Rail safety investigations & reports

Runaway of grain train 8960, Dombarton to Unanderra, NSW, on 22 April 2017

Investigation number:
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 22 April 2017, Qube Logistics (Qube) grain train 8960, travelling from Bogan Gate to Inner Harbour, Port Kembla, New South Wales, ranaway as it descended the Illawarra Mountain between Dombarton and Unanderra. After passing Dombarton, the driver realised he had lost control of the train. At 1248, the driver contacted the ARTC network controller who, in conjunction with Sydney Trains’ train controller, cleared a pathway for 8960. The maximum allowable speed for the Dombarton to Unanderra section was 30 km/h; however, the train reached a maximum speed of 107 km/h. At 1255, the train stopped, assisted by a shallower gradient near Unanderra station. There were no injuries or damage because of the incident.

What the ATSB found

The ATSB’s investigation found that as train 8960 was operated down the Illawarra Mountain, the train management actions by the driver did not conform to train handling procedures. After passing Summit Tank, the driver made ten brake applications and in doing so did not allow the train’s pneumatic brake system to fully recharge. This resulted in a loss of necessary braking capability to be able to control the train’s speed on the steep continuous descent. The incident was further compounded when the driver’s actions caused the locomotive’s dynamic braking system to be rendered inoperative, further reducing control of the train.

The braking system was operating within specification and were loaded below the maximum allowable payload. However, the train was loaded by approximately 10% more than that recorded on the train’s consist record. It is probable that the additional mass placed an extra load on the braking system and affected the handling characteristics of the train.

After the incident, the train controller in Sydney directed the driver of train 8690 to move the train from the rail network to Inner Harbour Terminal without any formal inspection following the runaway event. The Pacific National yard train controller in Inner Harbour did not alert ground personnel of the emergency event or of a runaway train being directed into their terminal.

What's been done as a result

Immediately following the incident, Qube withdrew the QBX locomotives and CGSY wagons from this route pending testing and inspections. They have since been cleared to return to operate on this route. Qube also changed the requirements for competency assessment on the Moss Vale to Unanderra section, from a single initial assessment to every six months. If a train driver has not been rostered over the corridor within six months he or she must be reassessed on this route. Qube also implemented other more stringent requirements for the training of drivers and weekly auditing of train operations between Moss Vale and Inner Harbour.

A review between the various rail infrastructure managers was conducted regarding the plans and procedures enacted in emergency events, and the decision-making process to move trains from the rail network to Inner Harbour.

Safety message

In order to minimise the risk of runaway events, freight operators should ensure that train drivers receive regular training and competency assessment for steep continuous gradient routes. The standards that apply to these routes should ensure that the locomotive and wagon braking ratios are suitable for the terrain the train will encounter on its route. Contingency plans and procedures to accommodate runaway trains in this area should be continually reviewed and tested by rail infrastructure managers.

Download final report
[Download  PDF: 2.1MB]

The occurrence


Safety analysis


Safety issues and actions

Sources and submissions

Safety Issue

Go to RO-2017-001-SI-01 -

Loading of train

The train was loaded by approximately 10 per cent more than that recorded on the consist, it is probable that the additional mass placed an extra load on the braking system and affected the handling characteristics of the train.

Safety issue details
Issue number: RO-2017-001-SI-01
Who it affects: All owners and operators of freight wagons
Status: Adequately addressed
General details
Date: 22 April 2017   Investigation status: Completed  
Time: 1248 AEST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Dombarton   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 05 December 2018   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Australian Rail Track Corp (ARTC)  
Train operator Qube Logistics  
Train registration 8960  
Type of operation Freight  
Sector Freight  
Damage to train Nil  
Departure point Goulburn, NSW  
Destination Inner Harbour, NSW  
Last update 03 April 2020