Rail safety investigations & reports

Uncontrolled runaway and derailment of banking locomotives Kankool, New South Wales, on 3 June 2020

Investigation number:
RO-2020-008
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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This investigation was conducted under the Transport Safety Investigation Act 2003 (Commonwealth) by the Office of Transport Safety Investigations (NSW) on behalf of the ATSB in accordance with the Collaboration Agreement. Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

What happened

On the evening of 3 June 2020, two Aurizon banking locomotives assisted a loaded coal train, WH512, up the Ardglen bank in the Hunter Region of New South Wales (NSW). On completion of the banking assist at Ardglen yard, the train crew prepared the lead locomotive 5031 to become the trailing locomotive, then transferred to locomotive 5034.

The two banking locomotives started to move while the train crew were walking from 5031 to 5034. The train crew boarded 5034 and attempted to take control of the locomotives without success. As the locomotives rolled back down the Ardglen bank, the train crew attempted to stop the locomotives with a series of brake applications. The locomotives reached speeds of up to 114 km/h before derailing and overturning on their side and coming to rest 13 m apart.

The train crew sustained minor injuries in the crash and were able to exit the cabin. The locomotives were significantly damaged and approximately 100 m of rail track was also damaged.

What the ATSB found

During the process of changing ends, the driver likely depressed the Independent Brake Handle accidently, at the same time as placing locomotive 5031 into Trail Cut-out mode. This released the automatic air brake application on both locomotives.

The park brakes were ineffective in holding the locomotives on the grade at Ardglen and the banking locomotives started to roll away after the train crew left the cab of locomotive 5031. The train crew were then unable to establish control once the locomotives started rolling and the banking locomotives rolled approximately 3 km before derailing at 366.529 km near Kankool.

Aurizon did not ensure that the train crew had a consistent understanding of how to safely change ends on banking locomotives. Further, the train crew had not been trained to use the forced lead function which would have likely allowed the train crew to regain control of the locomotives.

Aurizon had not fully considered emergency egress from a locomotive overturned on its side. This increased the risk of further injury to the train crew and could also have prevented emergency services accessing personnel within the locomotive in a timely manner.

What has been done as a result

Aurizon completed their internal investigation and advised the following actions were commenced and completed to prevent recurrence:

  • Completed modifications on the locomotive classes involved in the derailment to improve alignment in the braking system, resulting in improved park brake force.
  • Modified the procedure clarifying steps for changing ends and when to use forced lead function and monitoring the correct application of the procedure through regular analysis of locomotive downloads.
  • Developed training resources to enable more effective training in emergency situations.

Safety message

Rail transport operators should ensure, parking brake systems on locomotives are effective, regularly inspected and maintained. Their safety management systems should contain operational work instructions with sufficient detail on how to carry out safety critical tasks, such as forced lead function. Additionally, rail transport operators’ competency management systems should assess all safety critical competencies, including emergency operational instructions and emergency egress and ensure train crew are trained and assessed.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

About the ATSB

Summary

The ATSB is investigating the loss of control and derailment of banking locomotives 5031 and 5034 near Kankool, New South Wales (NSW), on 3 June 2020.

The two Aurizon locomotives had finished banking a train up a hill and were on the return journey back to Chilcotts Creek. At 1948, the train driver advised the network controller that they had lost brakes. Following this, the locomotives started accelerating down the hill. As they negotiated a series of curves, both locomotives derailed onto the Down side of the single bi-directional track.

The locomotives separated and came to rest on their sides. The two crew climbed out of the locomotive cab and were later transported to hospital by ambulance. They sustained minor injuries and were released from hospital later that night. A Fire and Rescue NSW Hazmat service attended to contain a diesel fuel leak.

This investigation is being led by the  NSW Office of Transport Safety Investigations (OTSI). OTSI conducts rail investigations in NSW on behalf of the ATSB under the Transport Safety Investigation Act 2003. Investigators have commenced collecting evidence from involved parties.

Should any safety critical information be discovered at any time during the investigation, the ATSB will immediately notify operators and regulators so appropriate and timely safety action can be taken.

A final report will be published at the conclusion of the investigation.

Safety Issues

Go to RO-2020-008-SI-01 - Go to RO-2020-008-SI-02 - Go to RO-2020-008-SI-03 -

The park brakes were ineffective

The park brakes were ineffective in holding the locomotives on the grade in Ardglen Yard

Safety issue details
Issue number: RO-2020-008-SI-01
Status: Closed – Adequately addressed

Change of ends process is unclear

Aurizon did not ensure train crews had a consistent understanding of how to safely change ends on banking locomotives

Safety issue details
Issue number: RO-2020-008-SI-02
Status: Closed – Adequately addressed

Unaware of forced lead function

The train crew had not been trained to use forced lead function which would likely have allowed the train crew to regain control of the locomotives

Safety issue details
Issue number: RO-2020-008-SI-03
Status: Closed – Adequately addressed
General details
Date: 03 June 2020   Investigation status: Completed  
Time: 1948 - AEST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Kankool   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 01 February 2022   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: Minor  

Train details

Train details
Line operator ARTC  
Train operator Aurizon  
Train registration AZBK  
Type of operation Banking  
Sector Freight  
Damage to train Substantial  
Departure point Chilcotts Creek, New South Wales  
Destination Chilcotts Creek, New South Wales  
Last update 01 February 2022