Rail safety investigations & reports

Runaway of freight train wagons Bordertown, South Australia, on 23 November 2019

Investigation number:
RO-2019-020
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

At about 1600 on 23 November 2019, three locomotive drivers signed on at the Bordertown siding, to prepare train 2122S for a journey to Adelaide, South Australia. Train 2122S moved out from the siding and onto the Bordertown crossing loop, where a driver detached the two locomotives so they could conduct a run-around movement and reattached the locomotives to the other end of the train consist.

As the locomotives started the run-around movement, the unattended wagons started to roll back towards the siding. The wagons rolled over a level crossing (which operated automatically as designed), bounced over a derailer (signalling infrastructure on the rail) and continued back into the Bordertown siding.

A driver who was still in the siding, observed the unattended rolling freight wagons, so ran alongside and commenced applying the handbrake on one of the wagons. The runaway wagons slowed and came to a stop, having rolled unattended for about 1,425 m. The wagons stopped about 47 m from the end of the siding, a road and level crossing.

There was only minor damage to the derailer, associated rodding and slight misalignment of sleepers.

What the ATSB found

The ATSB found that while detaching the locomotives, the brake pipe air taps were closed by the driver on ground uncoupling the wagons before a full application of the train air brakes by the driver in the lead locomotive. This prevented further reduction of brake pipe air pressure, so the wagon brakes did not fully apply. In addition, handbrakes were not applied to any wagons. Once the locomotives were detached, the lack of air brakes and handbrakes allowed the wagons to roll away on the descending grade.

While not contributing to the incident, the ATSB also found that the device (a baulk) installed at the siding for restraining runaway wagons was likely insufficient to restrain runaway wagons under some conditions.

What has been done as a result

Bowmans Rail issued a safety alert requiring uncoupled wagons to have all air exhausted and handbrakes applied when left unattended. The alert also reinforced that all procedures must be adhered to when coupling and uncoupling rollingstock. Additionally, Bowmans Rail have communicated the findings of their investigation and their expectations to train crew, as well as consulted on improvements planned for its Bordertown shunting processes.

The Australian Rail Track Corporation (ARTC) has installed an arrestor bed on the track at the Bordertown dead end, with further works to the arrestor bed planned in October 2020.

Safety message

This incident highlights how omitting a procedural step may result in over-reliance on remaining protective measures. In this case, the non-application of handbrakes increased reliance on the full application of wagon air brakes to prevent a runaway. However, a slight out of sequence implementation of the air brake process resulted in only partial application of the wagon air brakes and the subsequent runaway of unattended wagons. It is essential that all procedural steps are undertaken when uncoupling wagons for run-around movements.

Download final report
[Download  PDF: 658KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety actions

Sources and submissions

Appendices

General details
Date: 23 November 2019   Investigation status: Completed  
Time: 1620 CDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Bordertown   Investigation phase: Final report: Dissemination  
State: South Australia    
Release date: 23 September 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Australian Rail Track Corporation (ARTC)  
Train operator Bowmans Rail  
Train registration 2122S  
Type of operation Freight  
Sector Freight  
Damage to train Nil  
Departure point Bordertown Crossing Loop, South Australia  
Destination Port Adelaide, South Australia  
Last update 23 September 2020