the performance of the train ‘very sluggish’, as it was not rolling as it had prior to rounding a curve on the approach to Dry Creek South. The train crew notified the Australian Rail Track Corporation (ATRC) network control officer at Mile End, SA of their situation and that they intended to inspect their train. A short time later, the train crew confirmed to the network control officer that the last three wagons from 1501S had derailed. The train crew were uninjured. However, there was substantial damage to the wagons, track and signalling infrastructure.

What the ATSB found

The ATSB found a vertical split head defect had developed undetected from imperfections introduced during the manufacture of the rail 90 years ago. The defect propagated vertically and longitudinally, roughly through the centre line of the lower leg rail in the curve approaching Dry Creek South.

The passage of a previous train (1122) over this section of track caused an initial rail break, affecting the integrity of the rail and electrical continuity of the associated track circuit, which prevented a signal from clearing for the next train (1501S). The network control officer authorised the driver to pass the signal at stop, with the condition that the train travel at low speed.

However, the rail break was not visually obvious to the train crew as the locomotive rounded the curve. As the rear of that train passed over the break, a 2 m section of rail fragmented causing the last three wagons to derail.

Detailed (ultrasonic) inspection of the track about one month prior to the occurrence recorded a sustained loss of back wall echo at the derailment location, automatically marking the rail with a spray of paint. However, the ultrasonic inspection operator attributed the recorded event to the poor surface condition of the railhead, which is a common condition that can inhibit the testing. There was no retesting initiated or surface condition report lodged in response to the recorded event. The absence of any follow-up missed an opportunity to identify the presence of the vertical split head defect prior to the rail fracture and the subsequent derailment of 1501S.

What's been done as a result

Following the incident, Speno implemented a review of testing techniques used by operators where poor surface condition exists and the procedures for reporting and testing of rail affected by surface condition.

The Australian Rail Track Corporation reaffirmed the adequacy of the Track and Civil Code of Practice for ultrasonic inspections and the reporting requirements in accordance with contractual arrangements with the ultrasonic inspection operator. The rail in the Dry Creek area is programmed for replacement during 2018 as part of the Adelaide to Tarcoola Re-Railing Project.

Safety message

Defects can develop in rails (and welds) due to a wide range of reasons. Early detection and treatment of a defect that could cause a fracture of the rail is of major importance. While poor surface condition of the railhead is a known limit to the effectiveness of ultrasonic testing, its presence can mask internal track defects, particularly when the condition exists over an extended area. If an inspection cannot test or can only partly test rails, maintenance personnel must report the shortfall to highlight operational risk and the requirement for a timely supplementary examination.

Fractured rail section in lower rail of curve

Source:  ATSB

The occurrence

At about 0145 on the 28 July 2017, a Bowmans Rail freight train (1501S) was prepared for departure from Port Flat near Adelaide, South Australia (Figure 1). Train 1501S was an empty containerised ore service comprised of two locomotives (GL108 leading, CM3308 trailing) and 56 wagons. The train was 802 m long, with a trailing mass of 1,283 t and crewed by two drivers. The train was to travel via Dry Creek in South Australia to the Bemax Siding located between Thackaringa and Kanandah in New South Wales.

At about 0548, the driver of 1501S contacted the Australian Rail Track Corporation (ARTC) network control officer (NCO) located at Mile End in South Australia to advise that they were ready to depart Port Flat. The NCO notified the driver that they would travel under signal indication up to Signal 1 at Dry Creek, where a Train Authority^[1] would be required for train 1501S to proceed. The NCO was unable to clear signal 1 to a proceed indication,^[2] as a track circuit^[3] had remained occupied following the passage of the previous train (1122) about 30 minutes earlier.

Figure 1: Location of the derailment of Train 1501S in South Australia

Source: Geoscience Australia annotated by ATSB

At about 0608, the train crew stopped train 1501S at signal 1, and the NCO issued the train authority for the crew to pass the signal at stop. The NCO included instructions for the train crew to proceed at low speed and stop at the points^[4] to ensure they were set correctly for the route to the next fixed signal^[5] (signal 5). After confirming the content of the train authority with the NCO, the driver passed signal 1 and continued toward Dry Creek South, controlling train 1501S to maintain a speed below 25 km/h.

The driver recalled that when travelling about half way around the curve between signals 1 and 5 he felt the lead locomotive pass over a dip in the left (lower leg) rail. A short time later, train performance ‘felt very sluggish’ and it was not running as it was prior to the curve. At the time, the lead locomotive (GL108) was travelling at about 17 km/h. At about 0617, the driver contacted the NCO, and advised that train 1501S had stopped at Dry Creek South and that they would inspect the train.

At about 0626, an ARTC signal maintainer arrived onsite to investigate the cause of an earlier reported fault; that is, signal 1 not clearing. Shortly after, the signal maintainer contacted the NCO advising that the rear of train 1501S had derailed and there was substantial damage to the wagons, track, location case^[6] and other signalling infrastructure (Figure 2).

Figure 2: Derailed rear three wagons of 1501S and damaged signal 5 location case

Source: ATSB

At about 0627, the driver of train 1501S contacted the NCO confirming that the last three wagons (CQYY 3264-G, CQYY 3261-C and CQYY 3265-P) had derailed. The wagons had travelled about 285 m in a derailed state before train 1501S stopped.

Site inspection

An inspection of the track identified a 2 m section of rail had fractured, on the lower leg of the left curve (Figure 3).

Figure 3: Fractured section of rail

Source: ATSB

The railhead had split vertically and longitudinally, roughly through the centre line of the rail in the affected section. The split propagated through to the head/web transition region and outward through the railhead toward the gauge side of the rail, separating the head from the web^[7] (Figure 4).

The web had also fractured at several points through the affected section. These breaks were predominately vertical through the web, and transverse in the foot of the rail. The breaks through the web were due to overstress, which probably occurred during the passage of the previous train 1122, and the subsequent passage of 1501S that derailed.

Figure 4: Vertical split head section

Source: ATSB

Passing signal 1 at stop

The ARTC Code of Practice, Volume 3 (CoP) defines the operations and safe working rules for managing train movement^[8] through the Dry Creek area. Before authorising the crew of a train to pass a signal at stop, the CoP required the NCO, and train crew, to assess the situation including:

• why the signal is at stop
• if the section is clear or occupied
• if the track is safe or unsafe
• the conditions to be included in the Train Authority to authorise the train to pass the signal at stop.

Track circuits in the Dry Creek area used the rails and other signalling equipment as conductors to form an electric circuit. The presence of a train or other rollingstock, or a break in the electrical continuity of the circuit, will cause the track circuit to signal an occupancy.

In this case, the signal was at stop due to an indication the track section remained occupied following the movement of the previous train (1122). A track section might indicate as occupied due to a number of reasons, such as an obstruction, faulty equipment, broken electrical connections, or as in this case, a broken rail.

When travelling on a track section indicated as occupied, there is an increased risk that the train may encounter an obstruction, points incorrectly set for the intended route, or other equipment not operating as expected (for example, level crossings). Consequently, when authorising a train to pass the signal at stop, an NCO should apply conditions to ensure appropriate management of these risks.

Prior to authorising the train crew to pass signal 1, the NCO communicated to the train crew that a track circuit in the route was indicating an occupancy, preventing the signal from clearing. There was no further discussion related to the safety of the track. However, the NCO issued conditions in the train authority for the driver to proceed past signal 1 at low speed and for the train to stop at points to ensure they were set correctly for the intended route. The CoP defined low speed as a speed which will enable a train movement to be stopped within half the distance that the track is seen to be clear ahead, but does not exceed 25 km/h.

Typically, a simple rail break would not result in a derailment, especially if a train is travelling at low speed. This is because, as in this case, the CoP also required a train crew to maintain vigilance by being alert, observing the track (including rails) in the direction of the movement, and being prepared to stop or reduce train speed if required.

Train 1501S passed signal 1 about an hour before sunrise. The driver continued at speeds below 25 km/h, travelling approximately 1,290 m toward Dry Creek South before stopping. Although the driver reported to the NCO that the locomotive dipped to the left when rounding the curve, the train crew did not report observing any significant anomaly with the track and were likely unaware that a rail had broken.

The locomotives and all wagons with the exception of the last three remained on the track. It is likely the rail disintegrated during the passage of one of the last two wagons (CQYY 3261-C or CQYY 3265-P) over the failed section of track. The derailment of the last two wagons likely pulled the rear bogie of the third to last wagon, CQYY 3264-G from the track. The rear of train 1501S travelled about 285 m from the point of derailment (break in the rail) before stopping.

Track inspection arrangements

The ARTC Track and Civil Code of Practice – Rail, defines the guidelines for the scheduled inspection the assessment of rail and rail wear. The scheduled inspections included:

• A patrol inspection of the rail for visible defects and conditions (i.e. indications of a defect) that may affect the integrity of the track structure, including the following:
  • broken rails and rail welds
  • rail and rail weld deformations and discontinuities
  • wheel burns
  • damage to rail surface or section
  • unusual patterns of gauge face contact
  • unusual vehicle tracking patterns
  • rail corrugation
  • rail crippling
  • other obvious indications of defects (e.g. bleeding).^[9]

The patrol inspections were typically carried out from an on-rail vehicle travelling at a speed consistent with the inspection or by walking. Where track circuits were installed, these could also be employed as an additional method to detect rail failures (such as a break). Patrols conducted two type of inspections:

• A general inspection to visually inspect new welds or where the response following detection of a rail or weld defect is to ‘observe’.
• A detailed inspection, carried out through continuous or manual ultrasonic rail flaw detection.
  • Continuous and manual ultrasonic rail flaw detection involved passing sound waves into the rail and monitoring the echo returned by the sound waves reflecting off internal and external surfaces (reflectors). Defects within the rail create reflectors that return echo patterns depending on their type, location and size. Examination of the reflectors enables a skilled operator to deduce the existence, type and size of a suspected rail defect.

The ARTC Civil Technical Maintenance Plan ETE-00-03 sets out the routine inspection tasks and minimum inspection frequency for the track and civil infrastructure (Table 1).

Table 1: Summary from Technical Maintenance Plan – Track System

Source: ARTC modified by ATSB

Track Patrol inspection

The ARTC standard for Track Patrol, Front of Train, General and Detailed Inspections specifies the scope and methodology for the performance of this inspection. The standard recognises the track patrol is principally:

A visual inspection intended to detect obvious, abnormal conditions. It is unlikely that hidden failures or conditions that don’t have a significant visual impact will be detected by Track Patrol which is typically performed from a hi-rail vehicle at moderate speed. Other scheduled (and ad-hoc) general and detailed inspections focus on specific components or conditions and are intended to detect these less obvious defects.

On 27 July 2017, the day preceding the derailment of 1501S, the ARTC track inspector completed a track patrol inspection for the section of rail between the Dry Creek Triangle^[11] and Pelican Point. The track inspector did not record observing any anomaly in the rail condition through the area where the derailment occurred.

Continuous ultrasonic rail flaw inspections

ATRC’s technical maintenance plan specified the minimum frequency for a detailed inspection (ultrasonic rail flaw inspection) was at least every 15 MGT. Although the track section between the Dry Creek Triangle and Pelican Point carried around 7 – 10 MGT per annum, ARTC scheduled the detailed inspections yearly.

ARTC undertook the detailed inspections in the Dry Creek Triangle to Pelican Point section through a contractual arrangement with Speno Rail Maintenance Australia (Speno). The Speno Site Safety, Environmental & Quality Management Plan ARTC - Rail Flaw Detection, detailed the specific requirements for Speno accessing the rail network and the rail testing process undertaken.

The rail testing process typically involved the operation of two on-track vehicles. For this type of operation, a main test vehicle (Figure 5) would conduct continuous testing where the ultrasonic operator would interpret, mark and log ultrasonic events displayed on the test vehicles display monitors. Automatic paint guns sprayed a white paint mark on the gauge side, rail web and foot of each rail when the system detected the presence of a defined event.

Following the identification of an event, the operator in the main test vehicle relayed information to a following vehicle, where an operator in that vehicle was responsible for manual ultrasonic testing to localise, identify, size and assess the detected flaw in accordance with the relevant ARTC standards.

The ARTC Manual for Non-Destructive Testing of Rail, ETN-01-04 included specifications for the ultrasonic test equipment and the types and sizes of rail flaws for detection. The manual required the ultrasonic operators to use a range of probes when inspecting the rail and welds for cracks and similar discontinuities. The main test vehicle used in testing the rail in the Dry Creek area towed the roller search unit equipped with an array of 0°, 38° and 70° probes (Figure 5). The arrangement of the probes enabled continuous inspection of each rail leg for defects in various orientations.

Figure 5: FL-18 (RFAS-2100) rail analysis system (main test vehicle)

The 0° probe examined the full rail depth, including welds (Figure 6). Defects located by this probe include bolt hole cracks and longitudinal defects of a horizontal nature in the railhead, web and foot. However, vertical defects are more difficult to detect by continuous ultrasonic testing of rail, since the vertical surface of the defect is less likely to provide a clear reflection from any probe.

While the presence of a vertical split head defect may not display as a distinctive signature in the reflected signal on the operators screen, there are signature patterns that may indicate a potential issue. A vertical defect in the railhead may present as a loss of back wall echo (LBWE), where the signal from the 0o probe is deflected, thereby causing the reflected signal from the base of the rail (foot) to drop below a pre-defined level.

Figure 6: Area 0° probe coverage

Source:  Australian Rail Track Corporation

A loss of signal from the bottom of the rail, over any length greater than 4 mm is displayed to the operator in the raw data. A loss of signal over 50 mm will activate an audible signal to the operator that has a unique tone dependent on the respective rail and display the LBWE as a length value to the operator. The pulse echo reliant transducers also activate the automatic paint guns spraying location marks on the rail web. Any ultrasonic shielding (LBWE) or anomalous indication should trigger a localised visual inspection and manual ultrasonic scanning from other faces of the rail to investigate.

The ARTC standard, Non-Destructive Testing of Rail ETE-01-03 detailed the response actions and timeframe to levels of shielding and testability of rail (Table 2).

Table 2: Summary from standard, non-destructive testing of rail

Source: ARTC modified by ATSB

The continuous ultrasonic inspection was undertaken on 26 June 2017, about one month prior to the derailment of train 1501S. There was no ultrasonic reflector indicating a vertical split head defect. However, there were occasions of intermittent LBWE and a prolonged period of LBWE over about 2 m that coincided with the derailment location (Figure 7). The inspection also indicated the presence of spurious reflectors from the 70° shear wave transducers. These reflectors likely emanated from the poor rail surface condition that often occurs when the roller search unit is having difficulty maintaining continuity with the rail.

Figure 7: Ultrasonic signatures at derailment location on 26 June 2017

Source: Speno Maintenance Australia, annotated by ATSB

Following the derailment, Speno reviewed replays and examined the ultrasonic signatures from other track structures (insulated joints and boltholes) taken in the area and confirmed the ultrasonic testing system in the main test vehicle was operating within normal parameters at that time.

Examination of the replays also suggested that the operator was having trouble (on occasion) in maintaining continuity of the roller search unit with the rail surface during the run. To compensate, the operator of the test vehicle was undertaking the testing at a reduced speed of 5 km/h, as specified in the response actions of the ARTC procedure.

The Speno rail analysis unit was equipped with audible alarms and paint spray guns that flagged the LBWE event as an exceedance and marked the rail during the ultrasonic inspection of the 26 June 2017 (Figure 8).

The prolonged LBWE event and continued difficulty experienced in testing should have triggered the next level of response action. If rail could not be tested or only partly tested, due to ultrasonic shielding, ARTC required the operator to test the affected area by hand or to forward a Rail Surface Condition Report detailing the circumstances that impeded the testing. Neither a response action nor a condition report was initiated in this case.

Figure 8: Failed section of railhead showing markings from ultrasonic car testing

Source: Speno Maintenance Australia, annotated by ATSB

The previous ultrasonic test of rail in the Dry Creek area occurred in May of 2016. This test also recorded an intermittent LBWE in the same vicinity. Prolonged periods of LBWE also occurred on the opposite rail (Figure 9) illustrated at the 0.226 km mark. Similarly, there was also no record of retesting or the lodgement of a surface condition report. It is likely that the operator on this occasion also assessed the spurious reflectors and LBWE were, in the absence of defined defect signatures, due to the poor surface condition of the railhead.

Figure 9: Ultrasonic signatures at 0.226 km point 4 May 2016

Source: Speno Maintenance Australia, annotated by ATSB

__________

1. An instruction in the prescribed format issued by the train controller in connection with the movement of a train.
2. Any signal indication other than stop.
3. An electric circuit that uses the rails of a railway as conductors such that a train electrically connects them via its axles. The absence or presence of this rail-to-rail connection indicates the absence or presence of a train or item of rollingstock.
4. A set of points permits rail traffic to change from one track to another. Points are normally referred to as left or right hand denoting the turnout direction as viewed from the toe end.
5. A manually or power operated signal which is permanently located near the line.
6. Signalling lineside apparatus housings at a particular site and the equipment contained therein.
7. That part of the rail between the head and the flange (foot).
8. The operation on rail of a train or other track vehicle or machine.
9. Discolouration on the web due to the movement of oxides to the surface.
10. Million Gross Tonnes.
11. Dry Creek Triangle includes the track section between signal 1 and signal 5.

Safety analysis

The rail installed in the lower leg of the curve at the Dry Creek North Fork displayed the manufacturer brand, AS BHP Co Ltd 1X27 100LBS OH. The branding indicates the manufacture date was in 1927, from an open-hearth (OH) furnace process. Older rails, produced by means of OH furnaces and cast into ingots, generally exhibited higher levels of impurities than rails produced through the current continuous casting process.^[12]

The rail at the derailment site was installed in 1999. The running surface of the rail at the derailment location and in the curve exhibited rolling contact fatigue (RCF) defects that developed from shear stresses at the rail-wheel interface. The presence of RCF defects such as plastic flow, flaking and minor spalling, can mask the signal during ultrasonic inspection and hence prevent the detection of larger and deeper defects that may be present within the railhead.^[13]

On-site examination of the section of rail showed evidence of an internal seam extending vertically within the centreline of the railhead. The seam surfaces were heavily corroded and punctuated by an elongated band of inclusions and oxidation located at a depth of around 10 mm from the running surface of the railhead (Figure 10). The general appearance and orientation of the inclusion banding indicated that it was pre-existing and very likely to have been produced when the rail was cast at the time of manufacture. Fatigue cracking had developed from the inclusion bands and had then propagated toward the railhead-running surface and the web transition region, creating a ‘vertical split head’. Typically, longitudinal crack propagation is influenced by a combination of increasing axle loads, wheel impacts or eccentric loading on a railhead exhibiting a flattened profile.

Figure 10: Railhead section detailing interior seam of inclusions/imperfections

Source: ATSB

The vertical split head in this instance propagated undetected into a critical defect of around 2 m in length. The defect exhibited the typical visual indicators of well-developed dark oxide streaking on the centreline of the running surface and oxide streaks (bleeding) on the fillet area of the rail web under the defect (Figure 11). The forces exerted by the passage of train 1501S across the area of rail containing the vertical split defect (and broken rail) resulted in the fragmentation of that section of rail. The disruption of the rail running surface then led to the derailment of the last three wagons of train 1501S.

Track inspection

As neither the scheduled track patrol nor ultrasonic inspection identified the presence of a defect, it cannot be determined when the vertical split defect first propagated towards a critical size. The yearly ultrasonic inspection is heavily reliant on the ability of the individual operator to detect and interpret anomalies in the rail infrastructure (or displayed ultrasonic signatures) that signal the presence of a potential defect.

Figure 11: Failed section of railhead

Source: ATSB

The continuous inspection of rail infrastructure by track patrol or ultrasonic test vehicles typically involves the operator undertaking repetitive tasks in scanning the track structures (or visual display screens) for anomalies while operating a vehicle or other on-board equipment over long sections of track. Track patrols undertaken from road-rail vehicles target the identification of abnormal conditions that may affect the integrity of the infrastructure or operation of rollingstock. Defects that do not have a significant visual impact may be overlooked, increasing the reliance on the detailed inspections to detect hidden conditions.

The Australian Rail Track Corporation (ARTC) also recognised that the non-destructive testing used in undertaking the detailed inspections did not assure detection of all defects due to limitations of existing ultrasonic techniques.

To minimise the risk of a missed defect, ARTC required the ultrasonic testing process, and in particular the conditions in the testing vehicle, be optimised to facilitate the concentration of the operator on the data being analysed. This included:

• the judicious use of post analysis facilities of recorded data
• in-car working conditions and temperature
• computer screens that are adequately protected from sun glare
• monitoring that the speed of the car is compatible with the ability to analyse data presented
• safe working practices are adequately catered for outside the time allowed for test analysis
• fatigue management of operators (consideration of rotation of operators with hand testers)
• undue pressure on time allowed in section
• peer development and regular training in compliance with this document
• monitoring of operators’ performance in terms of percentage of defect identified.

On the 26 June 2017, Speno Rail Maintenance Australia (Speno) commenced the ultrasonic inspection of track at Pelican Point and then proceeded towards Dry Creek. Speno identified that the inspection run at Dry Creek through the area of the derailment would therefore have occurred at about 1645, toward the end of the operators shift. However, there was no further evidence to suggest that fatigue contributed to a failure to detect a rail defect.

The rail in the area of the derailment and a number of other areas along this section of track was in relatively poor condition and exhibited heavily flowed head^[14] with severe flaking^[15] on the rail surface. The condition of the railhead probably resulted in the failure of the roller search unit to maintain effective contact with the rail surface during the run, either producing spurious reflectors or inhibiting transmission of ultrasonic signals from a defect.

The operator did not follow-up the loss of back wall echo (LBWE) trace and alarm in the area of the derailment by triggering a localised ground inspection or forwarding a rail surface condition report to ARTC.

The generally poor condition of the track in the area of the derailment meant the operator received many spurious ultrasonic reflectors and alarms while traversing that track section. It is likely that the operator’s assessment of the importance of the indications decreased relative to the rail condition, track category and test frequency. Consequently, the operator attributed the LBWE indications to surface condition, rather than the presence of a defect.^[16]

__________

12. Vertical split head defects – some insights into their development and growth, Stephen Marich and Malcom Kerr, RTSA Conference on Railway Engineering, Darwin 20-30 June 2004, p 21.3
13. Rail defect handbook RC2400, Australian Rail Track Corporation Issue A, Revision 0, March 2006, p29
14. Rolling out of the metal of the head towards the sides without a breaking down of the underside of the head.
15. A condition that occurs on the running surface appearing as a mosaic like pattern of small cracks.
16. Speno Broken rail report CTT 2014-016, 8 August 2017.

Findings

From the evidence available, the following findings are made with respect to the derailment of freight train 1501S near Dry Creek on the 28 July 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors

• An undetected defect resulted in the formation of a longitudinal fracture within the railhead that propagated both longitudinally and vertically (parallel to the side of the head).
• The forces exerted by the passage of train 1501S across the area of rail containing the vertical split defect (and broken rail) resulted in the fragmentation of a 2 m section of rail. The disruption of the rail running surface resulted in the derailment of the last three wagons of train 1501S.

Other factors that increased risk

• The operator undertaking ultrasonic testing of rail at Dry Creek North Fork on 26 June 2017 assumed the reflectors recorded resulted from the poor surface condition of the railhead and did not follow-up the loss of back wall echo indication that occurred at the location of the rail break.

Other findings

• The passage of a previous train (1122) across the section of rail containing the vertical split defect likely caused the rail to break, further reduced the integrity of the track to support the passage of rollingstock at this location.

Safety actions

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence

Proactive safety action taken by Speno Rail Maintenance Australia

Following the incident, Speno Rail Maintenance Australia investigated the broken rail occurrence and implemented a review of testing techniques used by operators in areas where poor surface condition exists and the implementation of procedures for reporting and testing of rail affected by surface condition.

Proactive safety action taken by Australian Rail Track Corporation

Following the incident, the Australian Rail Track Corporation (ARTC) addressed with Speno the reporting arrangements required in accordance with the contract between the two parties. Additionally ARTC reaffirmed the adequacy of the Track and Civil Code of Practice in relation to ultrasonic inspections.

The rail in the Dry Creek area is programmed for replacement during 2018 as part to the Adelaide to Tarcoola Re-Railing Project.

Sources and submissions

Sources of information

The sources of information during the investigation included the:

• Australian Rail Track Corporation
• Bowmans Rail
• Speno Rail Maintenance Australia

References

Track and Civil Code of Practice, Rail, Section 1, Version 3.3, 22 July 2016, Australian Rail Track Corporation

Code of Practice for the Defined Interstate Rail Network, Volume 4, Operations and Safe working , Part 1: Rules, DOTARS Version 2: May 2002, ARTC Version 2.2: 04 October 2015, Department of Transport and Regional Services

Engineering (Track & Civil) Manual, Manual for Non-Destructive Testing of Rail, ETN-01-04, Version 1.3 07 July 2009, Australian Rail Track Corporation

Non-Destructive Testing of Rail (for Internal & Surface Defects), ETE-01-03, Version 1.6, 6 October 2016, Australian Rail Track Corporation

Rail Defects Handbook, Some Rail Defects, their Characteristics, Causes and Control, RC 2400 Issue A, Revision 0, March 2006, Australian Rail Track Corporation, pp. 48-54

Rail Defect Manual, Sperry Products Inc., Hobroken. N.J. 1942

Site Safety, Environmental & Quality Management Plan, ARTC – Rail Flaw Detection, Version 3 17/02/2015, Speno Rail Maintenance Australia

Site Safety, Environmental & Quality Management Plan ARTC - Rail Flaw Detection, Version 3 17.02.2015, Speno Rail Maintenance Australia

Track Patrol, Front of Train, General and Detailed Inspections, ETE-00-02, Version 1.7 28 Jun 16, Australian Rail Track Corporation

Vertical split head defects – some insights into their development and growth, Stephen Marich and Malcom Kerr, RTSA Conference on Railway Engineering, Darwin 20-30 June 2004, p 21.3

Submissions

Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the Australian Transport Safety Bureau (ATSB) may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.

A draft of this report was provided to the Australian Rail Track Corporation, Bowmans Intermodal, Speno Rail Maintenance Australia and the Office of the National Rail Safety Regulator.

Submissions were received from the Australian Rail Track Corporation, Speno Rail Maintenance Australia and the Office of the National Rail Safety Regulator. The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.

Purpose of safety investigations & publishing information

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2018 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

On 14 June 2017, the ATSB commenced an investigation into a level crossing collision between a car and XPT NT32, Kyogle, New South Wales, Australia.

At approximately 0810 (AEST) on 14 June 2017, the driver of a white Holden Commodore was driving across the Andrew Street level crossing at Kyogle.  At the same time, XPT NT32 travelling from Brisbane to Sydney was approaching the level crossing. The train struck the motor vehicle and as a result of the collision, the driver of the car suffered fatal injuries.

ATSB’s preliminary evidence collection revealed:

• The passive level crossing approach signage was to standard.
• The sighting distances from both sides of the level crossing were unobstructed and provided ample time for safe crossing.
• There was no evidence of the level crossing being poorly maintained.
• There were no mechanical issues identified with the train.
• There were no issues identified with the train driver.
• The driver of the car was walking their pet dog beside the vehicle over the level crossing.

Based on this information, it is likely the driver of the car did not see the train approaching and did not abide by the passive level crossing warning signs. The ATSB considered it was very unlikely that further investigation would identify any systemic safety issues. Consequently, the ATSB has discontinued this investigation.

Safety summary

What happened

On 21 July 2017, a loaded coal train derailed at a level crossing on the Western Line between Oakey and Jondaryan, Queensland. The hauling locomotives and 18 wagons came off the track, destroying about 300 m of rail infrastructure.

It is very likely that the underframe of a low-clearance heavy road vehicle collided with the railway infrastructure as it traversed the level crossing soon before the coal train reached the crossing. The impact with railway infrastructure resulted in the lateral displacement of rail lines, which consequently derailed the coal train.

What the ATSB found

The rail infrastructure manager’s monitoring and inspection process at the Dunkeld Access Road level crossing did not ensure the approach roads within the rail corridor and the crossing surface were maintained within safe operating limits throughout its lifecycle. As a result, the elevated gravel-based level crossing road and crossing surface deteriorated to a point where the underframe of a low-clearance heavy road vehicle collided with the exposed head of each rail as it traversed the crossing.

The driver of the heavy road vehicle did not report the collision with rail infrastructure to the asset owner (Queensland Rail) or the local police in accordance with the Queensland Government road transport guidelines. Therefore, the relevant authorities were not in a position to contact the driver of the train before reaching the level crossing.

At the time of the derailment, there was no interface agreement between the rail infrastructure manager and a responsible road authority.

What's been done as a result?

Following the derailment, Queensland Rail (QR) repaired the level crossing and installed a sealed asphalt surface on both sides of the crossing to mitigate the risk of erosion and deterioration. QR also advised that it had taken or was undertaking a series of actions to improve its inspection processes of level crossings to ensure that more focus is placed on inspecting the condition of the approach roads at the crossings. In addition, QR is reviewing its safety standards and relevant documentation in relation to identified defects at level crossings and how the defects are recorded and managed.

QR also advised it had a state-wide audit program in place to assess the current safety status of all private crossings, and upgrade them to the QR standard and/or seek to enter interface agreements.

Safety message

Rail infrastructure managers, who are responsible for the management of the rail corridor, need to ensure that approach roads and the crossing surface at level crossings are subject to regular and effective inspection and monitoring processes. This is particularly relevant for level crossings with gravel-based road surfaces and inclined approach roads.

If rail infrastructure is damaged due to a road accident, it is vitally important that the driver responsible report the matter to the local police or the asset owner as soon as possible.

The occurrence

At about 1550 Eastern Standard Time^[1] on 21 July 2017, loaded Aurizon coal train 9869, operating on the Queensland Rail network, departed from the Jondaryan Coal Siding for Fisherman Islands, Queensland (Figure 1). The train was crewed by two drivers, and the consist included two locomotives and 41 wagons.

Figure 1: Jondaryan Coal Siding to Fisherman Islands rail route

The image shows the projected journey of train 9869 from Jondaryan Coal Siding to Fisherman Islands. Source: Queensland Rail (QR)

At about 1534, prior to the departure of the train, a low-clearance heavy road vehicle (prime mover and low-loader) was travelling west along the Warrego Highway between Oakey and Jondaryan. The driver of the heavy road vehicle made a right turn off the highway on to Dunkeld Access Road and passed over level crossing ID 2309, which provided a connection from the highway to McKenzie Road (Figure 2). The level crossing was located at the 38.620 km^[2] mark on the Western Line.

Figure 2: Travel direction of the heavy road vehicle over level crossing ID 2309

The image depicts the movement of the heavy road vehicle (white arrows) and the passageway of train 9869 (white solid line) in relation to the level crossing. Source: Google Earth - annotated by Australian Transport Safety Bureau (ATSB)

A member of the public saw the heavy road vehicle come to a sudden stop as it passed over the level crossing. According to the witness, the driver left the driving cab of the prime mover and inspected under the low-loader while it was stopped on the level crossing. The heavy road vehicle then continued on its journey, proceeding east along McKenzie Road.

At about 1557, as train 9869 approached level crossing ID 2309, the driver operating the train detected something on the track ahead. Initially, he thought a bird or small animal on the rails had distorted the appearance of the track, which is a common sight in this region. However, as the train neared the level crossing, the driver noticed a ‘kink’ in both rails. At that point, the speed of the train was 55 km/h, which was within the relevant limit for that section of track.

The driver reported that, as soon as he noticed the kink in the rails, he attempted to stop the train. At about 1558, the data logger on the locomotive recorded a full service brake application, which was initiated by the train driver to control the train to stop. The driver stated that the lead locomotive shuddered as it passed through the level crossing, and through the side mirrors he observed a number of wagons derail as the train slowed.

There were no injuries to the train crew or members of the public. A visual inspection of the train identified both locomotives and 18 coal wagons had derailed. There was also damage to about 300 m of rail infrastructure (Figure 3).

Figure 3: Derailed coal wagons of train 9869

The image shows derailed coal wagons of train 9869 – all wagons in the scene were in a derailed state.

Source: ATSB

__________

1. Eastern Standard Time (EST): Coordinated Universal Time (UTC) + 10 hours.
2. Kilometres west of Toowoomba.

Context

Level crossing information

History and location of level crossing ID 2309

In 1948, the Commissioner for Railways in Queensland, at the request of a local property owner, closed the occupation level crossing at the 124 miles 52 chains Western Line and relocated it to the 124 miles 70 chains, opposite the property owner’s farm. The relocation of the crossing provided the property owner with ready access to the Warrego Highway. Over time, the property was subdivided into smaller farms, which border the northern side of McKenzie Road and the Western Line.

Level crossing ID 2309 is currently located midway between Oakey and Jondaryan on the Western Line. Although the location of the level crossing has not changed in 70 years, under the metric system, its position is at the 38.620 km mark Western Line. It was categorised as a private (occupation) level crossing.^[3] At the time of the derailment, the crossing was used by the general public, including heavy road vehicles.

Queensland Rail (QR) has been the sole contributor to maintenance for both the level crossing and the approach roads within the rail corridor^[4] since the relocation in 1948.

Maintenance requirements for private level crossings

QR’s Level Crossing Safety Standard MD-10-115 stated that QR was responsible for audits, inspections, maintenance and testing at private level crossings. The maintenance responsibilities included (in part):

• erecting and maintaining all signs immediately adjacent to the tracks as set out in the level crossing agreement, deed or license (if applicable);

• maintaining the road surface within the rail corridor…

In the case of level crossing ID 2309, QR had no interface agreement with the road manager(s) and therefore it was responsible for the maintenance of the approach roads within the rail corridor (also see Level crossing interface agreements).

Maintenance of level crossing ID 2309

QR records showed that in October 2011, repair work was undertaken to eliminate longstanding drainage issues at level crossing ID 2309. In addition, the approach roads to the level crossing were upgraded (Figure 4).

Figure 4: Dunkeld Access Road / level crossing ID 2309 upgrade in October 2011

The images show the condition of the approach road surface on the day of the upgrade (October 2011). Source: QR

In July 2012, an assessment of the level crossing identified problems with the condition of the crossing surface. In the July 2012 assessment report, there was an ‘Observations’ section and a ‘Proposals’ section. A comment in the ‘Observations’ section stated:

Crossing gravel surface is breaking up. Track is “pumping”^[5] and contributing to surface deterioration… [Figure 5]

Figure 5: An image taken by the assessor during the July 2012 assessment of level crossing ID 2309

The assessors report recorded that the crossing gravel surface is breaking up and the track is ‘pumping’ and contributing to surface deterioration. Source: QR

In the ‘Proposals’ section of the report, the assessor noted:

Repair gravel surface in accordance with QR Standard Drawing No.2586. Carry out track maintenance works to address track ‘pumping’ issue.

Queensland Rail’s Standard Drawing No.2586, as referred to by the assessor in the report, is a civil engineering standard for public level crossings. In part, it stated:

Road pavement to be sealed with asphaltic cement or a similar material for a minimum distance of 10m on both sides of the railway.

An asphaltic cement prevents road surface deterioration, which is common with gravel-based road surfaces, particularly when the approach road is steeply inclined as it was at level crossing ID 2309. In addition, a sealed surface reduces the risk of low clearance vehicles striking the tracks as they cross. In the case of level crossing ID 2309, the assessor’s proposal was not actioned and the road surface remained unsealed (see Level crossing assessments).

Between October 2011 and the derailment in July 2017, there were two track defects recorded near the crossing:

• a low priority defect recorded in November 2015, which went untreated until after the derailment
• a critical track alignment issue recorded on 28 August 2016, which was rectified the following day.

Although the critical track alignment was not directly connected to the deteriorated condition of the level crossing, it is possible that the maintenance rectification work included some type of repair to the crossing surface. However, the extent of the repair work at the level crossing between July 2012 and August 2016 could not be determined based on the available records.

Accident site examination

Examination of approach roads

On 22 July 2017, the day after the derailment, the ATSB examined the accident site, which included the level crossing and approach roads to the crossing.

The approach roads to the level crossing were unsealed and constructed from compressed gravel road base. The on-site examination identified noticeable wheel furrows cut into the road surface on the approach to the level crossing from both sides (Figure 6).

Figure 6: The condition of the gravel-based road surface at the crossing on 22 July 2017

The images show the deteriorated state of the road surface and evidence of wheel furrow marks cut into the road surface. Source ATSB

Australian Standard 7658:2012 Railway Infrastructure: Railway Level Crossings stated:

The level crossing surface shall be flush with the top of rail, planar^[6] between the two rails and flush with the approach roads.

When inspected by the ATSB following the derailment, the head of each running rail at the level crossing was standing noticeably proud above the crossing surface. In some areas, the web^[7] of the rail was exposed (although see Examination of rail track). This was particularly noticeable where the wheel furrows in the road surface intersected with the rail lines (Figure 7).

Figure 7: The exposed railhead and rail web at level crossing ID 2309

There was evidence on both sides of the approach road of a pair of dual wheel tread marks, consistent with a large road vehicle having recently passed over the crossing. The tread marks followed the path of the wheel furrows. There was no evidence of gouge/score marks in the gravel-based road surface between the wheel furrows approaching the rail lines on either side of the crossing surface.

To provide guidance for underbody clearance for rolling stock and road vehicles at level crossings, QR developed civil engineering drawings. Level crossing civil drawing No.2587 defined road-grading limits at private level crossings. Where the approaches to a level crossing had a maximum incline of 6 per cent, the crossing surface design was to exhibit a level plane for 3,000 mm on either side of the track centre line.^[8]

The rail track in the area near the level crossing was elevated above the surrounding terrain. Measurements using a laser scanner identified that the approach roads (Dunkeld Access Road) on either side of the level crossing were inclined at about 5 per cent. However, the crossing surface did not exhibit a level plane on either side of the track centre line in accordance with the civil engineering drawing No. 2587. That is, the 5 per cent incline in the approach roads extended all the way up to the edge of the sleepers.

Examination of rail track

The site examination identified lateral displacement to the rails and significant gauge variation at the level crossing. There were side impact marks to the head of each rail at the point of lateral displacement.

The rail on the Warrego Highway side of the level crossing, which took the initial impact, was broken at the impact mark. The matching impact mark to the head of the parallel rail showed distortion to the gauge face, resulting in a gauge disparity of 55 mm (Figure 8).

Figure 8: Damage to the rails at level crossing ID 2309

The image shows corresponding impact marks in the head of each rail, which distorted the gauge and compromised the track integrity. Source: ATSB

The impact marks to each rail were located in the middle of the level crossing, between the wheel furrows made by road vehicles as they passed over the level crossing.

The impact marks covered the entire height of the head of each rail. Together with the absence of gouging/scoring in the road surface, this confirmed that the head of the rails were exposed at the point of impact.

As noted in Examination of approach roads, the site examination identified that the web of each rail was partially exposed at the level crossing and was clearly visible above the crossing surface. This was at least partly due to the low clearance vehicle colliding with the rails together with the derailment lifting the rails and displacing the gravel-based material previously surrounding the rails. Therefore, the extent to which the rail webs had been exposed, prior to the impact, was not able to be determined. However, it was noted that, where the wheel furrows intersected with the rails, the top of the rail webs had a distinctly different appearance to the lower sections of the webs, indicating that they had been exposed for some time.

Laboratory testing of a section of the damaged rail and the analysis of fracture propagation marks indicated that a factor external to the rail environment was involved in the lateral displacement of the rails. More specifically, the impact marks on each railhead indicated that the underframe of a low-clearance heavy road vehicle struck the track at some stage prior to the derailment. The impact marks confirmed that the road vehicle involved entered the level crossing from the Warrego Highway side.

Evidence relating to train activity on the day of the derailment confirmed that the condition of the track at the level crossing was free from damage at 1530. An empty coal train (9L16) passed through the level crossing at this time and did not encounter an issue with the track. Therefore, it is very likely that the underframe of a low-clearance heavy road vehicle collided with the rail infrastructure as it traversed the level crossing sometime between 1530 and 1557 on 21 July 2017.

Road vehicle information

Heavy road vehicle information

On the afternoon of 21 July 2018, the driver of a heavy road vehicle (prime mover and low-loader) was delivering a front-end loader to a worksite adjacent to the Devon Park Road level crossing just west of Oakey. QR had engaged a transport company to deliver the front-end loader to the worksite for the purpose of planned track maintenance work.

The heavy road vehicle was operating under the provisions of Guideline for Excess Dimension Vehicles Carrying Indivisible Articles in Queensland – Form Number 4 (Version 8) February 2013. The gross load capacity of the low-loader (trailer) was 55,000 kg, and the weight of the end-loader was under 20,000 kg. Therefore, the low clearance heavy road vehicle was not overloaded when traversing the level crossing.

The driver of the vehicle stated that he had delivered heavy earthmoving machinery to this location on many occasions. He further stated that on all occasions the same prime mover and low-loader combination had been used to deliver the machinery.

The driver stated he normally turned off the Warrego Highway at Devon Park Road to reach the worksite, passing over the level crossing and unloading the machinery on the northern side of the rail corridor. He added that he would then continue along McKenzie Road, and turn left at level crossing ID 2309 to gain access to the Warrego Highway (Figure 9).

Figure 9: The preferred route after delivering heavy machinery to the worksite

The image shows the route normally taken by the driver of the heavy road vehicle after delivering earthmoving machinery for planned maintenance work during 2017. Source: Google Earth, annotated by the ATSB

However, on this particular occasion, due to traffic build-up at the Devon Park Road level crossing, the driver of the heavy road vehicle chose to use an alternate route. He chose to continue along the Warrego Highway, turn off at the next level crossing (ID 2309) and proceed along McKenzie Road in order to reach his destination.

In this instance, by travelling the alternate route, the low-clearance heavy road vehicle was passing over level crossing ID 2309 in a loaded condition, rather than an unloaded condition as it normally would. It was also entering the level crossing from a different direction to normal (that is, it was entering from the Warrego Highway side).

The driver of the heavy road vehicle stated that he recalled passing over level crossing ID 2309, but insisted that the vehicle did not collide with the rail infrastructure at the crossing.

Additional evidence relating to the movement of the heavy road vehicle

At about 1534 on 21 July 2017, video footage recorded by a camera fitted to a private vehicle travelling east on the Warrego Highway showed a prime mover and low-loader combination travelling west on approach to level crossing ID 2309. The heavy road vehicle was transporting a yellow front-end loader (Figure 10).

Figure 10: Dash camera footage from a private vehicle

The image shows a prime mover and low-loader carrying a front-end loader as it approached level crossing ID 2309. The time stamped on the image is 1534:22 on Friday 21 July 2017. Source: private vehicle operator

A short time later, a member of the public, who provided information to the local police, stated that he observed a prime mover and low-loader combination, transporting a front-end loader, come to a sudden stop as it passed over level crossing ID 2309 from the Warrego Highway side.

The witness stated that the heavy road vehicle appeared to have ‘bottomed-out’ on the crossing. He also stated that the driver of the heavy road vehicle left the driving cab of the prime mover and checked the underframe of the low-loader while it was stopped on the level crossing.

Reporting damage or safety incidents at level crossings

There were ‘incident reporting signs’ in place at the level crossing on the day the railway infrastructure was damaged. The signs provided an emergency contact number for reporting faults or safety incidents at the level crossing (Figure 11).

The Queensland Department of Transport and Main Roads has provided guidelines for the operation of excess dimension vehicles in Queensland. It detailed the responsibilities of the driver if a vehicle causes damage at a level crossing. It stated:

The driver of the vehicle must immediately report any damage caused to the asset owner and in the event that it presents a dangerous situation, to the local police.

On the day of the derailment, no advice of rail infrastructure damage at the level crossing was received by QR or the local police.

Figure 11: Incident reporting sign at level crossing ID 2309

The image shows the incident reporting sign and the emergency contact number, in place at level crossing ID 2309 on the day of the derailment. Source: ATSB

Inspections and assessments of level crossing ID 2309

Scheduled inspections of rail corridor

Inspection is the process by which QR collects and records information on the condition of the track and its components. Inspection must commence when the track is new and continue through its operational life.

QR’s Civil Engineering Track Standard, Module 1 – Track Monitoring, prescribed the regime to inspect the condition of the track^[9] and track components in accordance with its standard. It lists three inspection types relevant to the inspection of track, each of which includes level crossings as an element for inspection. The three inspection types were:

• Scheduled patrol inspection (maximum interval between inspections is 96 hours). On the Western Line, these inspections were conducted by a single infrastructure worker driving an on-track vehicle through the rail corridor. The inspection was to detail all elements within the rail corridor including level crossings, stopping as required to inspect recorded defects. A scheduled patrol inspection occurred on 20 July 2017, 1 day prior to the derailment, with no defects identified at level crossing ID 2309.
• Scheduled general inspection (maximum interval between inspections is 4 months). On the Western Line, these inspections were typically conducted with two infrastructure workers, who travelled through the rail corridor using an on-track vehicle. The inspections detailed all elements within the rail corridor including level crossings, stopping as required to inspect recorded defects. The two scheduled general inspections undertaken prior to the derailment occurred on 16 January 2017 and 17 July 2017. Neither of the inspections identified issues at level crossing ID 2309.
• Scheduled detailed inspection (maximum intervals between inspections was 48 months). These inspections were typically conducted by walking the rail corridor. In addition to the requirements for general inspections, detailed inspections must be at a level of detail sufficient to record the condition of the track for specific purposes such as determining required repairs or remedial actions. The last scheduled detailed inspection occurred on 18 May 2016, with no defects at level crossing ID 2309.

In accordance with QR’s Civil Engineering Track Standard, the infrastructure workers conducting these inspections were required to keep a lookout for obvious unsafe conditions, changed conditions or evidence of high rates of deterioration, which indicated unacceptable risk to operations.

Workers who conducted these inspections informed the ATSB that they stopped at all level crossings to inspect the lights, boom gates and guardrails where applicable. They advised that they also inspected the road surface and crossing surface of level crossings to ensure the safe passage of trains and vehicles. Workers advised that they could not readily distinguish between public and private level crossings without referring to documentation. Additionally, the infrastructure workers were unable to determine the balance of responsibilities of the rail infrastructure manager and the road manager at a level crossing if an interface agreement existed.

Level crossing assessments

QR undertook ‘assessments’ of level crossings

…to determine the appropriate level of control to reduce the risk of collision between a road vehicle/pedestrian and a train as far as is reasonably practicable.

QR’s Level Crossing Safety Standard MD-10-115 stated:

If a private crossing has substantial public use, the recognised level crossing risk assessment model (ALCAM) shall be used. For this purpose, public traffic is defined as vehicular traffic which is not owned or strictly controlled by the Responsible Road Manager…

Private, maintenance and temporary construction level crossings will be reviewed by Queensland Rail at not more than five yearly intervals. These reviews shall be carried out to ensure compliance with the controls approved following the initial assessment for the crossing, and verify that the conditions applying at the time of the initial assessment are still current and the controls are still effective.

These level crossing assessments are separate from the scheduled inspections of the rail corridor discussed in the previous section.

Documentation provided by QR showed that the last assessment/review undertaken at level crossing ID 2309 was on 2 July 2012. The next review should have occurred prior to 2 July 2017. However, this did not occur and, at the time of the derailment on 21 July 2017, the review was overdue.

A notation recorded by the assessor within the July 2012 assessment report stated:

Whilst at present this is a private (occupation) level crossing, it has been assessed as a public level crossing.^[10]

The report was brief in nature, and there was no explanation within the report on the decision, for the purpose of the assessment, to upgrade the level crossing from private (occupation) to public. In accordance with the requirements for public level crossings in QR’s Level Crossing Safety Standard MD-10-115, the assessor used the Australian Level Crossing Assessment Model^[11] (ALCAM) to evaluate the level crossing.^[12]

QR’s level crossing database contains information relating to individual level crossings. After an assessment/review or audit, the assessor updates the system by populating information into the values and fields sections relevant to the level crossing. The system has the capacity to produce a characteristics report. The report reflects on the condition and characteristics of the level crossing at the time of the last entry.

On 15 August 2017, at the request of the ATSB, QR provided the latest characteristics report relating to the level crossing. The last recorded entry date in the comments section of the level crossing database was on 2 July 2012 (following the assessment). In part, the characteristics report stated the crossing condition was ‘bad’.

Based on the evidence supplied by QR, there was no record entered into QR’s asset management database to indicate whether any action regarding the assessor’s proposals in July 2012 to repair the approach road and crossing surface in accordance with QR Standard Drawing No.2586 (see Maintenance of level crossing ID 2309) was approved or actioned. Other proposals in the assessment report (such as installing advance warning signage and incident reporting signage) were actioned at some stage, but not recorded as being actioned in the asset management database.

Other level crossings

The ATSB did not conduct a detailed review of other level crossings in the area. However, it did examine level crossing ID 2310, located 1.5 km west of level crossing ID 2309. This was a private level crossing, and only supported traffic to and from a private property. There were noticeable wheel furrows on the approach roads. In addition, a significant portion of the railhead and web were exposed.

Level crossing interface agreements

An interface agreement is a written agreement between the rail infrastructure manager and road manager and sets out the responsibilities, mutual understanding and arrangement for the management of risks to safety at the shared level crossing interface.

Legislation, introduced in 2010 and current at the time of the derailment, stated the rail infrastructure manager (in this case QR) must identify, so far as is reasonably practicable, risks to the safety of persons arising or potentially arising from railway operations for a private road.

If the rail infrastructure manager forms the opinion that it is necessary to manage the identified risk in conjunction with the responsible road manager, the rail infrastructure manager should reasonably seek to enter into an interface agreement with that responsible road manager.

Alternatively, if the rail infrastructure manager forms the opinion that it is not necessary to manage the identified risks in conjunction with the responsible road manager, then the rail infrastructure manager for the road should keep a written record of the reasons for forming that opinion. The legislation stated that a responsible road manager for a private road meant the owner of the road.^[13]

The Dunkeld Access Road was a private (occupation) road passing over a railway. It joined two public roads, the Warrego Highway and the nearby McKenzie Road (Figure 2). In effect, QR was the road owner within the rail corridor and was responsible for the inspection and maintenance of the level crossing. In addition, there is evidence that QR was maintaining the Dunkeld Access Road outside the boundary of the rail corridor.

At the request of the ATSB, QR provided correspondence stating that there was no interface agreement with a responsible road manager for level crossing ID 2309. There was also no evidence provided to indicate that QR had attempted to enter into an interface agreement with either the owner of the nearby property or a road authority. Nor was there a written record regarding the reason QR chose not to manage the risks in conjunction with a responsible road manager.

__________

3. A private (occupation) level crossing is used to provide access to private land either from one part of the property to another or to access the property from a dedicated road for use by the responsible road manager (property owner) and their invitees only.
4. The land on which a railway is built; comprising all property between property fences, or, where there are no fences, 10 m from the outside rail of the outside track.
5. Pumping refers to the vertical movement of the track under the movement of rail vehicles.
6. A flat two-dimensional surface.
7. The web of the rail is the vertical section that supports the railhead.
8. A level crossing surface helps minimise the potential for the rail line to be damaged by low clearance vehicles passing over the rails. Civil engineering drawing No.2587 stated that the approach roads for private crossings could be made from compressed gravel. Civil engineering drawing No.2586, which applied to public level crossings, had the same requirements for incline and crossing surface, but it also required an asphalt or similar surface.
9. ‘Track’ meaning all the features on the right of way, excluding: bridges, culverts, signals, electrical infrastructure and buildings.
10. A public crossing is a level crossing provided to maintain continuity of a public vehicular thoroughfare across a railway at grade and available for use by the general public.
11. ALCAM is an assessment tool used to identify key potential risks at level crossings and to assist in the prioritisation of crossings for upgrades. The risk model is used to support a decision making process for both the road and pedestrian level crossings and to help determine the most cost-efficient treatments.
12. MD-10-115 stated that the assessment of private crossings was to be conducted using a ‘Private & Queensland Rail Maintenance Level Crossing Assessment Report Form’. However, it also stated ‘Private crossings that are substantially used by members of the public shall be assessed using ALCAM.’
13. The legislation had similar requirements for public roads, but stated that the rail infrastructure manager must reasonably seek to enter into an interface agreement with the responsible road manager. The legislation stated that a responsible road manager for a public road could be the local government or state government.

Safety analysis

Introduction

The loaded coal train derailed at level crossing ID 2309 due to the misalignment of the rail track. No factors associated with the operation of the train or the rolling stock contributed to the derailment.

This analysis will discuss the factors associated with the rail track misalignment. These include the condition of the level crossing, the collision of a heavy road vehicle with the rail infrastructure, the absence of reporting the collision and the processes used to ensure the condition of the level crossing.

Condition of level crossing ID 2309

The railway track at the level crossing was elevated above the surrounding terrain. The approach roads on either side of the level crossing were inclined at about 5 per cent, which was within but close to the maximum allowed incline of 6 per cent. This incline, and the fact that the road and crossing surface were constructed of compacted gravel-based material, meant the crossing was vulnerable to erosion and deterioration.

The available evidence suggests that local traffic and heavy road vehicles used the crossing, and the condition of the level crossing deteriorated over a period of time. The assessment of the level crossing in July 2012, 8 months after a comprehensive upgrade in October 2011, noted that the crossing surface was breaking up and deteriorating. The report included a proposal to replace the gravel-based road surface with asphalt or a similar sealed surface, but this was not done. It is possible some repair of the gravel-based road surface was done at this time, or after this time, such as when a critical track irregularity was identified and repaired in August 2016. However, the extent of any repair work could not be determined based on the available records.

An examination of the level crossing on 22 July 2017, the day after the derailment, identified that the approach roads to the level crossing were in a deteriorated state. There were significant wheel furrows in the gravel-based approach roads, which lowered the underframe of vehicles relative to the road surface, if they followed the furrows. In addition, there was not a level plane over the crossing surface, with the 5 per cent incline in the approach roads extending up close to the rails. The available evidence also indicated that the head and probably some of the web of each rail was exposed above the crossing surface, although the extent the webs were exposed could not be determined. Collectively, these factors, in the period leading up to the derailment, presented a significant risk associated with low-clearance road vehicles and agricultural machinery passing over the level crossing and damaging the rail infrastructure.

Collision with rail infrastructure at level crossing ID 2309

An examination of the accident site identified identical impact marks to the head of each rail at the level crossing. The lateral impact distorted both rails resulting in misalignment of the rail track. Analysis of the marks indicated that they were the result of impact from a low-clearance road vehicle that turned off the Warrego Highway and passed over the level crossing from that direction. The available evidence also indicated that the collision occurred between 1530 and 1557 (just prior to the train reaching the crossing).

It is very likely that the vehicle involved in the collision was the low-clearance heavy road vehicle (prime mover and low-loader combination) delivering the front-end loader to a worksite on the northern side of the rail corridor. It was observed approaching the level crossing at 1534, and a witness saw the low-clearance road vehicle come to a sudden stop at the level crossing shortly after.

It is possible that another low-clearance heavy road vehicle was involved in the collision. However, no other vehicles were sighted passing over the level crossing in the relevant period. In addition, although the same low-clearance heavy road vehicle had crossed the level crossing on previous occasions without incident, it is notable that on those occasions it had crossed without a load and crossed from the other direction.

Collision with rail infrastructure not reported

The heavy impact marks to the head of each rail and the resulting rail infrastructure damage suggests that the collision was significant. Therefore, it is highly likely that the driver of the low-clearance heavy road vehicle that caused the damage would have been aware that the vehicle struck the rail track.

Any damage to rail infrastructure such as rail track misalignment can have very adverse consequences. Accordingly, it is vitally important that any suspected damage is reported as soon as possible. The requirements for reporting such damage have been promulgated, and were also posted at the level crossing. In this case, had the damage been promptly reported, it is likely that advice of the potential problem could have been provided to the train crew prior to the train reaching the level crossing.

Scheduled inspections relating to level crossing ID 2309

The fact that the level crossing had deteriorated outside safe operating parameters suggests it was not being appropriately maintained. It is possible that the condition of the level crossing had only recently deteriorated. However, the level of deterioration that occurred between the upgrade in October 2011 and the assessment in July 2012 suggests that the crossing had a significant potential to degrade over time. The available information suggests that road vehicles, including heavy road vehicles, regularly used the level crossing. Together with factors such as the relatively steep incline and the gravel-based surface, this created the potential for degradation of the crossing surface and the approach roads.

In order for the level crossing to be maintained, the deterioration had to be detected through an assessment or review or scheduled inspections. The last assessment was conducted just over 5 years before the derailment. If an assessment had been done on or just prior to the scheduled date, it is likely that it would have detected the deterioration. Nevertheless, a slight extension to the 5-year timeframe would not be unreasonable in most circumstances (if requested). In addition, there was the significant potential for the problem with the access roads to have developed within 5 years. Therefore, the scheduled inspection processes played an important role in detecting problems before they reached a significant level of deterioration.

According to QR’s documented procedures, level crossing ID 2309 should have undergone a series of scheduled inspections at 96-hour, 4-month and 48-month intervals. The level of detail required in each inspection varied, but they all required aspects of the level crossing, including the road surface within the rail corridor, to be examined.

Overall, there should have been more than 540 combined inspections undertaken at the level crossing between the upgrade in October 2011 and the derailment in July 2017. A number of different personnel would have undertaken these inspections. However, none of these inspections identified the deterioration of the level crossing, which strongly indicates that the inspection process for detecting deficiencies associated with the approach roads and level crossing surface was inadequate. The ATSB also notes that the condition of the approach roads of another private level crossing, located near ID 2309, also had deteriorated to the extent that a significant portion of the railhead and rail web was exposed.

The benefit of an interface agreement

Other than an indemnity agreement between a local property owner and the Commissioner for Railways in 1947, there is no record of an interface agreement involving QR and a road manager(s) at level crossing ID 2309. In the absence of an interface agreement with the road manager(s), QR’s responsibility within the rail corridor was to monitor, inspect and maintain the condition of the road and level crossing throughout their operational life.

Alternatively, QR could have entered into an agreement with another entity to manage the road at the level crossing. As the level crossing forms a connection between a local council road and national highway, the responsible road manager could be either the local road authority, state government or both.

Although level crossing ID 2309 was classified as a private (occupation) level crossing, its unrestricted access as a thoroughfare between two public roads likely presented a level of risk similar to that of a public road crossing. The available evidence also indicates it was frequently used as a public road. In addition, the person who undertook the assessment of the level crossing in July 2012 conducted the assessment as if it was a public crossing. This presented an opportunity for QR to reconsider its classification of the crossing, and/or consider entering into an interface agreement with a responsible road authority.

The benefit of an interface agreement is that both QR and the road manager(s) would have shared the identified risks through a controlled process. Accordingly, if responsibilities for inspecting the condition of the road surface by a road manager at regular intervals was appropriately documented and controlled, this could have increased the potential to identify the developing problem.

However, without knowing exactly how the responsibilities within the rail corridor would have been documented and controlled, it is difficult to determine whether an interface agreement by itself would have led to the identification of the deterioration in the approach road and crossing surface on Dunkeld Access Road prior to the collision with rail infrastructure and subsequent derailment. Ultimately, QR was still responsible for inspecting the approach roads within the rail corridor, and had not identified the deterioration.

It should be noted that the QR network has more than 1,000 private level crossings. A substantial number of these do not have an interface agreement. Consequently, QR’s inspection processes need to be adequate when inspecting approach roads and crossing surfaces at such locations.

Findings

From the evidence available, the following findings are made with respect to the derailment of train 9869 at level crossing ID 2309, near Oakey, Queensland on 21 July 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

Contributing factors

• The condition of level crossing ID 2309 was degraded, with significant wheel furrows in the approach roads, the absence of a level plane over the crossing surface, and the head of both rails was exposed. Some of the web of the rails was also probably exposed.
• It is very likely that the underframe of a low-clearance heavy road vehicle collided with the exposed head of the rails as the vehicle traversed level crossing ID 2309.
• As a result of the collision by a low-clearance heavy road vehicle, the rail lines at level crossing ID 2309 were laterally displaced, creating the potential for a derailment.
• The driver of the low-clearance heavy road vehicle that collided with and damaged the rail infrastructure at level crossing ID 2309 did not report the occurrence to the relevant authorities.
• Queensland Rail’s track monitoring and inspection processes were not effective in identifying significant deterioration in the condition of level crossing ID 2309 and its approach roads to ensure the safe operating limits of the level crossing throughout its lifecycle. [Safety issue]

Other factors that increased risk

• Queensland Rail had not entered into an interface agreement with a responsible road authority at level crossing ID 2309, even though Dunkeld Access Road and the level crossing were in effect being used as a public thoroughfare. It is likely that an interface agreement would have resulted in a co-ordinated approach to managing the shared risks at the level crossing.

Safety issues and actions

The safety issues identified during this investigation are listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

Depending on the level of risk of the safety issue, the extent of corrective action taken by the relevant organisation, or the desirability of directing a broad safety message to the rail industry, the ATSB may issue safety recommendations or safety advisory notices as part of the final report.

All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.

Descriptions of each safety issue, and any associated safety recommendations, are detailed below. Click the link to read the full safety issue description, including the issue status and any safety action/s taken. Safety issues and actions are updated on this website when safety issue owners provide further information concerning the implementation of safety action.

QR’s track monitoring and inspection processes

Safety issue number: RO-2017-007-SI-01

Safety issue description: Queensland Rail’s track monitoring and inspection processes were not effective in identifying significant deterioration in the condition of level crossing ID 2309 and its approach roads to ensure the safe operating limits of the level crossing throughout its lifecycle.

Additional safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Queensland Rail

Following the derailment, Queensland Rail (QR) repaired the level crossing. During this repair, a sealed asphalt road was installed, covering both sides of the crossing surface.

In its response to the draft investigation report in April 2019, QR advised that since the derailment it had attempted to enter into an interface agreement with a local land owner (who did not want the crossing closed) and the local council (who did not want to make the crossing public).

In April 2019, QR also advised the following in relation to interface agreements:

QR has an audit programme in place to assess all private crossings, upgrade them to the QR standard as necessary, and seek to enter into interface agreements.

QR have requested that the land owner for this crossing enter into an interface agreement with Queensland Rail for the safe operation and use of this level crossing.

An Interface Agreement for Occupational Crossing ID 2309 (Dunkeld Access Road, Oakey (38.62km Western Line) was sent to the private land owner on 9 April 2019. Receipt of the letter was acknowledged on 15 April 2019.

In relation to the ongoing audit programme, audits so far have been completed within the North, Central, North Coast/ Wide Bay/ Burnett regions of Queensland. To date, the audits have identified 72 crossings for closure (as they are no longer required by any party), 28 crossings will be changed from private to public status crossings (as they appear to be used by the general public), 7 crossings will be changed from private to maintenance status crossings and 3 crossings have been identified as requiring relocation. Also to date, licence/interface agreements for 411 have been sent to relevant parties in the regions noted above and 174 licence/interface agreements have been formalised.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• Aurizon (train operator)
• Queensland Police Service
• Queensland Department of Transport and Main Roads
• Queensland Rail (track owner)
• rail traffic crew of train 9869.

Submissions

Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the Australian Transport Safety Bureau (ATSB) may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.

A draft of this report was provided to Queensland Rail, the driver of the heavy road vehicle, the operator of train 9869 (Aurizon), the crew of train 9869 and the Office of National Rail Safety Regulator (ONRSR).

A submission was received from Queensland Rail. The submission was reviewed and, where considered appropriate, the text of the report was amended accordingly.

Purpose of safety investigations & publishing information

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2019 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

On 25 June 2017, the ATSB commenced an investigation into a near collision between a Track Maintenance Vehicle (TMV) NK83 and freight train 4190N due to a signal irregularity at Islington Junction, NSW.

At approximately 1020 (AEST) on 25 May 2017, a TMV NK83 travelling to Port Waratah was stopped by the Australian Rail Track Corporation (ARTC) train control at Signal IJ25. The crew in the rear locomotive of NK83 noticed that although they were foul of the Up main, the signals were clear for rail traffic to pass through. Soon after this, freight train 4190N was seen operating on the Up main headed towards NK83. The crew in the rear locomotive of NK83 made an urgent request to move NK83 forward to avoid a being struck by 4190N. NK83 moved forward and avoided being struck by 4190N.

ATSB’s preliminary evidence collection revealed:

• The signalling system at Islington junction was upgraded in 2007. The upgrade of the interlocking system did not include a risk control which previously prevented conflicting train movements at the junction.
• ARTC have since changed the interlocking system to manage the risk of conflicting movements at Islington Junction.
• Since the incident, ARTC have inspected similar crossings and confirmed that the missed interlocking risk control was isolated to the crossing at Islington Junction.

Following ARTC’s confirmation that the incident was isolated to the crossing at Islington Junction, the ATSB considered it was unlikely that further ATSB investigation would identify any systemic safety issues. As such, the ATSB has discontinued this investigation.

What happened

At about 1035 on 11 July 2017, a Pacific National freight train (8426N) departed Broken Hill, New South Wales (NSW) toward Condobolin (NSW). Train 8426N consisted of two locomotives (8184, 8249) and 27 wagons loaded with lead and zinc. The train was 437 m in length with a trailing mass of 1,998 t.

At about 1540 Eastern Standard Time,^[1] train 8426N was entering the Ivanhoe crossing loop and approaching the Cobb Highway level crossing, located about 2.1 km south-east of the Ivanhoe township. The Cobb Highway level crossing was equipped with flashing lights, an audible warning device (bell) as well as passive warning signs posted on the road approaching the crossing.

The Cobb Highway level crossing flashing lights activated at 15:43:16 with the approach of train 8426N. The train was travelling at 69 km/h and was about 300 m from the crossing when the train driver sighted the warning lights ahead were operating. The driver also saw a truck hauling two trailers (road-train) approaching the crossing from the south. The road-train was a Mack Superliner loaded with 43.7 t of road-base material.

The road-train driver was negotiating a sweeping right-hand bend before the road alignment straightened toward the crossing (Figure 1). The road-train driver reported travelling at about 70 km/h approaching the crossing (the posted speed limit was 80 km/h).

Figure 1: Aerial view of Cobb Highway level crossing and road approaches

Source: Google Earth, annotated by ATSB

According to the road-train driver, he saw the flashing lights when the road-train was within 180 m of the crossing. He started to brake but assessed that the road-train might not stop in time, so accelerated to cross ahead of the train.

The train driver saw the road-train decelerate and then increase speed. The driver reported that he sounded the locomotive’s horn when it was about 190 m from the crossing. Shortly after, he saw the road-train enter the level crossing. Data from the train’s event recorder showed that about 100 m from the crossing, the train driver made an emergency brake application and activated the ‘emergency in progress’ alarm on the train radio. The train crew then relocated to the floor of the locomotive cab in preparation for a collision.

Train 8426N subsequently collided with the near side rear corner of the last trailer of the road-train (Figure 2), travelling a further 319 m before stopping. Shortly after, the train driver reported the collision to the Australian Rail Track Corporation Junee Network Control Centre. The train crew and the driver of the road-train were shaken but otherwise unhurt.

Figure 2: Collision damage to the locomotive and the last trailer of the road-train

Source: NSW Police, annotated by ATSB

Australian Standards

Australian Standard AS 1742.7:2016 Manual of uniform traffic control devices – Railway crossings prescribes the requirements for road markings, roadside signs and configuration of active traffic controls at railway crossings throughout Australia.

The traffic controls installed at the Cobb Highway railway crossing comprised flashing lights, an audible warning device (bell) as well as road surface markings and passive warning signs on the road approaches to the crossing. The active traffic controls at the Cobb Highway railway crossing were consistent with the requirements of AS 1742.7.

Australian Standard AS 1742.7:2016 required that flashing signals commence activation a minimum of 20 seconds prior to the arrival of a train. Australian Standard AS 7658:2012 Railway Infrastructure - Railway Level Crossings stipulated that flashing light warning signals commence activation a minimum of 25 seconds prior to the arrival of a train.

The intent of the two standards (when lights commence flashing) is to allow road vehicles:

• to stop before entering the crossing,
• if unable to stop, to traverse and clear the crossing, before a train arrives.

AS 7658:2012 – item ‘4. Track & Civil’, section 4.1 clause 2(a) and 2(b) refers to the Austroads guidelines and at clause 3(a) sight distances, obstructions, and clause 3(b) time for road vehicles to traverse and clear the railway crossing. However, there are no specific guidelines for assessing sighting distance requirements for locations with active/flashing light control, or for locations where the requirement to negotiate curved approaches creates potential for compromised driver perception.

The flashing lights at the Cobb Highway level crossing were operating for 39 s before the arrival of train 8426N at the crossing. NSW Road Rules 2014, Part 10, Section 123 stipulates that a road user must not enter a railway crossing if the warning lights (or bell) are operating.

Road-train driver

The driver of the road-train reported being very familiar with the crossing, having used it on many occasions over the previous month, including multiple times on the day of the occurrence. During this time, the driver recalled only two instances of encountering a train.

On the day of the occurrence, the driver had completed a number of trips across the Cobb Highway level crossing. He noted that when travelling in a westerly direction later in the afternoon, a combination of sun glare and dust on the prime mover’s windscreen can reduce visibility ahead.

The driver stated that the alignment of the sweeping ‘S’ bend road approach and roadside vegetation meant that sighting of the flashing lights was also restricted until the vehicle had travelled through the bend and was within 180 m from the crossing. On sighting the level crossing operating, the driver assessed that there was now insufficient distance to stop the road‑train prior to it entering the crossing.

Previous occurrences

The ATSB has investigated 28 accidents at level crossings since 2002, many involving heavy road vehicles. On 23 September 2015, a collision occurred between a road-train and grain train at a protected level crossing near Narromine, NSW. The road approach to the level crossing contained a sweeping right-hand curve. The road-train driver sustained fatal injuries in the collision. The ATSB report, RO-2015-016 Collision involving road-train truck and train 8834N is available from the ATSB website.

The ATSB found that although the truck driver was probably travelling too fast for the prevailing conditions, the driver’s attention was probably focused on negotiating a sweeping right-hand curve that preceded the crossing, at a critical time when he needed to check for the activation of the crossing. The ATSB concluded that it was likely that when the driver perceived that the flashing lights were operating, he was too close to the crossing to stop, and collided with the train.

The ATSB identified a number of areas of potential improvement related to road design signage and standards associated with railway crossing traffic control, especially with respect to curved approaches before railway crossings. In response to the ATSB findings, Standards Australia commenced a review of AS 1742.7:2016, with respect to railway crossing approaches, in particular curved approaches, and the location signage.

Standards Australia received the project proposal for a Revised Text Amendment (RTA) to AS 1742.7:2006 in early 2017. The committee met on 9 August 2017 to initiate the project and established a working group to commence drafting the RTA. It is anticipated the standard will be published in the last quarter of 2018 subject to Standards Australia standards development process. The committee reviewed a draft of the ATSB investigation report for the 11 July 2017 occurrence and concluded there was no need to carry out any further amendment for update to AS 1742.7 beyond the scope of the current revision.

Safety analysis

The active level crossing warning equipment was consistent with the requirements of both AS 1742.7:2007 and AS 7658:2012. The driver of the road-train was traversing a sweeping bend on the approach to the Cobb Highway level crossing when he noticed the flashing lights were operating during his approach. The driver believed there was now insufficient time to stop the vehicle before entering the level crossing. He accelerated in an attempt to clear the level crossing ahead of the approaching train 8426N and avoid the potential for a collision between the prime mover or trailers and the train. However, the train collided with the rear trailer of the road-train. It is likely that one or more of the following factors affected the truck driver’s timely recognition of the flashing lights:

• focus on negotiating the curved approach to the crossing
• roadside vegetation
• frequent use of the level crossing combined with infrequent train presence.

Findings

These findings should not be read as apportioning blame or liability to any particular organisation or individual.

• It is likely that the truck driver did not look for, or sight, the activated flashing lights until relatively close to the crossing. This was probably due to one or more of: focus on negotiating the curved approach to the crossing, roadside vegetation and/or not expecting a train to be present.
• On sighting the level crossing lights and approaching train, the truck driver assessed there was insufficient available distance to stop the heavily laden road-train truck before the level crossing. Consequently, the truck driver accelerated and entered the crossing while the flashing lights were operating, contrary to the New South Wales road rules.

Safety message

It is imperative that road vehicle drivers always approach railway crossings with extreme care. The level of care and attention required increases as road vehicle gross mass increases.

Although motorists are primarily responsible for avoiding a collision with a train at railway crossings, prudent road design and/or advance warning of a train’s presence at railway crossings should be considered as a strategy to lower the risk of road and rail vehicle collisions.

Road and rail authorities should consider measures to enhance the awareness of motorists approaching railway crossings, especially at locations with restricted sighting due to curved approach roads.

For more information about level crossing safety, visit the ATSB website.

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2018 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

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1. Eastern Standard Time (EST): Universal Coordinated Time (UTC) + 10 hours.