Atsb transport Safety Report
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- Safety summary Train T842 at Cleveland station
- Whats been done as a result
- Contents The occurrence 4
- Findings 73
- General details 85
- Australian Transport Safety Bureau 93
ATSB Transport Safety Report Rail Occurrence Investigation RO-2013-005 Final – 20 December 2013  Collision of passenger train T842 with station platform Cleveland, Queensland, 31 January 2013 Front cover: Photo supplied by Queensland Police Service. Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Publishing information Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office: 62 Northbourne Avenue Canberra, Australian Capital Territory 2601 Telephone: 1800 020 616, from overseas +61 2 6257 4150 (24 hours) Accident and incident notification: 1800 011 034 (24 hours) Facsimile: 02 6247 3117, from overseas +61 2 6247 3117 Email: atsbinfo@atsb.gov.au Internet: www.atsb.gov.au © Commonwealth of Australia 2013 
Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form license agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. Addendum
Safety summary Train T842 at Cleveland station 
Source: Dept of Transport and Main Roads, Queensland What happened At about 0940 on 31 January 2013, a Queensland Rail passenger train (T842) failed to stop at the Cleveland station platform and collided with the end-of-line buffer stop, the platform and the station building at a speed of about 31 km/h. There were 19 people on board the train (including the driver and a guard); three people were on the platform and five were in the station building. A number of people were treated for minor injuries and transported to hospital for further examination. At the request of the Queensland Government, the ATSB initiated an investigation into the accident.
The ATSB’s investigation found that local environmental conditions had resulted in the formation of a contaminant substance on the rail running surface. This caused poor adhesion at the contact point between the train’s wheels and the rail head. The braking effectiveness of train T842 was reduced as a result of reduced adhesion and the train was unable to stop before hitting the end-of-line buffer stop. The ATSB concluded that Queensland Rail’s risk management processes prior to the accident had not adequately assessed, recorded, managed and communicated the risks associated with operating trains on their network under low adhesion conditions. In addition, Queensland Rail had not undertaken exercises to test the preparedness and effectiveness of their emergency management system. Shortfalls were identified in the response to the accident with respect to internal communications within train control and between staff at Cleveland station which resulted in incomplete information being provided to key personnel. What's been done as a result Queensland Rail initiated a risk mitigation strategy in response to the collision of train T842 at Cleveland station on 31 January 2013. The strategy included the formation of a Wheel Rail Interface Working Group that identified the wheel/rail interface risks, particularly for Queensland Rail’s fleet of IMU160/SMU260 class trains being operated under certain conditions. Queensland Rail have also implemented a series of risk controls including identifying localised black spot locations and applying vegetation control measures, treating rail-head contaminants, reviewing and updating driver training with enhanced train handling advice about wheel slide and the trialling of sanding equipment on IMU160/SMU260 class trains. Queensland Rail have now undertaken emergency exercises to test the effectiveness of their emergency response arrangements and are implementing new communication protocols for emergency incident response.
Rail operators should recognise that train braking performance may be significantly impaired when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion. Rail operators should put appropriate measures in place to assess and mitigate the risk to the safe operation of trains under these conditions. Contents The occurrence 4 Events prior to collision 4 Service T842 4 The collision 5 Post collision 8 Emergency response coordination 8 Vehicle recovery 9 Infrastructure repairs 10 Context 11 Location 11 Organisation 11 Infrastructure 11 Track 11 Overhead traction system 12 Buffer stop 12 Slippery track conditions 13 Track adhesion and friction 14 Rail head and train wheel contaminants 14 Rail head and train wheel profiles 17 Train driver 19 Driver’s actions 19 Train information 19 Braking system 20 Brake inspection and tests 22 Pre-service brake conformance testing (IMU160 class) 24 Brake software changes 25 Test train SMU292 25 Wheel tread dressing 26 Train crashworthiness 27 Station overruns 31 Frequency by train class 31 Locations where trains have higher incidence of overrun 32 Previous Queensland Rail train wheel slide occurrences 37 Beerwah 9 January 2009 37 Beerwah 9 March 2009 40 Narangba and Morayfield 28 January 2013 41 Caboolture - test train 41 Train testing and data irregularities 42 BCU 42 VCU 43
Brake test methodology 43 Investigations of slide occurrences by other organisations 44 Siemens Nexas train overruns - Melbourne 44 Derailment of CityRail train 312A - Thirroul, NSW 11 September 2006 45 Rail slide occurrences - United Kingdom 46 Reference documents for the management of wheel slide 46 Train driver training 47 Training and qualifications 47 Emergency response management 48 Documented emergency management procedures 49 Emergency management training of involved Queensland Rail staff 49 Exercising emergency management procedures 50 Roles and responsibilities of train control personnel 50 Procedures for the assurance of Overhead Line Equipment (OHLE) safety 51 Actions of Queensland Rail staff at the emergency site 52 Communications between network control and Cleveland station 53 Train operations internal emergency debrief 53 Management of safety risks 54 Regulatory oversight of Queensland Rail 55 Confidential reporting system 58 Safety analysis 59 Organisational risk management 59 Beerwah 60 Other occurrences 61 Buffer stop collision risk 61 Regulatory oversight 62 Beerwah 63 Investigation report reviews 64 DTMR spot and compliance safety audits 64 National Rail Safety Regulator (NRSR) 65 Driver training for braking under conditions of low adhesion 65 Effectiveness of emergency management response 67 Design and accessibility of the Emergency Management Specification: 67 Preparedness and role of customer service staff in emergency response 68 Exercising simulated emergencies 69 Actions and interactions of train control personnel 69 Managing and communicating OHLE status 70 Criticality of efficient and standard communication protocols 71 Opportunities for organisational learning about emergency management 72
Contributing factors 73 Other factors that increased risk 73 Other findings 74 Safety issues and actions 75 Management of risk associated with poor adhesion 75 Safety issue description: 75 Current status of the safety issue: 76 Assessment and recording of rail safety risks 76 Safety issue description: 76 Cross divisional recognition of rail safety risks 77 Safety issue description: 77 Current status of the safety issue: 77 Application of safety actions from internal investigations 78 Safety issue description: 78 Awareness of rail safety occurrences in other jurisdictions affecting rail fleet type 79 Safety issue description: 79 Current status of the safety issue: 79 Buffer stop design criterion 79 Safety issue description: 80 Driver’s manual explanation of effects and control of low adhesion 80 Safety issue description: 80 Effective coordination of emergency communications 82 Safety issue description: 82 Emergency management exercises 82 Safety issue description: 82 Post emergency debrief and findings 83 Safety issue description: 83 Occurrence notification standard and guideline 84 Safety issue description: 84 General details 85 Occurrence details 85 Train: T842 85
Sources of information 86 References 86 Submissions 87 Appendices 88 Appendix A - Safety issues update 88 Queensland Rail’s response to the ATSB’s preliminary report published on 13 March 2013 88 Appendix B – Other investigations 90 RAIB - Esher, United Kingdom 90 RAIB - Lewes, United Kingdom 90 RAIB - Review of adhesion-related incidents during autumn 2005 91
Purpose of safety investigations 93 Developing safety action 93
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