The reporter has raised a safety concern relating to a breach of safe working and operating procedures.
The reporter states, on [date], [Operator] scheduled a locomotive and a single vehicle transfer from [Location 1] to [Location 2]. This transfer consisted of [Operator] locomotives [type 1 Locomotive] and [type 2 Locomotive]. The consist also included wagon [identifier] which is an old freight wagon. This wagon was used in [Location 1] to facilitate and assist the shunting of locomotive-hauled passenger trains within the platform and yard limits areas at [Location 1] station.
The reporter believes this service was not operated in accordance with the operator's current safe working and operating procedures as the consist was led by a [type 2 locomotive]. [Operator] management would have intended and scheduled this transfer to operate from [Location 1] to [Location 2] with a [type 1 locomotive] leading the [type 2 locomotive], followed by the freight wagon. [Type 1 locomotive] (which should have led the consist) is equipped with two critical rail safety devices consisting of a [signal enforcement system] and a vigilance control (VC) system. Both systems are designed to stop a train without any input or action from a driver. [Signal enforcement system] is designed to stop a train in the event of a signal being passed at danger (SPAD) or if the speed of the train exceeds a speed indicated by the signalling system. The VC is designed to ensure that the driver remains awake and alert at all times. If the driver does not acknowledge the VC alert periodically, then a penalty brake will occur to stop the train. The operator's [type 2 locomotives] are not fitted with [signal enforcement system] and VC systems. [Type 2 locomotives] are only used by the operator for yard shunting work and are not used for any mainline operations due to a lack of safety equipment.
The reporter queried the decision to allow a locomotive not fitted with safety critical devices, to lead the consist, subsequently breaching [Operator] safety protocols. The reporter further believes [Operator] management is aware of this incident and have not taken action to prevent reoccurrence.
[Operator] has conducted a review into the circumstances of the operation of special [Service A] on [date], as raised in REPCON report RR2025-00015.
In response to the removal of the requirement to station a [type 2 locomotive] at [Location 1], [Operator] fleet made arrangements to transfer the [type 2 locomotive] and its accompanying flat wagon back to [Location 3]. Flat wagon [identifier] had been confined to [Location 1] yard for an extended period, and so [Operator] fleet together with maintenance contractor [Company], conducted a risk assessment to determine any controls needed for the main line movement. This assessment identified that as part of the transfer, a stop was required part way through the journey at [Location 4] to assess axle bearing temperature. A maximum speed of 40 km/h was to be applied, and the wagon was to be positioned between the two accompanying locomotives as a partial mitigation to a risk of train separation due to a failure of couplings.
These controls were documented and conveyed to [Planning department] by Fleet, for inclusion in the [Document 1] which would describe and plan the movement. In addition, wagon [identifier] required an endorsement to operate, as it was not included in the [planning document] which is a listing of approved vehicles for the [Operator]'s main line network. [Document 1] and [Document 2] were issued and distributed to describe the required approvals and controls. (Supplied to the ATSB and ONRSR)
[Type 2 locomotives] date from the [decade] and have been used for low-speed branch line, local and shunting work. [Operator] has a fleet of [x] [type 2 locomotives] for shunting operations in [Location 2] and [Location 1] passenger yards. Due to the typically short runs and a maximum speed of 65 km/h, [type 2 locomotives] have never been fitted with vigilance control (VC) or [signal enforcement system] equipment and are approved to be exempt from these requirements in the [planning document] - network operating requirements. While approved to operate as a lead locomotive on main line movements, in recent times [Operator] has normally provided a [type 1 locomotive] to lead any transfers of [type 2 locomotives] that have been required for maintenance.
The order of the vehicles was specified on [Document 1] as [type 1 locomotive] - [wagon] - [type 2 locomotive]. A train crew was allocated for the run and operated the [type 1 locomotive] to [Location 1] as [Service B]. The crew prepared train [Service A] for the transfer, however it was configured in a different order of [type 2 locomotive] - [type 1 locomotive] - [wagon]. The stop at [Location 4] was completed as planned and the train operated at reduced speed.
Leading with the [type 2 locomotive] meant that VC and [signal enforcement system] were not active for the run, however this configuration and risk profile is permitted due to a two-person crew being provided together with a maximum speed below 80 km/h. Records of the run demonstrated that the order of vehicles was not in accordance with the plan, and an incident report was raised on [date].
In response to the incident, [Operator] is reviewing its attendance requirements at risk assessments for non-standard transfer movements to include [department] representatives, together with documentation of controls for transfer to operations. In addition, the terms of the [planning document] exemption for main line movements of [type 2 locomotives] without vigilance control will be reviewed.
ONRSR confirms receipt of ATSB REPCON RR2025-00015, dated 7 July 2025, regarding concerns of a breach of safe working and operating procedures. ONRSR has reviewed the reporter’s concerns and operator’s response including supporting documentation.
In this instance noting the matter was reported internally and the operator has stated additional measures being undertaken, ONRSR is satisfied with the response provided by the operator.