Atsb transport Safety Report
Buffer stop design criterion
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- Safety issue description
- Response to safety issue by Queensland Rail
- ATSB comment in response
- Effective coordination of emergency communications
- ATSB safety recommendation to Queensland Rail
Buffer stop design criterion
Safety issue description: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.Response to safety issue by Queensland RailThe technical design of the buffer stop at Cleveland station at 31 January 2013 was 5 km/h with a 200 t train service. Friction element buffer stops have been installed at Cleveland stations that are now able to arrest a train weight of 255 t with a maximum impact speed of 15 km/h. Permanent speed boards displaying 15 km/h at the approach to Cleveland Station have been installed to align with the newly installed buffer stops. ATSB comment in response:The ATSB is satisfied that the action taken by Queensland Rail addresses this safety issue. Action status: Closed Driver’s manual explanation of effects and control of low adhesion
Safety issue description:The 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.Response to safety issue by Queensland RailTrain drivers are trained to drive to the environmental conditions including effective use of the train’s wheel slip-slide protection system. Following the Cleveland collision, rail traffic crew (RTC) received a safety critical notice detailing the train handling procedure for low adhesion conditions specific to the IMU160/SMU 260 class. Debriefing sessions were provided to RTC on the learnings from the Cleveland collision incident regarding wheel/rail adhesion. Updates regarding progress on the recommendations of the Rail Interface Working Group were also provided to the RTC on a regular basis. Under Queensland Rail's Safety and Environment Management System, a standard details the required actions for RTC, network control, network maintenance staff, rolling stock engineers and rail safety management following a wheel slide event. These actions were documented following the release of the ATSB's preliminary report into the Cleveland collision incident and communicated to relevant stakeholders. The procedures have also been incorporated in Queensland Rail's Train Management Manual. ATSB comment in response: The ATSB is satisfied that the action taken by Queensland Rail addresses this safety issue. Action status: Closed
Safety issue description: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.Response to safety issue by Queensland RailQueensland Rail has implemented an Emergency Preparedness and Response Plans (EPRP) for all City Network Stations. Training has been conducted and a process put in place to ensure the contents of the EPRP are reviewed and discussed regularly at focus group meetings and toolbox talks. Queensland Rail continues to develop and implement a single integrated process to address communication protocols within the network control centre and between the network control centre and an emergency site. The process includes incident management, site preservation and protection during response and recovery. ATSB comment in response: The ATSB notes that Queensland Rail continues to develop effective internal communication protocols to prevent misunderstandings between staff during an emergency incident response. ATSB safety recommendation to Queensland RailAction number: RO -2013-005-SR-021 Action status: Monitor The Australian Transport Safety Bureau recommends that Queensland Rail undertake further work to address this safety issue.
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