Safety summary

What happened

At about 1116 on 5 May 2010 a collision occurred between an XPT passenger train and a track-mounted excavator near Newbridge, New South Wales. The operator of the track-mounted excavator was fatally injured. During the course of the investigation a similar incident occurred near Wards River, New South Wales (17 March 2011), where two work groups had to hurriedly vacate their on-track worksite due to an approaching train (there were no injuries). Both incidents occurred despite the fact that the work groups had been authorised, under a Track Occupancy Authority (TOA), to occupy and work on the track.

What the ATSB found

The ATSB established that, for the accident at Newbridge, a TOA was an appropriate method of authorising the work to be performed. However, a combination of individual actions and systemic issues contributed to the collision. When requesting the TOA, neither the Protection Officer (PO) nor the Network Control Officer (NCO) positively identified the location and type of worksite. Their actions were influenced by a deficiency in the TOA form, in that no provision was provided to record this critical information. Consequently, both the PO and NCO incorrectly concluded that the train had already passed beyond the limits of the worksite. In addition, the workers accessed the danger zone before additional site protection measures (detonators and flags) had been put in place. The ATSB also found that the workers were relatively inexperienced and that their training had not specifically discussed the hazards and protections that were relevant when working under a TOA.

The scenario for the Wards River incident was similar in that the track access point for the work was about 16 km into the section defined by the limits of the proposed TOA. In this case, the location of the work (Wards River) was communicated at about 0735 when the TOA was first requested. Due to operational reasons the TOA was not issued until 0840. Similar to the Newbridge event the PO did not clearly identify the location of the worksite and the NCO did not ensure the train had passed beyond the worksite or track access point.

What has been done as a result

As a result of the incident at Newbridge on 5 May 2010, the Australian Rail Track Corporation (ARTC) took action to reinforce the rules and procedures associated with the issuing of TOAs. The ARTC also implemented the use of a revised TOA form that provides for the recording of critical information regarding the location and type of worksite. It is likely that implementation of the new form should reduce the risk of similar incidents.

Safety message

It is essential that information critical to the safe implementation of a TOA be clearly communicated between the Protection Officer and the Network Control Officer.

It is also essential that workers do not access the track until all levels of worksite protection have been fully implemented.

Fatal rail accident

On 8 June 2012 a New South Wales Coroner released findings into a 2010 fatal rail accident near Newbridge, NSW. The findings highlight safety concerns that require review by the rail industry in relation to the safety issues raised by the ATSB in its report released on 20 April 2012. During the course of its investigation, where safety issues were identified, these were communicated to interested parties for safety action.

Those issues cover:

• Deficient TOA form
• Minimum training levels
• Inconsistent TOA procedure
• Use of non-authorised forms
• Elevated risk due to fatigue

Circumstances of the accident

At about 11116 on 5 May 2010 collision occurred between a scheduled XPT passenger train and a track-mounted excavator near Newbridge, New South Wales. The operator of the excavator was fatally injured. The ATSB Investigation established that collision had occurred even though the work group using the excavator was authorised to be on the track under a Track Occupancy Authority (TOA) and that work had commenced prior to site protection measures being put in place. The ATSB also found that the members of work group were relatively inexperienced and that their training had not specifically discussed the relevant hazards and protections when working under a TOA.

Safety issues

The ATSB found the following safety issues as part of the investigation. The Coroner's findings were broadly consistent with the ATSB's findings:

1. Deficient TOA

During the Investigation the ATSB found that the TOA form in use at the time of the accident was deficient as there was no provision to record critical information regarding the location and type of worksite.

Consequently, the Protection Officer and Network Control Officer incorrectly conclude that the train had passed beyond the limits of the worksite. The Coroner found that 'the TOA form was deficient and that there was a miscommunication between the Protection Officer and the Network Control Officer. The Coroner also found that there was a weak management system within the Network Control Centre.

Prior to the release of the ATSB report the Australian Rail Track Corporation (ARTC) made changes to their rules and procedures which included changes to the TOA to ensure there was provision to record critical information. The ATSB assessed this action as adequately addressing the safety issue.

2. Minimum training levels

During the Investigation the ATSB found that the track workers were not provided with sufficient competency based or structured on the job training in relation the hazards and required protections for working under the TOA at Newbridge.

Prior to the release of the ATSB report the ARTC advised that it had reinforced with Protection Officers its requirements for Work Method Statement TRA-001 (Access to and working on or about track). The ARTC's internal audit program had also been redirected to safeworking with a focus on reviewing safeworking documentation for compliance with ARTC Network Rules and Procedures. The ATSB was satisfied that the ARTC had initiated action to address this safety issue.

The Coroner found that the supervision and training of the track workers was inadequate, and that some work practices had become sloppy and which were not being sufficiently overseen. The Coroner also found that ARTC rules and protocols were not adhered to by the track working crew. In particular two of the work crew commenced work without being instructed to do so and without regulation protection devices being placed.

3. Inconsistent TOA procedure

During the Investigation the ATSB found that ARTC procedure ANPR-701 (Using a Track Occupancy Authority) was inconsistent in that it did not allow for a scenario that would otherwise be permitted, and intended, under rule ANWT-304 (Track Occupancy Authority).

Prior to the release of the ATSB report the ARTC advised that it had trained its employees in this particular scenario and will review the procedure to ensure that it is consistent with the training and the TOA. The ATSB was satisfied that the ARTC had initiated action to address this safety issue.

4. Use of non-authorised forms

During the Investigation the ATSB found that some ARTC maintenance contractors were using non-authorised reproductions of the ARTC's TOA form.

Prior to the release of the ATSB report the ARTC conducted extensive briefings with all employees and contractors to explain changes to the ARTC TOA that took effect in November 2011. The ARTC made clear that only the new form was to be used and provided books of forms to employees and contractors. The ATSB was satisfied that the action taken would adequately address this safety issue.

5. Elevated risk due to fatigue

During the Investigation the ATSB found that it was possible that at times throughout the Network Control Officer's roster, fatigue levels were conducive to performance degradation.

Prior to the release of the ATSB report the ARTC advised that it is applying continuous improvement processes to fatigue as it does with all safety related matters. Recent activities that ARTC completed in relation to fatigue management included:

• Revising ARTC's fatigue policy and procedure to include more detailed hours of work guidelines, and information to support managers manage potential fatigue related matters,
• Scheduling managers to attend a supervisors fatigue management training course. This course trains managers in identifying and controlling possible fatigue related risks. This training supplements existing fatigue management training for all employees, and
• Rolling out an awareness campaign that has included sending a letter and pamphlet about rest and sleep directly to employee's homes, posters for display at all worksites, and a new safety.

The ATSB noted that ARTC mangers develop rosters in accordance with the ARTC policies and procedures. Considering the ARTC's advice that the fatigue policy and procedure is to be reviewed along with additional training and awareness programs, the ATSB was satisfied that the Australian Rail Track Corporation has initiated action to address this safety issue.

The Coroner concluded that there was insufficient evidence that the miscommunication in relation to the TOA (see Safety Issue 1 above) was the result of fatigue or other work conditions.

The ATSB emphasises that it is essential that information critical to the safe implementation of a TOA be clearly communicated between the PO and the NCO. The ATSB also emphasises that it is also essential that workers do not access the track until all levels or worksite protection have been fully implemented.

ATSB investigations and coronial inquiries

Inquests are separate to ATSB investigations. There are differences in the ATSB's and the Coroner's conclusions with respect to this accident. However, as outlined above The Coroner's findings were broadly consistent with those of the ATSB.

The ATSB's report can be downloaded by clicking on the PDF link to the top right of this page. Feedback can be provided via the link provided.

The Coroner's report can be obtained from the Coroner's Court of New South Wales, contact details are available via the Coroner's Court of NSW website.

Executive summary

At 1705 on 3 April 2010, the Chinese registered bulk carrier Shen Neng 1 grounded on Douglas Shoal, about 50 miles north of the entrance to the port of Gladstone, Queensland. The ship's hull was seriously damaged by the grounding, with the engine room and six water ballast and fuel oil tanks being breached, resulting in a small amount of pollution.

The ATSB investigation found that the grounding occurred because the chief mate did not alter the ship's course at the designated course alteration position. His monitoring of the ship's position was ineffective and his actions were affected by fatigue.

The ATSB identified four safety issues during the investigation: there was no effective fatigue management system in place to ensure that the bridge watchkeepers were fit to stand a navigational watch after they had supervised the loading of a cargo of coal in Gladstone; there was insufficient guidance in relation to the proper use of passage plans, including electronic route plans, in the ship's safety management system; there were no visual cues to warn either the chief mate or the seaman on lookout duty, as to the underwater dangers directly ahead of the ship; and, at the time of the grounding, the protections afforded by the requirement for compulsory pilotage and active monitoring of ships by REEFVTS, were not in place in the sea area off Gladstone.

The ATSB has issued two safety recommendations to Shen Neng 1's management company regarding the safety issues associated with fatigue management and passage planning and acknowledges the safety action taken by the Australian Maritime Safety Authority in relation to the extension of REEFVTS coverage to include the waters off Gladstone.

At 0826 Western Standard Time on 28 March 2010, a Piper Aircraft Corp. PA‑30 Twin Comanche aircraft, registered VH‑KDS, departed Jandakot Airport, Western Australia for a private flight under the visual flight rules (VFR). On board were two qualified pilots, both of whom were endorsed on the aircraft type. No details of the flight were submitted to Air Traffic Services nor left with any other person. At 1815, following the failure of the aircraft to return to Jandakot, the Australian Rescue Coordination Centre was notified, and a search was initiated to locate the aircraft.

Following examination of radar data, the aircraft was located the following morning by the crew of a search and rescue (SAR) helicopter. Upon landing, the helicopter crew established that the two occupants had sustained fatal injuries.

Analysis of data recorded by onboard Global Positioning System equipment identified that while maintaining about 3,500 ft above mean sea level, the speed of the aircraft steadily decreased followed by a steep descent that continued to ground level.

Examination of the aircraft identified that the propeller of the left engine was feathered prior to impact; however, no evidence of a defect or other circumstance that would have necessitated feathering of the propeller was identified.

The investigation identified that the circumstances of the accident were consistent with a loss of control due to sufficient airspeed not being maintained. In addition, the investigation found that the lack of flight details available for the search and rescue authorities and the non-activation of the portable emergency locator transmitter hampered the SAR response.

On 22 March 2010, an Air North Embraer S.A. EMB-120ER Brasilia aircraft (EMB-120), registration VH-ANB, crashed moments after take-off from runway 29 at Darwin Airport, Northern Territory, fatally injuring both pilots. The flight was for the purpose of revalidating the command instrument rating of the pilot under check and was under the command of a training and checking captain, who occupied the copilot's seat. The take-off included a simulated engine failure.

Data from the aircraft's flight recorders was used to establish the circumstances leading to the accident and showed that the pilot in command (PIC) retarded the left power lever to flight idle to simulate an engine failure. That introduced a simultaneous failure of the left engine and propeller autofeathering system.

The increased drag from the 'windmilling' propeller increased the control forces required to maintain the aircraft's flightpath. The pilot under check allowed the speed to decrease and the aircraft to bank toward the inoperative engine. Additionally, he increased power on the right engine, and engaged the yaw damper in an attempt to stabilise the aircraft's flight. Those actions increased his workload and made control of the aircraft more difficult. The PIC did not restore power to the left engine to discontinue the manoeuvre. The few seconds available before the aircraft became uncontrollable were insufficient to allow 'trouble shooting' and deliberation before resolving the situation.

Shortly after the accident, an EMB-120 simulator and its staff were approved to undertake the operator's training requirements. In response, the operator transitioned the majority of its EMB-120 proficiency checking, including asymmetric flight sequences, to ground‑based training at that facility.

No organisational or systemic issues that might adversely affect the future safety of aviation operations were identified. However, the occurrence provides a timely reminder of the risks associated with in-flight asymmetric training and the importance of the work being carried out by the Civil Aviation Safety Authority to mandate the use of simulators for non-normal flying training and proficiency checks in larger aircraft. In addition, the importance of appropriate operator procedures, and pilot awareness of the potential hazards were reinforced as risk mitigators where the only option was in-flight asymmetric training and checking.

Animation

A computer graphics animation of the Flight Data Recorder data was produced.  The animation covered a 2-minute period commencing with the aircraft taxiing onto the runway and continuing until the end of recording.