Background

On 16 December 2010, the ATSB released the final report of its safety investigation into the February 2009 grounding of the piloted tanker Atlantic Blue in the Torres Strait. The report identified deficiencies in the safety management of Queensland coastal pilotage operations, similar to the safety issues identified by the ATSB in previous safety investigations. In response to the ATSB’s findings, the Australian Maritime Safety Authority (AMSA), in its capacity as the coastal pilotage safety regulator, indicated its concern that there might be systemic issues affecting the safety of coastal pilotage operations, arising in particular, from the impact of commercial competitive pressures. Furthermore, AMSA felt that, given the ATSB’s independence and investigative powers, the ATSB was ideally placed to investigate these issues and indicated that it would be pleased to see the ATSB investigate this matter. Consequently, the ATSB initiated a systemic safety issue investigation into Queensland coastal pilotage.

Queensland coastal pilotage

In 1991, Australia introduced a system of compulsory coastal pilotage to protect the sensitive Great Barrier Reef (GBR) environment which lies in Queensland’s coastal waters. The GBR and Torres Strait are both recognised as particularly sensitive sea areas (PSSA)¹.To protect these PSSAs, Australia requires large ships² to use the services of an AMSA licensed coastal pilot³ when navigating the Torres Strait, the Inner Route of the GBR north of Cairns (Inner Route), the Hydrographers Passage off Mackay, and the Whitsunday Islands area.

The coastal waters of Queensland are the only area in Australia where coastal pilotage takes place. All coastal pilotages are undertaken by a single pilot. Depending on a ship’s speed, an Inner Route transit takes between 25 and 40 hours, making it the longest single-handed pilotage in the world. Transits of the Torres Strait and the Hydrographers Passage, the two other main routes, take 8 to 10 hours and 5 to 7 hours, respectively.

In July 1993, when AMSA took over responsibility for coastal pilotage from the Queensland Government, an annual average of about 2,300 piloted ships transited the three main pilotage routes. In 2010, more than 4,700 piloted ships transited these routes. Piloted traffic in the region has, therefore, doubled in less than 20 years as the economies of Queensland and Australia have expanded. Shipping traffic in the region is forecast to increase at a greater rate with traffic in the southern part of the GBR expected to double over the 10 years to 2020.⁴A proportion of that increased traffic will transit the compulsory coastal pilotage areas and piloted traffic in the region will probably increase at a faster rate than seen since 1993.

Since July 1993, there have been five collisions and nine groundings (including the grounding of Atlantic Blue) during a coastal pilotage. All of those incidents were mainly the result of the inadequate management of the pilotage or navigation and not due to extraordinary circumstances beyond the control of the pilot or crew. None of the incidents resulted in serious pollution or loss of life and damage to the ships involved was limited (i.e. these incidents were not classified as ‘very serious casualties’⁵).

Any serious shipping incident in the GBR or Torres Strait can have potentially severe and unacceptable consequences in these environmentally sensitive areas. In 2012, a United Nations report focused the attention of the international and Australian community on risks to the GBR environment.⁶The report documented ‘extreme concern’ over increased developments, including ports and infrastructure, in and around the GBR. Recommendations included that Australia sustain and increase efforts and resources to conserve the GBR environment, and that new developments outside existing long-established major port areas not be permitted.

Coastal pilotage is a critical defence against a shipping incident about which other defences within the broader safety system to protect the GBR and Torres Strait are centred. Other measures, such as vessel traffic services and a comprehensive system of navigational aids, complement and assist with the coastal pilotage task. Coastal pilots oversee the passage of large cargo or passenger ships along the long and navigationally challenging shipping routes in areas which are prone to strong winds and tides. The ships are often constrained by their draught⁷ and the proximity of shoal waters means there is little margin for navigational error. Coastal pilots have a key role in mitigating a critical risk to Australia’s most sensitive marine environment and therefore it is essential that the service provided by this small cadre of specialist coastal navigators is as safe and effective as it can be.

ATSB investigation

The ATSB safety issue investigation into Queensland coastal pilotage included a 92 question survey of all 82 licensed coastal pilots in January 2011. The survey questions were based on confidential, de-identified, pilot-reported safety concerns supplied by AMSA, matters identified in past reviews, various aspects of safety management and other relevant issues. Collectively, the pilots’ survey responses were a principal source of evidence for the investigation.

Following the survey, 22 pilots were interviewed by the investigation team. The ATSB held meetings with all key stakeholders, including AMSA and the three private companies authorised by AMSA as ‘pilotage providers’ who assign licensed pilots to ships. The ATSB also obtained pilotage related records from AMSA and the pilotage providers. Fifteen stakeholders made submissions at the outset of the investigation.

A draft investigation report, identifying the safety issues, was prepared using the evidence collected and, in December 2011, was provided to all stakeholders for comment. Eighty-nine submissions on the draft report were received from pilots and organisational stakeholders. Additional evidence and information in the submissions was used to finalise the investigation report.

Coastal pilotage services

There are three providers of coastal pilotage services operating in direct competition with each other. The two larger pilotage providers, Australian Reef Pilots and Torres Pilots, service all of the pilotage areas and, between them, have 95 per cent of the market share. Both of these companies were formed in 1993 from the former Queensland Government regulated monopoly pilot service when economic regulation was discontinued, thus allowing competition in coastal pilotage. Hydro Pilots, the smallest provider, was established in 1996 and services only the Hydrographers Passage.

At the time of the ATSB survey, all coastal pilots were self-employed and exclusively contracted to either Australian Reef Pilots or Torres Pilots with the exception of two pilots contracted to Hydro Pilots. The three pilotage providers compete with each other for pilot bookings from ship owners or their agents. The providers assign their contractor pilots to booked ships and arrange pilot transfers using boats or helicopters.⁸ Hence, the actual pilotage service on any ship is provided by an individual contractor pilot.

Marine Orders Part 54

From 1993 onward, the regulatory framework for the safety of coastal pilotage operations has been contained in five successive issues of Marine Orders Part 54 (MO 54), regulations formed under the Commonwealth’s Navigation Act 1912 and administered by AMSA.

In 2001, issue 3 of MO 54 introduced the requirement for a pilotage provider to implement a safety management system (SMS) for its operations and areas of responsibility. A provider was defined as ‘a person who assigns or allocates a pilot’ to a ship’s transit, consistent with their existing role and functions (to manage pilot bookings, assign pilots and arrange pilot transfers). Consequently, provider SMSs pertained only to their operations, primarily assigning pilots to ships and pilot transfer services. The SMSs did not contain any specific content directly related to the actual pilotage task (e.g. standard operating procedures).

Also under MO 54 (issue 3), the responsibility for the safe conduct of a pilotage was specifically assigned to an individual pilot, consistent with the existing roles of pilots and providers. This reinforced the situation where each pilot had a unique piloting system including procedures and passage plans. While similar, no two pilots’ systems were the same. Since 2003, the adequacy of these different piloting systems, and the competency of pilots, has been assessed by their peers who are AMSA-licensed ‘check pilots’.

In 2006, issue 4 of MO 54 superseded issue 3 but largely retained the features described above. In December 2010, when the ATSB initiated this investigation, issue 4 of MO 54 was in force. Its provisions have largely shaped coastal pilotage operations until the time of the investigation and the survey in 2011 and hence, issue 4 directly relates to the subjects discussed in the investigation report.

On 1 July 2011, more than 6 months after the ATSB investigation started, issue 5 of MO 54 came into force. While issue 5 has a number of revised provisions relating to important areas such as SMSs and pilot boat standards, it still does not clearly assign the responsibility for the overall management of safety risks associated with pilotage to any organisation(s). Issue 5 was to be reviewed from 1 July 2012 (i.e. 12 months after its implementation).

The safety management of coastal pilotage differs from the modern, systems-based approach used in many Australian ports, where an SMS has been introduced to cover all safety aspects of pilotage operations. These SMSs have been implemented by the organisation responsible for the day-to-day management of pilotage in the port, i.e. a ‘pilot organisation’. Their objective is to reduce all of the identified safety risks associated with the port’s pilotage operations to as low as reasonably practicable and support pilots in the performance of their safety critical task. Consequently, the SMSs aim to provide risk-analysed, best-practice procedures, including standard passage plans for their port/pilotage areas, i.e. a ‘pilotage SMS’. The adequacy of these port pilotage SMSs is currently assessed through internal and external audits, in some cases by safety regulators, and reviews of the SMSs are regularly undertaken for continuous improvement.

However, in coastal pilotage, it is the individual pilots and check pilots, rather than the providers contracting them, who have responsibility for the safe management of pilotage operations. The providers mainly manage the bookings and logistics of pilotage services and there is no pilot organisation(s) identifying or managing all the safety risks associated with the actual pilotage task. The absence of a pilot organisation(s) defines the culture within the coastal pilotage sector, including working relationships, and impacts all pilotage related operations.

Standard passage plans

When this investigation was initiated, there were no standard passage plans or standard procedures for the various pilotages in the GBR and Torres Strait region. Hence, ship’s crews could not effectively prepare for a pilotage as the passage plan prepared by the crew in advance often had to be changed to reflect the individual plan of a pilot after he boarded. The same pilotage using a different pilot can also vary significantly. Each pilot employs different practices in the overall conduct of the pilotage and may provide different guidance, take different rest breaks during the long pilotages and have differing expectations of the crew.

In July 2011, AMSA posted an industry passage plan (IPP) model on its website to address the issue of non-standard passage plans. Issue 5 of MO 54 requires that all pilots must prepare detailed passage plans that use the IPP model and carry hard and electronic copies of the model plan. Ships can also request pilotage providers for the latest edition of the IPP or download an electronic copy via the internet.

Coastal pilot working arrangements

Coastal pilots are remunerated a set amount (depending on the pilotage area/route) for each discrete pilotage they perform, regardless of the time they are away from home on duty. They have no paid leave or other entitlements. Hence, the greater the number of pilotages performed by a pilot, the more the pilot will earn. Faster ships, higher paying pilotage routes and minimal periods between consecutive pilotages offer a better financial return for a pilot’s time. This remuneration framework has the potential to create a strong incentive to complete a pilotage quickly rather than as safely as possible. In the survey, half of the pilots asserted that financial disadvantage conflicts with the importance they aim to give to safety, largely because they are actively competing for work with other pilots contracted to the same provider.

A pilot’s fee for a pilotage is decided and set by the pilotage provider, with no input from the pilot. There is no set hourly or daily wage rate for coastal pilots (through regulation or otherwise). The majority of pilots have indicated they would prefer to be employees rather than contractors for the certainty and security of income and conditions. In general, the survey and submissions indicated a high level of discontent amongst pilots. At the time of the survey, five licensed pilots had effectively been dismissed by their provider by not being allocated work or offered a valid contract. In the 12 months following the survey, a further eight pilots left coastal pilotage for other employment and at least five others retired.

Pilot recruitment and training

Trainee pilots are recruited by the pilotage providers if they meet AMSA’s requirements for a trainee pilot licence. These requirements include qualifications as a ship’s master and recent seagoing experience. However, experience in the GBR or Torres Strait regions (local area experience) has not been a requirement since 1993, and most trainee pilots recruited after 2000 had little or no local area experience when they started.

Once issued with a trainee pilot licence, trainees fund most of their own training and receive reduced or no remuneration during that time. The providers see their role as merely providing a trainee pilot with the opportunity to complete the AMSA training program. The program is based on ‘self-learning’ by observing different pilots and generally requires a trainee to complete at least four transits of a pilotage area with a check pilot. At least one of the four transits must be fully assessed in accordance with the check pilot system.

In the absence of a pilotage SMS, including standard procedures and passage plans, a trainee pilot tends to develop a piloting system similar to but not necessarily the same as those he has observed. Initial training is not augmented with bridge simulator courses focused on coastal pilotage and there is no training in the use of electronic charting or equivalent systems.

Trainee pilots usually obtain a restricted licence in a couple of months (generally after completing a few more transits than the minimum of four). They can then pilot independently and earn an income. During the year or so that it usually takes them to obtain a full licence (without ship type or draught restrictions), new pilots gain more local area experience and develop their skills and individual piloting systems. For a new pilot with little or no previous local area experience, it is the transits undertaken in the first couple of years of piloting which provide the experience, knowledge and skill necessary for a local knowledge expert to operate confidently in a range of conditions and areas, particularly in confined passages.

Ongoing training consists of a mandatory course (usually 3 to 5 days) approved by AMSA for coastal pilot professional development once every 4 years. Both main pilotage providers pay the course fee for mandatory professional development courses for their contracted pilots while the pilots cover other costs, such as their travel and accommodation.

Pilot fatigue

The long coastal pilotages, particularly in the Inner Route, mean that pilot fatigue is a significant risk. A fatigue management plan has been implemented by AMSA based on mandatory rest periods before pilotage and between tours of duty, and minimum ‘leave’ periods. Pilots are expected to self-manage their fatigue during the actual pilotage where AMSA acknowledges that they need to rest, particularly during the long Inner Route pilotage.

The fatigue management plan does not prescribe the use of any method for predicting potential fatigue levels (best and worst case scenarios) nor is there measurement or assessment of actual levels of fatigue or the amount and quality of sleep that a pilot is able to have. Conditions during a pilotage, such as weather, traffic and the ship’s crew or equipment, may not allow the pilot to get the expected rest. In addition, a pilot’s travel and transfer time before boarding a ship have sometimes been included in the mandated rest periods, contrary to fatigue plan requirements.

The ATSB survey, pilot interviews and submissions indicated that pilot transfer services are a major source of discontent amongst most pilots because of long waiting times due to the scheduling of pilot boat or helicopter transfers and/or the condition of pilot boats.⁹ Transfers in the Torres Strait and Hydrographers Passage involve long distances and are influenced by factors such as the weather and transfer scheduling. In these areas, transfer times of 2 hours are common and, at times, can be much more. Scheduling transfers to carry more than one pilot minimises the provider’s costs but may also lead to additional waiting time for pilots. The survey suggested that travel and transfer time significantly affect the adequacy of a pilot’s rest before a pilotage.

The check pilot system

In the absence of a pilotage SMS promulgating uniform practices and procedures, AMSA’s check pilot system is relied on to assure safe pilotage standards (instead of a holistic SMS that includes a check pilot system). The AMSA system combines a pilot competency assessment, the usual function of a check pilot system, with an audit of the individual pilot’s system of pilotage against certain AMSA-defined criteria. With so many different piloting systems, including the check pilot’s own system, it is difficult for a check pilot to make objective and consistent assessments. Furthermore, AMSA’s guidance states that an assessment is only the check pilot’s opinion, not an indication of the assessed pilot’s competence or capability.

Although check pilots are effectively acting as AMSA’s delegates in the process, they are remunerated by the provider to assess contracted pilots. Assessing a pilot as ‘overall unsatisfactory’ (i.e. fail) can severely affect the failed pilot’s livelihood and disrupt the provider’s operations.

In case of an overall unsatisfactory assessment of an individual pilot, AMSA has a formal process to review the check pilot’s assessment. However, in the 550 check pilot assessments conducted until 2011, an AMSA review had never taken place because no pilot had been assessed as ‘overall unsatisfactory’. Analysis of these assessments by the ATSB showed that there can be a significant number of unsatisfactory findings with respect to different criteria without an ‘overall unsatisfactory’ rating. Furthermore, while a wealth of information has been gathered through the assessments, it has not been used by anyone to continuously improve pilotage practices or analyse the training needs of coastal pilots.

Risk event and incident reporting

Reporting of risk events, near misses and incidents is critical to understanding and mitigating the risks to the safety of navigation in the GBR and Torres Strait. The survey of pilots showed that the number of grounding or collision risk events which they claimed to have experienced was about 10 times the number of reports of such events in records held by AMSA and the providers. The main reasons given by pilots for under-reporting risk events are personal disadvantage, lack of corrective action and financial or organisational pressure; all these reasons largely related to their providers.

Another concern is the claimed incidence of collision risk events between piloted ships. The survey indicated that such high risk events occurred about once a month and usually involved the pilots of competing pilotage providers. A number of the pilots’ comments indicated that a lack of understanding each other’s intentions and/or communication was a factor in these cases due to an underlying reluctance to contact a pilot from a competing provider. This may be attributed to the fact that some pilots consider other pilots, including those contracted to their own provider, as competitors.

Great Barrier Reef and Torres Strait Vessel Traffic Service (REEFVTS)

The comments of pilots (in the survey, at interview and in submission) indicated that, in general, they were not aware of the capability and limitations of REEFVTS to monitor shipping and issue warnings to help avoid a serious incident. The service’s potential to support pilotage can be fully realised only when pilots better understand its systems and by improvements to the automated warning systems to ensure that they are optimally set up for the early detection of hazardous situations in all areas, particularly those areas in the Inner Route where pilots usually leave the bridge to rest.

Coastal pilotage in a system of safety

In recognition of the potentially severe and unacceptable environmental consequences of a serious shipping incident in the Torres Strait or GBR, Australia has a number of defences in the broader system of safety to protect the region. Coastal pilotage is the final layer in defences that include REEFVTS, enhanced ship routing and modern navigational aids, through which AMSA has enhanced the safety of navigation in the area.

However, while coastal pilotage is a critical defence, its safety management has lacked a pilot organisation responsible for managing all the risks associated with pilotage operations on a day-to-day basis. This safety issue is central to other issues and impacts all pilotage operations and related activities. The defence that a pilot provides against an incident can be much more effective when supported by a systems-based approach to managing risk through a pilot organisation’s SMS.

In the absence of organisational responsibility for the actual task of pilotage, the organisational influences of current pilotage providers affect all their business activities related to pilotage services. The contractual working arrangements of pilots and generally poor working relationships with their providers are a result of these organisational influences. A particular feature that promotes competition between pilots is their ‘per job’ (instead of time based) system of remuneration.

The sole objective of compulsory coastal pilotage is to provide assurance that the risk of a shipping accident in the GBR and Torres Strait PSSAs is reduced to as low as reasonably practicable or ALARP. This can only be effectively achieved by a pilot organisation(s) that actively and systematically manages all foreseeable safety risks in providing pilotage services with an appropriate level of guidance and oversight by the safety regulator. Further, the implementation of an effective safety management system in coastal pilotage can only be achieved by an organisation which promotes and fosters an effective organisational and industry safety culture with a business imperative to provide the safest possible coastal pilotage service.

Submissions to the draft investigation report

Eighty-nine stakeholders, including 71 pilots made submissions on the draft investigation report. Fifty-one pilots indicated support for the draft report/findings, two pilots opposed it and 18 submitted no comment without indicating whether or not they agreed with the report/findings. The submission from AMSA included safety action to address the safety issues identified in the report. The pilotage providers were opposed to the draft report and its findings and, effectively, did not propose any safety action. A number of stakeholders were positive that safety issues had been identified, a few made no significant comment and one organisation opposed some of the investigation’s findings.

The submissions served to highlight that addressing any safety issues in this fragmented pilotage sector is complicated.

ATSB investigation findings

The following summarise the safety issues identified by the ATSB:

• Successive issues of MO 54 have not assigned the responsibility for the overall management of the safety risks associated with pilotage operations, including the task of pilotage itself, to pilotage providers or any other organisation(s). Therefore, no organisation has taken on the role of managing risk during pilotage on a day-to-day basis and developed a safety management system that addresses safety risks associated with all operations, including those during pilotage. Instead, each coastal pilot has his own piloting system and passage plans, and ship crews could not always obtain a passage plan before the pilot boarded. These multiple piloting systems increase the potential for less than optimal pilotage practices and are outside the scope of AMSA audits of provider safety management systems. The individual systems of pilots are only assessed by their peers under AMSA’s delegated check pilot system.

• The effectiveness of the check pilot system is limited by the absence of standards against which to make objective assessments. The system is impacted by conflicts of interest as a result of complex working relationships and check pilots assessing peers on behalf of AMSA where an ‘overall unsatisfactory’ assessment (i.e. fail) could disadvantage the assessed pilot, the check pilot or the pilotage provider remunerating him. In addition, there is no formal review of assessments to help achieve continuous improvement and inform corrective action, unless a pilot is assessed as ‘overall unsatisfactory’ (which has never occurred).

• The effectiveness of the pilot training program is limited by the absence of a pilotage safety management system, electronic charting systems training and the use of bridge simulators to augment shipboard transits for initial training. The mainly self-funded trainee pilots are also motivated to complete the training program quickly so they can pilot independently and earn to their potential. New pilots with little or no local area experience undertaking the program probably gain the experience, knowledge and skill appropriate for a local knowledge expert to operate in a range of conditions only after a couple of years of piloting.
• The effectiveness of the fatigue management plan depends mainly on a self-managed approach and individual pilots face potentially conflicting priorities related to the impact on their earnings. The plan relies on the self-reporting of rest periods and evidence indicates that pilot travel and transfer times have sometimes been included (incorrectly) in rest periods. During long Inner Route pilotages, pilots may not be able to manage their anticipated rest adequately due to constraints imposed by weather, traffic or other circumstances. The plan’s effectiveness is further limited as it does not take into account variations in sleep patterns due to irregular working hours, the actual sleep a pilot achieves and the effect of multiple consecutive pilotages.

• The apparent level of under-reporting of risk events, including near miss groundings and collisions, means valuable opportunities for improved risk management are being lost because many pilots believe they may be personally disadvantaged by reporting. Ad hoc, informal reports made by pilots in the past were not recorded or analysed by AMSA.

• The potential for REEFVTS to support pilotage is under-utilised because many pilots are not fully aware of the service’s ship traffic monitoring capability and limitations, and its value as an additional ‘bridge resource’. Safety enhancements can also be achieved by focusing on improvements to the service’s automated warning systems to ensure that they are optimally set up for the early detection of hazardous situations in all areas, particularly those areas where pilots usually leave the bridge to rest.

The ATSB also found that, since the safety of pilotage operations is not the responsibility or the highest priority of pilotage providers, this is reflected in organisational influences that affect all their business activities related to pilotage services and pilots. The providers mainly operate a pilot booking and transfer service. The generally poor working relationships that pilots have with their providers are related to their contractual working arrangements and the ‘per job’ basis of remunerating pilots, which also promote competition between pilots. The areas impacted by these factors include fatigue management, the check pilot system and the incidence of risk events and their reporting.

Another key finding of the investigation is that the effectiveness of the broader system of safety protecting the GBR and Torres Strait PSSAs has been enhanced through a number of measures, including compulsory coastal pilotage, REEFVTS, ship routing and navigational aids. These are all measures attributable to AMSA’s action with the assistance of other agencies such as Maritime Safety Queensland, the state’s maritime regulator.

Safety action

Action has been taken or proposed by AMSA to address the safety issues identified. In addition to publishing the industry passage plan (IPP) model, significant action includes initiating the development of standard operating procedures for the task of conducting a pilotage. Following AMSA audits of the safety management systems of pilotage providers in January 2012, each provider has undertaken to develop such standard procedures for the pilots that they assign to ships.

In addition, a review of the provisions of MO 54, issue 5 by AMSA (from 1 July 2012) will seek to more clearly assign and articulate the responsibility of a pilotage provider for the overall management of safety risks associated with pilotage operations. In this respect, the Navigation Act 2012 (received the Royal Assent on 13 September 2012) includes a significantly revised, much broader definition for a pilotage provider that is consistent with an organisation that can be assigned responsibility for the overall safety management of pilotage under MO 54.

In 2012, AMSA initiated reviews of the check pilot system and the pilot training program which should complement improvements expected through passage plans based on the IPP model and standard pilotage procedures. Workshops that focus on pilot training have been hosted by AMSA, a pilotage training steering committee has been formed, and AMSA is considering the use of bridge simulators and the independence of check pilots.

Improvements to pilot fatigue management being considered by AMSA include going beyond straight rostering and hours on/off, and encouraging providers to develop fatigue management plans. In addition, AMSA will investigate the merits of a requirement for two pilots to conduct pilotages in the Inner Route.

To improve risk event reporting, AMSA implemented an on-line reporting system in 2012 and is considering opportunities to encourage pilot feedback and reporting through an increasing use of electronic exchange of information. The REEFVTS annual review process and invigorated stakeholder interaction will be used to enhance the service in areas identified by the ATSB investigation.

The ATSB has issued three recommendations to AMSA to fully address the central safety issue related to assigning responsibility for the overall safety management of pilotage to an organisation(s), and the issues concerning pilot training and fatigue management. Action to address the central issue is essential and will impact on the effectiveness of all other safety action taken.

The ATSB has also issued two recommendations to each of the three pilotage providers to take safety action in relation to fatigue management and risk event reporting that will support and facilitate the action taken by AMSA to address those safety issues.

Abstract

At about 0153 on 9 December 2010 an Up (northbound) loaded grain train travelling from Barellan, New South Wales (NSW) to Maldon, NSW and numbered as 3234N, collided at low speed with the rear of another Up (northbound) loaded grain train, numbered as 8922N, on the Down Main line at Yass Junction, NSW. The intended operation had been for both trains to wait, one behind the other, on the Down Main line at Yass Junction to enable a third northbound goods train, 4MB2, to pass them both on the adjacent Up Main line.

Train 3234N proceeded as intended past a signal which indicated that the route was not clear and that the train should proceed at caution. Train 3234N braked as soon as train 8922N was sighted but a collision nevertheless ensued. The investigation highlighted that the definition of restricted speed applying in these sorts of cases requires considerable judgement on the part of train drivers.