Rail safety investigations & reports

Collision between coal trains MB526 and AH378 Kooragang, New South Wales, on 29 July 2020

Investigation number:
RO-2020-013
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 29 July 2020 at 0508, a loaded Pacific National (PN) coal train MB526 collided with the rear of a One Rail Australia (ORA) coal train AH378. MB526 was routed behind AH378 on number 3 arrival road in Kooragang Coal Terminal. At the time of impact, MB526 was moving at approximately 16 km/h. AH378 was stationary due to technical issues that occurred while it was unloading coal.

The collision resulted in significant damage to the rail infrastructure and the derailment of the last two wagons of AH378 and the leading locomotive of MB526. The derailed locomotive and wagons also came into contact with two adjacent stationary trains, BC346 and HV274. These trains sustained minor damage. The driver of the derailed locomotive experienced minor injuries.

What the ATSB found

While AH378 was unloading at Kooragang Island Coal Terminal, several penalty brake applications, associated with a fault in its electronic pneumatic brake system, disabled the train bringing it to a standstill. The crew investigated the faults using a series of technical exercises, which then caused the End of Train (EOT) light on AH378 to be extinguished. The disablement of AH378 constituted a Condition Affecting the Network (CAN) but the crew did not report it to the Kooragang Network Controller as they were required to do. As the Kooragang Network Controller was unaware that AH378 was disabled on number 3 arrival road, they set a signal for MB526 which allowed it to proceed, with caution along number 3 arrival road. When the crew of MB526 saw the shunt proceed signal combined with information they had received earlier, they were expecting any train ahead to be operating farther along the track and illuminated with an EOT light.

The terminal area where the accident occurred was poorly lit by artificial trackside lighting and the absence of the EOT light on AH378 reduced its conspicuity. Light produced by an overhead gantry, above the accident site, may also have caused disabling glare for the drivers of train MB526. In combination, these factors reduced the likelihood that the drivers of MB526 would have seen train AH378 in time to prevent a collision.

The crew’s expectations combined with glare from a nearby overhead signal gantry concealed the presence of AH378 until it was too late to avoid a collision.

What has been done as a result

On 1 August 2020, PN issued notices that informed drivers that on receiving a shunt proceed signal within Kooragang Coal Terminal, they must not exceed 8 km/h and should also proceed as if the line ahead is already occupied.

ORA added programmed monitoring of EOT lights into its asset management plan. ORA also circulated safety information (Notice to Drivers -HV-0046) to their drivers which reminded them of the requirement to communicate all conditions affecting the network to network control.

The Australian Rail Track Corporation (ARTC) provided advice to rail operators to clarify, the operation of trains with defective EOT lights. ARTC also updated information contained in the Rail Access Standard general information.

Safety message

This accident highlights the importance of train crews communicating conditions affecting the network to network control. It also emphasises the need for train crews operating in areas of restricted visibility to be prepared to stop short of any obstruction on the track.

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The investigation

Summary

The ATSB is investigating the collision between coal trains MB526 and AH378 at Kooragang Coal Terminal, NSW, on 29 July 2020.

At approximately 0508 on, a Pacific National loaded coal train, MB526, collided with the rear of a One Rail loaded coal train, AH378. At the time, AH378 was unloading at Kooragang Coal Terminal. AH378 had approximately 60 wagons to be unloaded when MB526 collided with it. The collision resulted in the derailment of the last two wagons of AH378, and significant damage to the rail infrastructure. The leading locomotive of MB526 also derailed. The derailed locomotive and wagons came into contact with two adjacent stationary trains (BC346 & HV274), disabling both. The driver of the derailed locomotive sustained minor injuries.

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.

General details
Date: 29 July 2020   Investigation status: Completed  
Time: 0508 AEST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Kooragang Island   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 04 April 2022   Occurrence category: Accident  
Report status: Final   Highest injury level: Minor  

Train 1 details

Train 1 details
Line operator Australian Rail Track Corporation (ARTC)  
Train operator Pacific National  
Train registration MB526  
Type of operation Freight  
Sector Freight  
Damage to train Substantial  
Departure point Whitehaven Coal, Maules Creek, New South Wales  
Destination Kooragan Coal Terminal, New South Wales  

Train 2 details

Train 2 details
Line operator Australian Rail Track Corporation (ARTC)  
Train operator One Rail  
Train registration AH378  
Type of operation Freight  
Sector Freight  
Damage to train Substantial  
Departure point Ashton Coal Project, Camberwell, New South Wales  
Destination Kooragang Coal Terminal, New South Wales  
Last update 03 April 2022