Rail safety investigations & reports

Collision between two ore trains, Andoom, near Weipa, Queensland, on 22 September 2019

Investigation number:
RO-2019-017
Status: Active
Investigation in progress
Phase: Final report: Internal review Read more information on this investigation phase

Progress Update 2

Investigation progress update published 3 February 2021

The ATSB investigation into the collision between two ore trains at Andoom, near Weipa, Queensland, on 22 September 2019 is continuing and is currently in the final stages of the evidence examination and analysis phase of the investigation.

This investigation update should be read in conjunction with the ATSB preliminary report released on 21 November 2019 and progress update 1 dated 26 November 2020.

To date, the ATSB has:

  • interviewed the train driver and witnesses
  • conducted analysis of data from the locomotive’s event recorder
  • analysed the reasons for degraded train brake performance
  • analysed the actions of the driver and plant supervisor
  • conducted preliminary human factor analysis
  • analysed the securing components of the modular operating cab
  • analysed the crashworthiness of the cab mounting system
  • reviewed similar occurrences worldwide involving modular cabs
  • analysed cab mount design and placement, resilience to impact, and survivable space
  • analysed the crashworthiness standards used in Australia and internationally
  • completed analysis of the event recorder for data trends relating to operations
  • further analysed policies, procedures and guidelines relating to train connections and pre‑departure testing.

Due to the complexity of the investigation, and potential safety factors identified, the investigation scope has been expanded to systemic.

Further investigation activity by the ATSB will involve:

  • stakeholder engagement between key parties relating to the crashworthiness of locomotive modular cabs
  • continued analysis of audit and compliance of policies, procedures and guidelines relating to train connections.

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 expected completed date in the general details table below.

Progress update

The ATSB investigation into the collision between two ore trains at Andoom, near Weipa, Queensland, on 22 September 2019 is continuing and is currently in the evidence examination and analysis phase of the investigation.

This investigation update should be read in conjunction with the ATSB preliminary report released on 21 November 2019.

To date, the ATSB has:

  • interviewed the train driver and witnesses
  • conducted analysis of data from the locomotive’s event recorder
  • analysed the reasons for degraded train brake performance
  • analysed the actions of the driver and plant supervisor
  • conducted preliminary human factor analysis
  • analysed the securing components of the modular operating cab
  • analysed the crashworthiness of the cab mounting system
  • reviewed similar occurrences worldwide involving modular cabs

Due to the complexity of the investigation, and potential safety factors identified, the investigation scope has been expanded to defined.

Further investigation activity by the ATSB will involve:

  • an analysis of cab mount design and placement, resilience to impact, and survivable space
  • an analysis of the crashworthiness standards used in Australia and internationally
  • further analysis of the event recorder for data trends relating to operations
  • further analysis of policies, procedures and guidelines relating to train connections and pre‑departure testing
  • audit and compliance of policies, procedures and guidelines relating to train connections.

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 expected completed date in the general details table below.

Preliminary Report

Preliminary report published 21 November 2019

What happened

On 22 September 2019, an empty bauxite train was travelling the 19.5-km route between Lorim Point and Andoom, near Weipa, Queensland. At the 17.5 km mark, travelling at 64 km/h, the driver made a service brake application to slow the train for the 25-km/h turnout on the approach to Andoom, however, the brake application did not slow the train. In response, the driver released the brake, applied the dynamic brake on the locomotive, and again attempted to apply a service brake application.

Recognising the train was not slowing enough for the turnout, the driver made an emergency brake application, which was not effective. At 59 km/h, the driver applied the locomotive independent brake as a means to slow the train. As the independent brake only applies on the locomotive, there was only a slight decrease in train speed.

The train passed through the turnout at 54 km/h. At the time, a rake of wagons was being loaded at the automated loading point at Andoom, 635 m from the turnout. The driver was aware that a train collision was imminent but was unable to prevent it. During this period, the driver contacted the control communication centre by radio and advised them of the circumstances.

At 37 km/h, the train collided with the partially loaded rake of wagons. The locomotive of the moving train, and four empty wagons at the rear of the partially loaded rake, derailed on impact. The collision resulted in the modular driver operating cab separating from the main structure of the locomotive, coming to rest on the ground (Figure 1 and Figure 2). The cab sustained substantial damage. The driver was initially trapped inside the cab but sustained only minor injuries.

Figure 1: Train collision at Andoom loading point

Figure 1: Train collision at Andoom loading point. Source Rio Tinto.

Locomotive R1006 with its detached and damaged modular operating cab resting inverted to the right of the locomotive. Empty wagons shown are from the rake of wagons the train collided with.
Source Rio Tinto.

Figure 2: Damaged modular operating cab of locomotive R1006

Figure 2: Damaged modular operating cab of locomotive R1006. Source Rio Tinto.

Detached and damaged modular operating cab from locomotive R1006.
Source: Rio Tinto.

Further investigation

To date, the ATSB has:

  • interviewed the train driver and witnesses
  • conducted preliminary analysis of data from the locomotive’s event recorder
  • obtained the securing components of the modular operating cab.

The ATSB investigation is continuing and will examine:

  • analysis and testing the crashworthiness of the modular operating cab
  • factors associated with the braking on the train
  • further analysis of the event recorder
  • policies, procedures and guidelines relating to Rio Tinto rail operations at Weipa.

_____________

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 preliminary report. As such, no analysis or findings are included.

General details
Date: 22 September 2019   Investigation status: Active  
Time: 0930 AEST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Andoom (near Weipa)   Investigation phase: Final report: Internal review  
State: Queensland    
Release date: 21 November 2019   Occurrence category: Accident  
Report status: Preliminary   Highest injury level: Minor  
Anticipated completion: 3rd Quarter 2022    

Train details

Train details
Line operator Rio Tinto Aluminium  
Train operator Rio Tinto Aluminium  
Train registration Locomotive R1006  
Type of operation Bulk ore (35 empty ore wagons, 933 tonnes)  
Sector Freight  
Damage to train Substantial  
Departure point Lorim Point, Queensland  
Destination Andoom, Queensland  
Last update 16 May 2022