Rail safety investigations & reports

Dewirement involving freight train YC77, Cooroy, Queensland, on 18 August 2018

Investigation number:
RO-2018-011
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 2.56MB]
 

What happened

On 18 August 2018, intermodal freight train YC77, operated by Aurizon, was en route from the Acacia Ridge Intermodal Terminal in Brisbane, Queensland. The train was powered by a diesel electric locomotive and one of its wagons contained a stack of three empty flat racks. During transit, the collapsible, rear end wall of the top flat rack extended upwards. This end wall contacted the Elm Street overpass on approach to Cooroy, and pulled down the high voltage overhead line equipment (OHLE). As a consequence, 1.3 km of OHLE was pulled down.

What the ATSB found

The ATSB found that personnel at the Acacia Ridge terminal did not check the collapsible end walls of the flat racks were secured on arrival at the terminal and after the flat racks were loaded onto YC77. In addition, Aurizon, did not have an effective system in place for ensuring personnel required to check the securing of unusual loads (such as empty flat racks) prior to departure had sufficient knowledge of their responsibilities, and had ready access to relevant procedures, guidance and checklists.

On multiple occasions following the dewirement, train crew accessed the exclusion zone associated with the close proximity of the extended end wall of the flat rack to the OHLE, prior to the wires being isolated and earthed on site. Network control centre personnel did not advise train crew of the status of the OHLE during the emergency response period, and Queensland Rail (QR) did not have an effective process in place to ensure that safety-critical actions were co-ordinated and completed when multiple network control officers were involved in responding to an OHLE emergency.

The ATSB also found that following the dewirement the driver and network control officer (NCO) did not follow required protocols for driver only operations (DOO) prior to the driver leaving the locomotive cabin, and Aurizon did not provide drivers with ready access to QR’s procedures for DOO and OHLE emergencies when they were operating on the QR network.

What's been done as a result

Aurizon has updated processes and checklists in relation to flat racks, with further theoretical training undertaken for loading personnel at Acacia Ridge in relation to securing requirements. In addition, Aurizon is currently undertaking a program to increase mobility of access to its safety management system (including relevant procedures and checklists). For driver only operations, Aurizon has commenced drafting a procedure for use on its own network, with a checklist for emergencies affixed to 2800 class locomotives that operate on the North Coast Line, at sign-on locations and attached to train lists.

QR has mandated the use of the network control officer (NCO) checklist for OHLE emergencies, and is currently reviewing related aspects of its emergency response procedures. In addition, QR have provided further training to both NCOs and train crew in relation to identifying objects in close proximity to OHLE and applicable exclusion zones. NCOs have also undertaken DOO emergency procedure refresher training.

Safety message

This occurrence has highlighted the importance of having checklists for rarely conducted tasks and emergency response tasks in the rail environment, and ensuring these checklists are readily available and used by operational personnel. This includes checklists for loading and securing personnel, rail traffic crew and network controllers.

Download final report
[Download  PDF: 2.56MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Train details

Sources and submissions

Appendices

Safety Issues

Go to RO-2018-011-SI-01 - Go to RO-2018-011-SI-02 - Go to RO-2018-011-SI-03 -

Unusual loads responsibilities and guidance material

Aurizon did not have an effective system in place for ensuring personnel required to check the securing of unusual loads (such as empty flat racks) prior to departure had sufficient knowledge of their responsibilities, and had ready access to relevant procedures, guidance and checklists.

Safety issue details
Issue number: RO-2018-011-SI-01
Status: Open – Safety action pending

Access to QR procedures and existence of Aurizon documents

Aurizon did not provide drivers with ready access to Queensland Rail’s procedures for driver only operations and overhead line equipment emergencies when they were operating on the Queensland Rail network. In addition, Aurizon did not have procedures for driver only operations that applied to its own network.

Safety issue details
Issue number: RO-2018-011-SI-02
Status: Open – Safety action pending

Process for co-ordinating network control activities during an emergency response

Queensland Rail did not have an effective process in place to ensure that safety-critical actions were co-ordinated and completed when multiple network control officers were involved in responding to an overhead line equipment emergency.  

Safety issue details
Issue number: RO-2018-011-SI-03
Status: Open – Safety action pending
General details
Date: 18 August 2018   Investigation status: Completed  
Time: 2102 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Elm Street overbridge on southern approach to Cooroy yard, North Coast Line   Investigation phase: Final report: Dissemination  
State: Queensland    
Release date: 01 September 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Queensland Rail  
Train operator Aurizon  
Train registration YC77  
Type of operation Intermodal freight  
Sector Freight  
Damage to train Minor  
Departure point Acacia Ridge (Brisbane), Queensland  
Destination Portsmith (Cairns), Queensland  
Last update 01 September 2020