Aurizon did not ensure train crews had a consistent understanding of how to safely change ends on banking locomotives
Status to be provided by Operator during DIP process
Aurizon has modified its procedure for changing ends and continues to monitor the correct application of the procedure through regular analysis of locomotive downloads.
Changes to the bank locomotive working Chilcotts Creek to Ardglen procedure added additional procedural controls to ensure control of the locomotives is maintained by train crew.
Ongoing monitoring for the correct application of the procedure is required to ensure effectiveness.