Atsb transport Safety Report
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- Contributing factors
- Other factors that increased risk
- Other findings
FindingsFrom the evidence available, the following findings are made with respect to collision of train T842 with the station platform at Cleveland and should not be read as apportioning blame or liability to any particular organisation or individual. Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time. Contributing factorsLocal environmental conditions resulted in the formation of a contaminant substance on the rail running surface that caused poor adhesion between the train’s wheels and the rail head. Queensland Rail’s risk management procedures did not sufficiently mitigate risk to the safe operation of trains when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion. [Safety issue] Poor wheel/rail adhesion was not recognised as a risk in any of Queensland Rail’s risk registers and therefore this risk to the safety of rail operations was not being actively managed. [Safety issue] Despite numerous occurrences of slip-slide events in the years leading up to the accident at Cleveland, Queensland Rail’s risk management processes did not precipitate a broad, cross-divisional, consideration of solutions to the issue including an investigation of the factors relating to poor wheel/rail adhesion. [Safety issue] Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in precipitating appropriate safety action to the findings and recommendations of their investigations into the Beerwah SPADs in 2009 which identified wheel/rail adhesion issues. [Safety issue] Queensland Rail’s strategic risk monitoring and analysis processes were ineffective in identifying safety issues pertinent to their fleet from rail safety occurrences in other jurisdictions involving poor wheel/rail adhesion. [Safety issue] The mass of the two IMU or SMU class train units travelling on the Cleveland line was commonly heavier than the design specification of the buffer stop at Cleveland station. It is probable that Queensland Rail’s risk management systems did not consider this design criterion for these train configurations arriving at Cleveland station. [Safety issue] Other factors that increased riskThe Queensland Rail driver’s manual did not explain the effects of low adhesion at the wheel/rail interface, how low adhesion is a precursor to prolonged wheel slide events and why these elements reduce the likelihood of achieving expected braking rates. [Safety issue] During the period immediately following the collision there were a series of communication issues which resulted in incomplete information being provided to key personnel. This resulted in the train control operator and train guard miscommunicating the status of the downed overhead power lines, leading to the guard permitting some passengers to exit the train before emergency services had ensured it was safe to do so. The successful management of an emergency event from a remote location is critically dependent on clear and effective communication protocols. Communications within train control, and between train control and Cleveland station, were not sufficiently coordinated and resulted in misunderstandings at the Cleveland station accident site. [Safety issue] Emergency management simulation exercises to test the preparedness of network control staff, train crew, and station customer service staff to respond cooperatively to rail safety emergencies had not been undertaken in accordance with the Queensland Rail Emergency Management Plan. [Safety issue] The Queensland Rail internal emergency debrief following the Cleveland station collision identified issues related to working with external agencies but did not address critical communication shortfalls within train control and between train control and the staff located at the Cleveland station accident site. [Safety issue] The Department of Transport and Main Roads did not adequately review and assess Queensland Rail’s investigation into the Beerwah SPADs in 2009 to ensure that Queensland Rail had processes in place to control the significant safety risks associated with wheel/rail adhesion. The national rail occurrence standard and guidelines (ON-S1/OC-G1) do not include significant train wheel slip/slide occurrences as a notification category/type which has the potential to lead to rail safety regulators being unaware of significant and/or systemic safety issues related to wheel/rail adhesion. [Safety issue] Other findingsAnalysis of the train driver’s actions on approach to Cleveland station with respect to speed and braking indicates that they were consistent with sound driving practice and did not contribute to the accident. Analysis of available data found that the operation of the braking systems on train T842 was consistent with the test train and system design parameters. Deceleration and stopping distance tests of IMU 160 and SMU 260 class trains were not carried out strictly in accordance with procedures and instructions developed by the train manufacturer or brake equipment supplier. Some wheel and rail samples were contaminated but this did not prevent examination and discovery of valid information. Samples should be collected by the application of sound forensic scientific principles as soon as possible and where practical before the accident scene is disturbed. Components of the on-board data from train T842 were unreliable but in this instance data from other sources was available for validation purposes. Ideally, data recording systems should be maintained and periodically audited to ensure currency and accuracy.
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