Rail safety investigations & reports

Safeworking Breach of Road-Rail Vehicles Crystal Brook, South Australia, 10 June 2021.

Investigation number:
RO-2021-006
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final Report
[Download  PDF: 1.39MB]
 

What happened

On 10 June 2021, two SPENO Rail Maintenance Australia Road-Rail Vehicles (RRVs), FL18 and SP128, on-tracked at about the 196.012 km point, Binney Road level crossing, at Crystal Brook, South Australia, to undertake ultrasonic rail flaw detection. However, the track worker level 2 (TW) for the RRV travel inadvertently requested the protection limits for Train Running Information (TRI) travel from a location about 3 km in advance of where the RRVs were to on-track. The RRVs on-tracked outside of the protection limits and travelled for about 3 km before protection for the movement was applied by the network controller (NC).

What the ATSB found

The TW incorrectly requested the signal for the protection limits for RRV travel as signal 24 Crystal Brook (current location), instead of signal 24 Rocky River, when communicating with the Australian Rail Track Corporation (ARTC) NC. In addition, there was no confirmation between the TW and the NC of where the RRV’s were to on-track while discussing the limits of protection required for the travel. Combined, these factors resulted in the NC applying Blocking Facilities from signal 24D at Crystal Brook to signal 3 at Coonamia and the RRV’s operating outside of the limits defined in the Train Running Information.

What has been done as a result

SPENO have undertaken a review and made amendments to processes for on-tracking of RRV’s. The proposed amendments include the provision to remove the single point of failure of the TW being responsible for identifying and communicating the location which RRVs would on-track in rail networks.

Safety message

This incident highlights the importance of identifying the location that travel or work on track will commence. Competent workers should provide all the information required for network controllers to identify and confirm that protection limits adequately cover the intended work site. Confirmation of location is especially important for providing Blocking Protection for RRV movements.

Download Final Report
[Download  PDF: 1.39MB]
 
 
 

The investigation

General details
Date: 10 June 2021   Investigation status: Completed  
Time: 0721 CST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Crystal Brook   Investigation phase: Final report: Dissemination  
State: South Australia    
Release date: 29 October 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train 1 details

Train 1 details
Line operator Australian Rail Track Corporation  
Train operator Speno  
Train registration FL18  
Type of operation Ultrasonic Testing  
Sector Other  
Damage to train Nil  
Departure point 196.012 km  
Destination Signal SJC -43 Spencer Junction  

Train 2 details

Train 2 details
Line operator Australian Rail Track Corporation  
Train operator Speno  
Train registration SP128  
Type of operation Ultrasonic testing  
Sector Other  
Damage to train Nil  
Departure point 196.012 km  
Destination Signal SJC -43 Spencer Junction  
Last update 29 October 2021