Rail safety investigations & reports

Safeworking irregularity at Robinson Road level crossing, Midland, Western Australia, on 14 July 2020

Investigation number:
RO-2020-010
Status: Discontinued
Phase: Final report: Dissemination Read more information on this investigation phase

Discontinuation

Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the ATSB to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation. The statement is published as a report in accordance with section 25 of the TSI Act, capturing information from the investigation up to the time of discontinuance.

 

The occurrence

On 14 July 2020, at about 0700 Western Standard Time,[1] a SPENO rail grinder track machine crew prepared for planned work on the Up Main line near Midland, Western Australia. At about 0830, the rail grinder crew received authority from the network control officer (NCO) to occupy the Up Main line between Midland and Forrestfield. The rail grinder departed Midland in the wrong running direction on the Up Main line, then travelled over the Robinson Road level crossing to begin work on the ARC Infrastructure network metro line. The rail grinding work was within the activation zone for the Robinson Road level crossing, which resulted in the flashing lights activating and the booms lowering to protect the crossing.

Due to the extended operation of the level crossing, road traffic began to build-up along Robinson Road. Some motorists ignored the warning signals and drove around the boom gates and across the level crossing without knowing if safe to do so.

At about 0930, an employee (RG1) associated with the rail grinder, travelling to the Midland Yard, noticed that road traffic was queued and that some motorists were driving around the boom gates. The RG1 stopped motorists from crossing until it could be confirmed that no trains were approaching.

The RG1 called the rail grinder crew and advised them that the presence of the rail grinder working had triggered the level crossing and traffic had queued and some illegally crossed. A second employee (RG2) attended the level crossing to assist with traffic management.

The RG2 contacted the protection officer on the rail grinder to determine train running information. They confirmed that, based on information obtained from the NCO the night before, there were no approaching trains.

The RG1 and RG2, with technical assistance via phone from the protection officer, latched the boom gates in the up position and began to allow road traffic over the level crossing. The NCO was unaware of this altered working condition at the Robinson Road level crossing.

At about 1034, the rail grinder completed work, outside of the level crossing activation zone, and travelled toward Midland in the right running direction on the Up Main line. The RG1 and RG2 restored the level crossing to normal operation and unlatched the boom gates. Once the rail grinder entered the activation zone, the level crossing activated and the booms lowered into place. Once the rail grinder cleared the level crossing, it restored to normal with the booms raising to the normal parked position. On observing this, the RG1 and RG2 departed in preparation for the next level crossing. Unbeknown to the RG1 and RG2, the raised boom gates had relatched into the locked (up) position.

The rail grinder and its crew proceeded to the next work location during the allocated time between trains and in accordance with their authority. A short time later, the rail grinder was moved clear of the Up Main line to allow train 2430 to pass.

Freight train 2430, travelling towards Perth on the Up Main line, passed through the Robinson Road level crossing. At that time, the train crew noticed that the boom gates had not lowered, however, the flashing lights operated. The crew reported their observations to the NCO. The NCO reported the fault to an on-call signal electrician. During this conversation, it was noted that the rail grinder had been working in the area and may be involved. The RG1 heard this call and went back to the crossing, where they identified that the boom gate locking mechanism had been locked into the latched-up position. They subsequently locked the boom gate into the unlatched (normal) position. Shortly after, the signal electrician attended the crossing and did not identify any faults.

Investigation activities

During the investigation, the ATSB:

  • interviewed members of the rail grinder work team
  • analysed the rail grinder scope of work
  • conducted analysis of data from event recorders and signalling infrastructure equipment
  • analysed the reasons for the level crossing activation and degraded level of protection
  • analysed the actions of the work crew
  • conducted preliminary analysis of training and human factor aspects
  • conducted an initial review of the rules and procedures for level crossing boom management and design
  • conducted a document review of local agreements and regulatory requirements
  • liaised with key stakeholders.

ATSB observations

From the investigation, the ATSB determined:

  • Following completion of rail grinding work near the Robinson Road active level crossing, the boom gate locking mechanisms were left in a position that resulted in providing partial protection as train 2430 approached and passed through the crossing.
  • The proximity of the rail grinder work to the level crossing meant that the crossing protections were continuously activated, which resulted in road users driving around the boom gates. Consequently, the gates were latched and locked in the up position.
  • The project planning and approval process for the rail grinding work did not identify the possibility of interference with the level crossing operation and the road network. This led to inadequate traffic management being placed at the level crossing resulting in traffic queues and an ad hoc response latching the boom gates.

Reasons for the discontinuation

The ATSB gives priority to transport safety investigations that have the potential to deliver the greatest public benefit through systemic improvements to transport safety.

Given the ATSB’s constrained resources, the ATSB considered it was unlikely that further investigation would identify systemic safety issues or identify opportunities for the enhancement of transport safety. Consequently, the ATSB has discontinued this investigation.

The ATSB has briefed ARC Infrastructure and SPENO about its observations from this investigation and potential learnings. However, it considered that broader communication of this information would not be of significant benefit to other parties.

The evidence collected during this investigation remains available to be used in future investigations or safety studies. The ATSB will also monitor for any similar occurrences that may indicate a need to undertake a further safety investigation.

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  1. Western Standard Time (WST): Coordinated Universal Time (UTC) + 8 hours.

Update

Investigation progress update, published 20 April 2021

The ATSB investigation into the safeworking irregularity at Robinson Road level crossing, Midland, Western Australia, on 14 July 2020 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 summary.

To date, the ATSB has:

  • interviewed members of the rail grinder work team
  • analysed the rail grinder scope of work
  • conducted analysis of data from event recorders and signalling infrastructure equipment
  • analysed the reasons for the level crossing activation and degraded level of protection
  • analysed the actions of the work crew
  • conducted preliminary analysis of training and human factor aspects
  • conducted an initial review of the rules and procedures for level crossing boom management and design
  • conducted a document review of local agreements and regulatory requirements
  • liaised with key stakeholders.

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 analysis of:

  • safety management systems and network level crossing management
  • training requirements
  • policies, procedures and guidelines relating to level crossing boom management
  • local agreements and regulatory requirements.

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.

Summary

The ATSB is investigating a level crossing boom irregularity on Robinson Road, Midland, Western Australia, on 14 July 2020.

A rail grinder entered into the Robinson Road level crossing activation zone and activated the level crossing. The rail grinder team were to spend some time working within this zone. Consequently, in order to prevent road traffic congestion, rail safety workers were sent to manage safe road travel over the crossing. The team latched the crossing boom arm in the ‘up’ position to allow road traffic to pass over the crossing. Upon completion of that work, the team handed back the track to train control.

At about 1140 Western Standard Time, a train travelled over the Robinson Road level crossing with only partial protections in place. The train crew notified train control that the boom gates did not lower, but the lights and bells were working.

As part of the investigation, the ATSB will obtain a report from the operator, interview the workers, and gather additional information.

General details
Date: 14 July 2020   Investigation status: Discontinued  
Time: 1140 WST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Midland   Investigation phase: Final report: Dissemination  
State: Western Australia    
Release date: 11 May 2022   Occurrence category: Serious Incident  
Report status: Discontinued   Highest injury level: None  

Train details

Train details
Line operator ARC Infrastructure  
Train operator SPENO  
Train registration RR24M30A  
Type of operation Rail grinding  
Sector Other  
Damage to train Nil  
Destination Midland, Western Australia  
Last update 11 May 2022