Rail safety investigations & reports

Collision with floodwater involving freight train 6792, Little Banyan Creek, Queensland, on 7 March 2018

Investigation number:
RO-2018-007
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

At 0152 on 7 March 2018, freight train 6792, operated by Aurizon, departed Cairns, Queensland, for a journey on Queensland Rail’s North Coast Line. A condition affecting the network (CAN) due to wet weather had been declared, and the train crew were required to operate at controlled speed for a significant part of the journey, which meant they were to be able to stop short of an obstruction within half the distance of clear line that was visible ahead.

At 0612, the train rounded the curve prior to the Little Banyan Creek rail bridge, which was under 0.6 m of flowing water. With a sighting distance of about 60 m to the bridge, the train’s speed (50 km/h) was significantly in excess of the controlled speed, and the train entered the floodwater. The train crew were not injured, but there was some damage to the train’s rolling stock, caused by immersion in water.

What the ATSB found

The Little Banyan Creek weather monitoring station’s water level sensor had been out of service for 57 days, and therefore no flood alarm was provided to network control and passed on to the train crew. Further, although there was a closed circuit television camera (CCTV) at the location to enable monitoring of water levels, the illuminator to enable effective operation at night had been out of service for 14 days. Queensland Rail (QR) also did not have an effective means of ensuring that, during situations such as a CAN, network control personnel were aware of the relevant weather monitoring systems that were unserviceable. In addition, QR did not have procedures that required network control personnel to actively search for information about track conditions ahead of a train during situations when conditions had the realistic potential to have deteriorated since the last patrol or train had run over the relevant sections.

The ATSB also found that QR did not have any restrictions on the distance or time that controlled speed could be used as a risk control for safe train operation in situations such as a CAN. The effectiveness of controlled speed has the significant potential to deteriorate over extended time periods due to its effect on driver workload, vigilance, fatigue and risk perception. In addition, Aurizon’s procedures and guidance for two-driver operation during situations such as a CAN did not facilitate the effective sharing of duties and teamwork to minimise the potential effects of degraded conditions on driver workload and fatigue.

What's been done as a result

Following the occurrence, QR improved its processes for ensuring the reliability of weather monitoring systems, and its procedures for ensuring network control personnel were aware of any faults. QR also developed new procedures and training for network control personnel for managing a CAN, including for proactively monitoring conditions on the network. In addition, QR is undertaking further work to guide the use and conditions around controlled speed and restricted speed, and Aurizon is undertaking further work to review its procedures for the management of workload in two-driver operations during a CAN.

Safety message

This occurrence highlights the importance of having serviceable weather monitoring stations at known flooding locations on a rail network, especially during the tropical wet season, and ensuring that if these systems are not functioning then all relevant parties are aware of the problem.

This occurrence also highlights the importance of effective communication between all relevant parties during a condition affecting the network. In particular, train controllers need to ensure that all relevant information associated with the conditions is passed on to train crews and track maintenance personnel so that they can effectively perform their roles.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issues

Go to RO-2018-007-SI-01 - Go to RO-2018-007-SI-02 - Go to RO-2018-007-SI-03 - Go to RO-2018-007-SI-04 -

Advice of weather monitoring station serviceability

Queensland Rail did not have an effective means of ensuring that, during situations such as a condition affecting the network (CAN), network control personnel were aware of the relevant weather monitoring systems that were unserviceable.

Safety issue details
Issue number: RO-2018-007-SI-01
Who it affects: Network control
Status: Closed – Adequately addressed

Procedures for actively monitoring conditions ahead of a train

Queensland Rail did not have procedures that required network control personnel to actively search for information about track conditions ahead of a train during situations such as a condition affecting the network (CAN), when conditions had the realistic potential to have deteriorated since the last patrol or train had run over the relevant sections.

Safety issue details
Issue number: RO-2018-007-SI-02
Who it affects: Network control
Status: Closed – Adequately addressed

Application of a controlled speed requirement by network control

Queensland Rail did not have any restrictions on the distance or time that controlled speed could be used as a risk control for safe train operation in situations such as a condition affecting the network (CAN). The effectiveness of controlled speed has the significant potential to deteriorate over extended time periods due to its effect on driver workload, vigilance, fatigue and risk perception.

Safety issue details
Issue number: RO-2018-007-SI-03
Who it affects: Network control
Status: Open – Safety action pending

Procedures for sharing workload in two-driver operation

Aurizon’s procedures and guidance for two-driver operation during situations such as a condition affecting the network (CAN) did not facilitate the effective sharing of duties and teamwork to minimise the potential effects of degraded conditions on driver workload and fatigue.

Safety issue details
Issue number: RO-2018-007-SI-04
Who it affects: The operator’s train crew
Status: Open – Safety action pending
General details
Date: 07 March 2018   Investigation status: Completed  
Time: 0615 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Little Banyan Creek, Tully   Investigation phase: Final report: Dissemination  
State: Queensland    
Release date: 30 June 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Queensland  
Train operator Aurizon  
Train registration 6792  
Type of operation Freight  
Sector Freight  
Damage to train Minor  
Departure point Portsmith, Queensland  
Destination Acacia Ridge, Queensland  
Last update 30 June 2020