Atsb transport Safety Report
Australian Transport Safety Bureau
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- Purpose of safety investigations
- Developing safety action
- Glossary
Australian Transport Safety BureauThe Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory agency. The ATSB is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers. The ATSB’s function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in: independent investigation of transport accidents and other safety occurrences; safety data recording, analysis and research; fostering safety awareness, knowledge and action. The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia that fall within Commonwealth jurisdiction, as well as participating in overseas investigations involving Australian registered aircraft and ships. A primary concern is the safety of commercial transport, with particular regard to fare-paying passenger operations. The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 and Regulations and, where applicable, relevant international agreements.
It is not a function of the ATSB to apportion blame or determine liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. Developing safety actionCentral to the ATSB’s investigation of transport safety matters is the early identification of safety issues in the transport environment. The ATSB prefers to encourage the relevant organisation(s) to initiate proactive safety action that addresses safety issues. Nevertheless, the ATSB may use its power to make a formal safety recommendation either during or at the end of an investigation, depending on the level of risk associated with a safety issue and the extent of corrective action undertaken by the relevant organisation. When safety recommendations are issued, they focus on clearly describing the safety issue of concern, rather than providing instructions or opinions on a preferred method of corrective action. As with equivalent overseas organisations, the ATSB has no power to enforce the implementation of its recommendations. It is a matter for the body to which an ATSB recommendation is directed to assess the costs and benefits of any particular means of addressing a safety issue. When the ATSB issues a safety recommendation to a person, organisation or agency, they must provide a written response within 90 days. That response must indicate whether they accept the recommendation, any reasons for not accepting part or all of the recommendation, and details of any proposed safety action to give effect to the recommendation. The ATSB can also issue safety advisory notices suggesting that an organisation or an industry sector consider a safety issue and take action where it believes it appropriate. There is no requirement for a formal response to an advisory notice, although the ATSB will publish any response it receives. GlossaryRegenerative Brake- This form of braking is when the traction motors are switched over to act as generators and therefore convert the kinetic energy of the train into electricity. In regenerative braking the electricity generated is recycled back into the overhead power supply if there is a difference in potential. This type of braking is affected by traffic density.63 Friction Brake - Friction braking is achieved by increasing the air pressure in disc brake units (brake cylinders) mounted adjacent to every wheel. An increase in brake cylinder pressure will result in a proportional increase in force being applied to brake blocks that contact the disc brake rotors fitted to the axles resulting in an increase in friction braking effort and an increase in the deceleration rate of the train.63 Anti-compounding - The parking brake unit is fitted with an anti-compound valve. The anti-compound valve prevents the addition of the force from the parking brake unit to the force from the service brake unit should they both be applied simultaneously.63 1 Bureau of Meteorology Special Climate Statement 44 – extreme rainfall and flooding in coastal Queensland and New South Wales 5 February 2013. 2 Bowen Hills station is a common Queensland Rail train crew change point. 3 A combination of a set of points, V crossing and guard rails which permits traffic to turnout from one track to another. Source: National Guideline Glossary of Railway Terminology Version 1.0, 3 December 2010. 4 The maximum braking position for normal service operations. 5 A vigilance system which reacts by making a penalty brake application if a continuous control input required of the driver is interrupted or not detected, commonly called the “dead man’s pedal”. 6 A structure erected at the end of a track at main line terminals or dead end sidings which is intended to stop rolling stock. 7 Multiple time sources have been used to reconstruct the sequence of events in the post collision response, including train control voice recordings, on-train CCTV footage, station platform CCTV footage, the electrical control officer log book, and the Queensland Rail train operations internal debrief document. Best efforts have been made to establish correct time sequence by corroborating multiple sources of evidence. 8 A measure of the rate at which the railway is inclined (rising or falling). Gradients are signed +ve (rising) or –ve (falling) in respect of the direction of travel. Source: National Guideline Glossary of Railway Terminology. 9 Lubrication applied to the rail gauge face is used to minimise rail wear. 10 Sometimes the term ‘traction’ is used for driving and the term ‘adhesion’ used for braking. 11 The BoM site recorded (at 0930) cloudy conditions with a temperature of 25.7 °C, relative humidity of 72 per cent and wind from the north-northeast at 13 km/h. 12 Wheel-rail interface handbook, edited by R. Lewis and U Olofsson (2009) 13 A MiniProf instrument is a tool for measuring cross sectional profiles of rolling stock wheels and rail. 14 Refer to Glossary section of this report for definitions. 15 Refer to Glossary section of this report for definitions. 16 Loss of roundness of the tread of a wheel usually caused by wheel slip or wheel slide. Source: National Guideline Glossary of Railway Terminology Version 1.0, 3 December 2010. 17 Finite element analysis is a mathematical computer model of a material or a design that is put under stress to verify that the proposed design is able to perform to engineering specifications before the product is constructed. 18 The transverse structural member located at the extreme end of the vehicle's under frame that supports the coupler. 19 The titles of network controller and Network Control are also referred to as train control operator and Train Control in Queensland Rail documentation. 20 Tribology is the branch of science and engineering dealing with friction, wear and the lubrication of interacting surfaces in relative motion. 21 A Tangara passenger train consists of four double-deck cars. 22 Transport (Rail Safety) Act 2010, s82. https://www.legislation.qld.gov.au/LEGISLTN/ACTS/2010/10AC006.pdf 23 Transport (Rail Safety) Regulations 2010, s14. https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/T/TrantRailR10.pdf 24 Queensland Rail (2012). MD-12-208. Emergency Management Standard. (Version 2.0) 25 Queensland Rail (2012). MD-12-279 Emergency Management Plan (Version 1.0). 26 Queensland Rail (2011). Specification SAF/SPC/0022/EMG Rail Emergency Response Plan. Version 1.1 27 A worker conducting ‘rail safety work’ as defined in the Transport (Rail Safety) Act 2010, s10. 28 Attorney General’s Department, see www.em.gov.au 29 Australian Emergency Management Institute. (2012). Managing Exercises. Handbook 3: Australian Emergency Management Handbook Series. Attorney General’s Department. www.em.gov.au/Publications/Australianemergencymanualseries/Pages/ManagingExercises.aspx 30 Transport (Rail Safety) Act 2010, s82. 31 Transport (Rail Safety) Regulations 2010, s14. 32 Australian Emergency Management Institute (2012). 33 The term ‘Functional Exercise’ is interchangeable with ‘Desktop Exercise.’ 34 Queensland Rail (2012). MD-12-279 Emergency Management Plan. Version 1.0, p19. 35 A Queensland Rail tourist railway service that operates between Croydon and Normanton in North Queensland. 36 Queensland Rail (2011). Specification SAF SPC/0022/EMG Module EP1-01 Rail Emergency Response Plan. Version 1.1. p10 37 Queensland Rail (2011). Specification SAF.SPC/0022/EMG. Module EP1-04 Overhead Line Equipment Emergency, Version 1.0. p6. 38 Queensland Rail (2011). Specification SAF.SPC/0022/EMG. Module EP1-07 Collision, Version 1.0. p6. 39 Queensland Rail (2011). Specification SAF SPC/0022/EMG Module EP1-01 Rail Emergency Response Plan. Version 1.1. p10 40 Queensland Rail (2011). Specification SAF SPC/0022/EMG Module EP1-01 Rail Emergency Response Plan. Version 1.1. p10 41 Queensland Rail (2011). Specification SAF.SPC/0022/EMG. Module EP1-04 Overhead Line Equipment Emergency, Version 1.0. p12. 42 Queensland Rail (2011). Specification SAF.SPC/0022/EMG. Module EP1-04 Overhead Line Equipment Emergency, Version 1.0 43 Leadbeater, A. (2010). Speaking as one: The joint provision of public information in emergencies. The Australian Journal of Emergency Management, 25 (3). p22. www.em.gov.au/Documents/Leadbeater.PDF 44 Transport (Rail Safety) Regulations 2010, s14. 45 Falkenrath, R. (2005.) Homeland Security and Consequence Management. The Challenge of Proliferation: A Report of the Aspen Strategy Group: The Brookings Institution. www.brookings.edu/~/media/research/files/articles/2005/6/summer%20terrorism%20falkenrath/2005_aspen.pdf 46 Queensland Rail (2013). Cleveland Derailment – Train Operations Internal Emergency Debrief QT.A 4697. 47 AS/NZS ISO 31000:2009 Risk management - Principles and guidelines 48 Reason, J. (1997). Managing the Risks of Organizational Accidents. Ashgate: Aldershot. p 117. 49 Hopkins, A. (2005). Safety, Culture and Risk. The Organisational Causes of Disasters. CCH: Sydney. p22. 50 The bowtie method is an approach to risk that is designed to link risk control and risk recovery processes. 51 SPAD at Beerwah 09/01/2009 - NIR09.4364. 52 A system that supervises train speed and target speed, alerts driver of the braking equipment, and enforces braking when necessary. 53 A measurement that represents the number of instances that have the equivalence of 1 fatal injury (as used by the RSSB, UK). 54 IMU160/SMU260 Driver’s Manual 1.12.2, page 36. 55 Flin, R., O’Connor, P., & Crichton, M. (2008). Safety at the Sharp End. A Guide to Non-Technical Skills. Ashgate: Aldershot. p53 56 Burian, B,, Barshi, I., & Dismukes, K. (2005). The Challenge of Aviation Emergency and Abnormal Situations. NASA Ames Research Center. 128.102.119.100/flightcognition/Publications/BurianTM_final.pdf 57 Queensland Rail/ATSB email correspondence 09 Sep 13 58 Transport and Main Roads (2013). Serious Injury Collision, St Vincents Road, Banyo. 14 September 2012. Final report, rail incident investigation TMR 4617. tmr.qld.gov.au/~/media/Safety/railsafety/safetyreports/banyonvestigationreport.pdf 59 The hierarchy of exercises ranges from varying levels of Discussion style (seminars, workshops, syndicate progressive, hypothetical) through to Deployment style (drills, functional exercises; field exercises). Australian Emergency Management Institute. (2012). Managing Exercises. Handbook 3: Australian Emergency Management Handbook Series. Attorney General’s Department. www.em.gov.au/Publications/Australianemergencymanualseries/Pages/ManagingExercises.aspx 60 Kahneman, D. (2011). Thinking Fast and Slow. Farrar, Straus & Giroux: New York. 61 There was evidence of an attempted call from the train control supervisor to the station master at 1004. 62 An onsite coordinator was appointed at 1021 with the arrival on site of Queensland Rail incident management staff. This appointment was not initiated by the train control operator, nor by the train control supervisor, but by the manager, rail operations response unit, who communicated this to the train control supervisor. This person was also then generally referred to as the incident commander in further communications from train control. 63 Rolling stock Engineering QR Services Report, Document No. 200907/P, Version 1.0, Dated 25.08/2009. Source Queensland Rail Directory: media media -> Applications to Drill media -> Unicef voices of Youth Chat Theme: Children and aids nigeria and Zimbabwe 13 October 2006 Background media -> Tsunami Terror Alert: Voices of Youth media -> Biblical Eschatology Presentation by: D. Paul Beck May 4, 2016 Ground Rules media -> Guide to completing the collection using the Omnibus system media -> The milk carton kids media -> Events Date and Location media -> The Gilded Age: The First Generation of Historians by H. Wayne Morgan University of Oklahoma, April 18, 1997 media -> Analysis of Law in the United Kingdom pertaining to Cross-Border Disaster Relief Prepared by: For the 30 June 2010 Foreword media -> Cuba fieldcourse 2010 Download 0.51 Mb. Share with your friends:
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