Update: 9 October 2020
The ATSB investigation into the runaway and derailment of a TasRail freight train in Devonport, Tasmania on 21 September 2018 is continuing and is nearing the end of the evidence examination and analysis phase of the investigation, with the drafting phase soon to commence.
This investigation update should be read in conjunction with the ATSB preliminary report released on 9 November 2018, and complements the details provided in the ATSB update published on 29 November 2019.
Further investigation activity by the ATSB will involve an analysis of:
- regulatory guidance and processes applicable to safety-related systems
- industry guidance for engineering design assurance
- the remote control equipment engineering.
Should any critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.
A final report will be published by the anticipated completion date in the general details table below.
Update: 29 November 2019
The investigation into the runaway and derailment of a TasRail freight train in Devonport, Tasmania on 21 September 2018 is continuing.
On the morning of 21 September 2018, a TasRail freight train rolled away from a loading facility at Railton, Tasmania while being remotely controlled. There was no train crew on board the freight train at the time. The train travelled for about 21 km before being routed into a dead-end siding in Devonport. The train collided with the end of a dead-end siding, destroyed a fence line and travelled in a derailed state for about 60 m into a public area, where two pedestrians received minor injuries from fence debris.
The information published in this update complements the details provided in the ATSB preliminary report published on 9 November 2018.
The investigation is currently near the end of the evidence collection phase, with the examination and analysis phase in progress.
In addition to the initial activities outlined in the preliminary report, the ATSB’s investigation has included the following activities to date:
- interviews with the manufacturers and/or suppliers of the remote control equipment, locomotive, and airbrake systems
- review of emergency services incident response
- review of train control records and audio recordings
- review of airbrake systems on TR class locomotives, THFY class wagons, and DV (Drivers Van)
- review of a range of documentation, including:
- Railton to Devonport mainline and siding rail infrastructure configuration
- locomotive, wagon and remote control equipment maintenance and test procedures
- locomotive (including on-board systems) and remote control equipment operational procedures
- TasRail driver training and assessments
- TasRail project management, change management, risk management and emergency management procedures
- generation 3 remote control equipment implementation records
- operator incident reports
- Office of the National Rail Safety Regulator audits and accreditation in relation to TasRail
- Rail Industry Safety and Standards Board standards and guidance materials
- analysis of locomotive datalogger, locomotive CCTV and airbrake log data
- verification of TasRail proactive safety actions, since the accident.
Future investigation activities will include:
- analysis of remote control equipment engineering
- review of generation 3 remote control equipment project management and change management processes
- on-site testing of airbrake systems and remote control equipment integration and operation
- further interviews with TasRail personnel.
Once the examination and analysis phase is complete, a final report will be drafted and undergo a rigorous internal review to ensure the report findings adequately and accurately reflect the analysis of available evidence. Following the completion of the internal review, a draft of the final report will be sent to all directly involved parties for their comment before the report is finalised and published.
Should any safety issues be identified during any phase of this investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.
The ATSB notes and acknowledges the full cooperation given to the investigation team by TasRail and the remote control equipment, locomotive and airbrake manufacturers during this investigation.
Preliminary report published: 9 November 2018
At approximately 0846 on 21 September 2018, a TasRail freight train rolled away from a loading facility at Railton, Tasmania. There was no train crew on board the freight train at the time. The train travelled for about 21 km before being routed into a dead-end siding in Devonport.
At about 0909, the train collided with the end of a dead-end siding, destroyed a fence line and travelled in a derailed state for about 60 m into a public area (Figure 1). Two pedestrians within the public area received minor injuries from fence debris.
Image shows location of injured pedestrians at time of collision and derailment, as well as the configuration of the cement train consist at the derailment site in Devonport on 22 September 2018.
Train and track information
The freight train weighed approximately 1132 t and was 220 m long. It consisted of a TR class locomotive (TR11), 16 THFY class bulk cement wagons and a trailing driver’s van (DV1). The freight train was a regular TasRail bulk cement service that operated between the loading facility in Railton and an unloading facility in Devonport (Figure 2).
The track from Railton descends from an elevation of about 58 m (above mean sea level) towards Devonport. Devonport is located on the northern coast of Tasmania and is a shipping port with an elevation of 3 m (Figure 2).
Image shows location of Railton with respect to Devonport within the TasRail network.
Source: TasRail and ARA Railways of Australia 2014, annotated by ATSB.
The TasRail bulk cement service is operated as a driver-alone operation in a push-pull configuration with motive power provided from one locomotive.
To facilitate this push-pull configuration, a portable remote control system is used to control the locomotive. The portable remote control system can be used both from outside of the train driver’s cabin during loading or unloading operations, and from within the leading driver’s cabin when travelling in either direction between Railton and Devonport. The leading driver’s cabin is dependent on direction of travel and can be either from the driver’s cabin in the powered locomotive (TR11), or the driver’s van (DV1) (Figure 1).
Sequence of events
On the morning of 21 September 2018, the train was being loaded at Railton. The driver was situated within the cement loading facility, and was remotely controlling the train to align wagons to the loading chutes. While the last pair of wagons were being aligned, the train came to a stop past the intended stop location.
The driver recalled that, at approximately 0842, he selected reverse to re-align the final two wagons with the loading chutes. However, after selecting reverse, the train became unresponsive to his remote commands.
The driver stated that he attempted multiple times to reset the remote control equipment with the portable remote transmitter. After allowing time for the remote control system to recover, the locomotive continued to be unresponsive to his commands.
The driver decided to walk to the lead locomotive TR11 to undertake a cold restart of the remote control system at the receiver located on the rear of the locomotive. Before he started to walk, at about 0846, the train slowly began rolling away towards Devonport. The driver recalled trying to activate the emergency stop features of the remote system by removing power to the portable remote control system’s transmitter. However, the train did not respond to these commands and gradually gained speed as it rolled away from the loading facility.
At 0848, the driver placed an emergency phone call to TasRail Train Control. He reported the runaway of the cement train to the train controller, who then contacted emergency services.
The Network Access Manager in TasRail Train Control, with the assistance of the TasRail Rolling Stock Assets Manager, were able to monitor the progress of the train using the real time locomotive performance monitoring system. The Network Access Manager communicated this information to the police during the runaway. The police used this information to coordinate their resources to the area ahead of the runaway train. The police concentrated on stopping vehicles and pedestrian traffic at level crossings and about the railway corridor.
During the runaway response, a decision to route the runaway train into the dead-end siding at Devonport was actioned (Figure 3).
Image shows route taken by runaway train, and dead-end siding.
Source: TasRail, annotated by ATSB.
At about 0909, the runaway train collided with a concrete footing and wooden fence line at the end of the dead-end siding in Devonport. As a result of the derailment and collision, two pedestrians received non-life threatening injuries from fence debris. The locomotive and eight THFY class wagons were significantly damaged.
TasRail advised that its bulk cement service between Railton and Devonport was the only service that used a locomotive remote control system. Following the accident on 21 September 2018, TasRail suspended all use of the remote control system from its operations, pending the conclusion of investigations.
The ATSB investigation has conducted interviews with the incident driver, the driver of the train’s previous trip, the rolling stock manager, the injured pedestrians, and the train controller and manager. The ATSB has also gathered documentation about the train, the remote control system and the train network.
Following the accident, a series of tests were organised by TasRail on the locomotive and remote control system. The ATSB were present for a number of these tests.
The ATSB investigation is continuing, and will include consideration of the following:
- serviceability of the locomotive, wagons, remote control system, and the interface between them at time of the accident
- remote control system and locomotive braking operational inspection and testing arrangements
- design and compatibility of the locomotive, remote control system, and the interface between them
- implementation management and on-going monitoring of remote control system and locomotive
- driver qualifications, experience and medical information
- recovery controls:
- runaway protection at Railton
- detection of unauthorised train access to main line from yard
- effectiveness of emergency response systems.
The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this update. As such, no analysis or findings are included in this update.
- EST, Eastern Standard Time.
- DV1 was a reclaimed Y class locomotive with no engine or traction motors, and was solely used for a driver to control a pushing locomotive with a portable remote control system when the powered locomotive was trailing the train.
- Driver-Alone Operation – Operations in which one rail safety worker has the responsibility for the control, operations and procedures of a train. Source: RISSB Glossary of Railway Terminology – Guideline, Version 1.0, 3 December 2010
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|Date:||21 September 2018||Investigation status:||Active|
|Time:||0909 EST||Investigation level:||Systemic - click for an explanation of investigation levels|
|Location:||Devonport||Investigation phase:||Final report: Drafting|
|Release date:||09 November 2018||Occurrence category:||Accident|
|Report status:||Preliminary||Highest injury level:||Minor|
|Anticipated completion:||4th Quarter 2021|
|Type of operation||Freight|
|Damage to train||Substantial|
|Departure point||Railton, Tas.|