Rail safety investigations & reports

Near miss with maintenance worker on Skitube Alpine Railway, Bullocks Flat, New South Wales, on 3 July 2019

Investigation number:
RO-2019-014
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 3 July 2019, a rolling stock maintenance electrician obtained clearance from the duty controller to enter the west track at the station terminus at Bullocks Flat. The electrician sought to install a missing traction motor cover retaining clip under stationary train Alpha 24. While the electrician was under the platform, he heard the train brakes release and the electrician moved out from under the train before the train moved a short distance. The electrician was not injured.

What the ATSB found

The duty controller granted an electrician access to the west track while the daily 1700 shunt on west track was taking place. It is likely the duty controller did not connect the two activities, the 1700 shunt and the electrician accessing west track, due to other activities occurring at the time, including a visit from an off-duty controller. The Skitube system for managing access to track did not detect the conflict of the rail maintenance worker under the train at the same time the train was being shunted.

The electrician had not applied the required protection flags to the train set to indicate work was being conducted on the train. The system of placing protection flags on both ends of a train set does not isolate energy to ensure a train cannot be moved when it is being worked on.

Elements of the Skitube safety and environment management system are reliant on procedures being followed to manage safety risks. There is little scope for the system to recover when there has been a human error or other procedural error.

The ATSB also found:

  • The rolling stock return to service authority was ineffective as a control in providing assurance that all required tasks were completed and verified.
  • The electrician felt an urgency to re-install the missing R-clip with concerns a dislodged inspection cover may lead to an equipment failure from the ingress of foreign material into the traction motor.

What has been done as a result

The temporary track access procedure and form were reviewed, updated and documented. The Skitube train red flag procedure was formalised and documented as a discrete procedure. Including the requirement to lower the pantograph, apply brakes, remove the keys, lock the driver’s cab and place a “Do Not Operate” tag onto all driver’s cabs when a person is required to be in close proximity to a stationary train. The feasibility of a positive lockout within the driver’s cabin that locks the pantograph in the lowered position is being reviewed. This is not a standard mechanism available from the manufacturer and requires re-engineering and completion of a change management process.

The completed changes and other major safety rules and processes were communicated to all staff who were required to demonstrate an understanding of the requirements prior to the 2020 operating season. Further consultation and communication will be undertaken with staff on other changes that are still in progress.

Safety message

Workers must ensure they are protected and follow safety procedures before entering the danger zone or when interacting with trains. Systems should identify when conflicting activities take place that increase the risk to workers. Organisations should assess their risk controls for adequacy in protecting workers, and where required consider additional lines of defence.

Download final report
[Download  PDF: 754KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

train details

Sources and submissions

Safety Issues

Go to RO-2019-014-SI-01 - Go to RO-2019-014-SI-03 - Go to RO-2019-014-SI-02 -

Managing track access

The Skitube system for managing access to track did not detect the conflict of the rail maintenance worker under the train at the same time the train was being shunted.

Safety issue details
Issue number: RO-2019-014-SI-01
Status: Closed – Adequately addressed

Positive isolation

The system of placing protection flags on both ends of a train set does not provide a positive isolation of energy to ensure a train cannot be moved while it is being worked on.

Safety issue details
Issue number: RO-2019-014-SI-03
Status: Closed – Adequately addressed

Elements of the safety and environment management system not error tolerant

Elements of the safety and environment management system are reliant on procedures being followed to manage safety risks. There is little scope for the system to recover when there has been a human error or other procedural error.

Safety issue details
Issue number: RO-2019-014-SI-02
Status: Closed – Partially addressed
General details
Date: 03 July 2019   Investigation status: Completed  
Time: 1700 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Bullocks Flat Terminal   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 17 November 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Skitube Alpine Railway  
Train operator Perisher Skitube  
Train registration Set 3  
Type of operation Passenger  
Sector Passenger - regional  
Damage to train Nil  
Departure point Bullocks Flat Terminal, New South Wales  
Destination Bullocks Flat Terminal, New South Wales  
Last update 17 November 2020