Executive summary
At 1303 on Wednesday 25 February 2004 an empty Endeavour passenger train D743 was placed on a collision course with a stationary loaded coal train LD166 at Sandgate. The crew of train D743 realised that number 157 points were in the wrong position and made an emergency brake application. Train D743 stopped about 75 metres short of train LD166.
Sandgate is located on the main northern railway corridor between Sydney and Brisbane about 170 kilometres from Central Railway Station, Sydney. The rail corridor contains four standard gauge tracks for non electric powered trains.
Train D743 was a relief train from Newcastle provided to render assistance to passenger train 604 which had broken down on the Up Main line at Beresfield station platform. The following two passenger trains 736 and 738 on the Up Main line were diverted to the Up Coal Road at Thornton to bypass train 604. Trains 736 and 738 were diverted back onto the Up Main line at Sandgate through number 157 points.
The wrong direction movement of train D743 via the Up Main line was controlled by a Special Proceed Authority (SPA) issued by the train controller at Broadmeadow and Yard Working authorised by the signaller. Train movements in the Sandgate area are controlled by a signaller located at Hanbury Junction signal box, 2.575 kilometres southeast from Sandgate station. Normal signal protection (unidirectional) could not be used for the wrong direction movement. The movement was manually controlled by the signaller. In addition to delayed trains and increased traffic movements, there were a number of factors competing for the signaller's attention.
The investigation concluded that the incident occurred because the signaller did not check the intended route for train D743 thoroughly or apply blocking facilities to the greatest effect to protect the route. Number 157 points were in the reverse position after the passage of train 738. Blocking facilities are physical devices used as memory aids for the signaller to prevent inappropriate issue of Proceed Authorities, or signalling or point equipment operation.