4 Final Report

4 4 Rail Safety Investigation

4 4 4 QT2493

Fatal Level Crossing Collision Aerodrome Road, Mundoo Near Innisfail, Queensland 1 January 2009 4 Final Report

4 4 Rail Safety Investigation

4 4 4 QT2493 ISBN 978-0-7345-2558-1

Fatal Level Crossing Collision Aerodrome Road, Mundoo Near Innisfail, Queensland 1 January 2009

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page ii Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Table of Contents

Preface v Terms of reference vi Executive summary vii 1 Factual information 1 1.1 Overview 1 1.1.1 Location 1 1.1.2 Train information 3 1.1.3 Truck information 5 1.2 The occurrence 7 1.3 Post occurrence 10 1.3.1 Loss and damage 11 1.4 Environmental information 13 2 Analysis 14 2.1 Sequence of events analysis 14 2.1.1 Passage of train – train speed 14 2.1.2 Passage of truck – truck speed 16 2.1.3 Emergency response 17 2.2 Traffic control system effectiveness 17 2.2.1 Level crossings in Australia 17 2.2.2 Railway level crossing management 19 2.2.3 Level crossing compliance - Aerodrome Road 21 2.2.4 Level crossing occurrence history 26 2.3 Human factors 26 2.3.1 Truck driver behaviour 26 2.3.2 Factors unlikely to have affected truck driver behaviour 28 2.3.3 Factors likely to have affected the truck driver’s behaviour 30 2.4 Crashworthiness of the train 34 2.4.1 Locomotives 34 2.4.2 The Sunlander carriages 36 2.5 Passenger questionnaire 38 3 Conclusions 40 3.1 Context 40 3.2 Findings 40 3.3 Contributing factors 42 4 Safety actions 43 4.1 Subloo’s Pty Ltd 43 4.1.1 Truck driver’s attention 43 4.1.2 Seatbelt usage 43

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page iii 4.2 QR Passenger Pty Ltd. 44 4.2.1 Train passenger contact details 44 4.2.2 Passenger transportation post-accident 44 4.3 Cassowary Coast Regional Council 44 4.3.1 Level crossing signage 44 4.4 Queensland Level Crossing Safety Committee 44 4.4.1 Level crossing signage 44 4.4.2 Level crossing road markings 45 4.5 Department of Transport and Main Roads 45 4.5.1 MUTCD Part 7, 2003 and AS1742.7 45 4.5.2 Queensland Rail Regulator 45 Appendix A : Sources and submissions 46 Sources of information 46 References 46 Notes 47

page iv Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Preface

At 11181 on 1 January 2009 a laden waste disposal truck drove into the path of The Sunlander passenger train at the Aerodrome Road level crossing, Mundoo (near Innisfail) North Queensland. The two lead locomotives and following six carriages derailed in the collision. As a result of the collision the truck driver was fatally injured. Both of the train drivers, nine passengers and four QR2 on-board staff members sustained minor to moderate injuries. Of those injured, six passengers and one QR employee were taken to hospital for observation.

This investigation was conducted by the Department of Transport and Main Roads3 in accordance with provisions of Queensland’s Transport Infrastructure Act 1994 (the Act), independently chaired by a senior rail safety investigator of the Australian Transport Safety Bureau.

Rail safety in Queensland is regulated by the Department of Transport and Main Roads. All railway managers and/or railway operators within Queensland are required to be accredited in accordance with the Act. The Department of Transport and Main Roads’ role in rail safety also includes the investigation of railway incidents.

The original Terms of Reference for a fatal level crossing collision at Rungoo involving the Cairns Tilt Train (CTT) was amended on 2 January 2009 following the collision between The Sunlander and a waste disposal truck at the Aerodrome Road level crossing, Mundoo (near Innisfail) North Queensland. The Terms of Reference was further amended on 19 June 2009 to allow two reports to be presented.

1 The 24 hour clock is used in this report to describe the local time of day, Eastern Standard Time (EST).

2 Throughout this report, QR refers to the parent company QR Limited and the subsidiary companies QR Network Pty Ltd and QR Passenger Pty Ltd unless there is a specific requirement to identify the parent company or subsidiary within the body of the report. Where necessary, QR Limited or QR Network or QR Passenger is specifically used.

3 Queensland Transport and the Department of Main Roads amalgamated on 26 March 2009 and became the Department of Transport and Main Roads. Throughout the report, Queensland Transport will be referred to as QT and the Department of Main Roads will be referred to as MR. Recommended Safety Actions on QT or MR will be referenced to the Department of Transport and Main Roads as the responsible body.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page v Terms of reference

In pursuance of the powers given to me under Section 216 of the Transport Infrastructure Act 1994, I hereby amend my directive issued on 2 January 2009 requiring you to investigate the circumstances and causes of the fatal occurrences involving firstly the collision between the diesel tilt train and semi trailer on the Bruce Highway level crossing at Rungoo on 27 November 2009 and secondly the collision between a diesel Sunlander train and a truck which occurred at Mundoo on 1 January 2009.

In pursuance of the powers given to me under Section 216 of the Transport Infrastructure Act 1994, I hereby require you to chair an independent investigation into:

The circumstance and causes of the fatal occurrence involving the collision between a diesel tilt train and semi trailer on the Bruce Highway level crossing at Rungoo on 27 November 2008; and

The circumstance and causes of the fatal occurrence involving the collision between a diesel Sunlander train and a truck which occurred at the Aerodrome Road level crossing at Mundoo near Innisfail on 1 January 2009.

Reports of your findings and recommendations in relation to these incidents are required in writing to the Director-General, Department of Transport and Main Roads by 1 November 2009.

Should the final report for either incident be unable to be provided by these dates then an interim report must be submitted.

The investigation will:

Clearly establish the factual circumstances of both occurrences;

Identify the direct cause or causes of these occurrences and any other contributing factors;

Assess human factors to identify any underlying matters which may have caused or contributed to the occurrences;

Clearly indentify any systemic issues; and

If necessary make appropriate recommendations designed to reduce the likelihood of a re- occurrence.

The investigation report should be based on a systematic style investigation approach and should not be written in a manner that apportions blame.

The investigation panel will be comprised of two Department of Transport and Main Roads Rail Safety Officers and an independent chair.

Dated this 19 of June 2009

Dave Stewart Director-General Department of Transport and Main Roads page vi Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Executive summary

At 1118 on 1 January 2009 a laden waste disposal truck drove into the path of The Sunlander passenger train at the Aerodrome Road level crossing (1590.447 km)4, Mundoo near Innisfail, North Queensland. The truck driver sustained fatal injuries and six passengers and six QR staff members (including both of the train drivers) sustained minor to moderate injuries. Of those injured, all six passengers and one QR staff member were taken to hospital for observation. Since the accident, a further three passengers notified QR that they required medical attention as a result of the collision, thereby bringing the total number of injured passengers to nine.

The Sunlander consisted of two locomotives hauling 18 carriages, including two Motorail wagons marshalled at the rear. The total weight of The Sunlander was 737.3 t and the length 363.6 m. There were 122 passengers and staff members on the train at the time of the collision.

The truck involved in the collision was an ‘Iveco ACCO 2350G’, a dual control waste disposal truck with automatic transmission and no anti-lock braking system. The truck could be driven either as ‘left-hand drive’ while collecting waste or ‘right-hand drive’ while engaged in normal road movement activities. The truck was collecting refuse from residential properties on the northern side of Aerodrome Road. Immediately prior to the accident the truck stopped at the last house just before the level crossing to empty a bin and then moved off towards the level crossing.

The Aerodrome Road level crossing was controlled by ‘passive’ advance warning signs, ‘Stop’ sign assemblies5 and pavement markings. The speed limit for road traffic approaching the level crossing was 50 km/h; the speed limit for rail traffic was 80 km/h. The authority responsible for managing and maintaining the rail corridor and the level crossing is QR Network. The authority for managing and maintaining Aerodrome Road to the boundaries of the level crossing is the Cassowary Coast Regional Council (CCRC)6.

Evidence obtained at the accident site, from the train drivers and an accident reconstruction, indicates that the truck driver drove the truck across the level crossing and into the path of The Sunlander at a fairly constant low speed. The investigation team concluded the vehicle reached an estimated 20 km/h and entered the level crossing without stopping at the ‘Stop’ sign. The truck was struck on the left-hand side directly above the rear drive wheels by The Sunlander at a speed of about 70 km/h.

The force of the impact catapulted the truck off the level crossing in the direction of train travel before it rolled, coming to rest upside down about 20 m from the point of impact. The

4 Rail distance is referenced from Roma Street in Brisbane, Queensland.

5 ‘Stop’ sign and ‘Stop’ sign assembly – Throughout this report ‘Stop sign’ and ‘Stop sign assembly’ refers to the ‘Railway level crossing stop assembly (RX-2)’ as defined within AS1742.7-2007 at Clause 2.2.2. See Fig. 4.4.

6 CCRC was formed on 15 March 2008 through the Queensland Government’s local government reform process and its area includes the former shires of Cardwell and Johnstone. Mundoo lies within the former Johnstone Shire Council boundaries.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page vii truck driver, who was not wearing a seatbelt, was ejected from the truck cabin and struck the side of the locomotive.

The force of the collision caused the lead locomotive (2196) to fully derail. It then rapidly decelerated before rotating through 150 degrees and rolling onto its right-hand side. The locomotive came to rest 120 m beyond the first point of collision. The second locomotive (2479) derailed all wheels and came to a stop in an upright position on the right-hand side of the track. The first five carriages (the baggage car, crew car, and three public sleeping carriages) derailed all wheels but remained substantially upright. The sixth carriage (a public sleeping carriage) derailed the front bogie only. The remaining 10 carriages and two Motorail wagons were not derailed and were undamaged.

There was significant damage to the train and in particular the lead locomotive. There was moderate damage to fixed infrastructure. The waste disposal truck was extensively damaged.

Evidence obtained from the train drivers regarding train handling was corroborated by the data recorded by the data logger of lead locomotive 2196. This evidence indicated that The Sunlander, on the approach to the Aerodrome Road level crossing, was travelling at 74 km/h, six km/h under the permitted speed of the train on the track at this location. The driver sounded the locomotive horn in the proximity of the ‘whistle board’ before throttling off to reduce the train’s speed in preparation for a 40 km/h sugar cane railway crossing to the south of the Aerodrome Road level crossing. Three seconds before impact the locomotive horn was again sounded and the service brake application increased to an emergency application.

The attendance of emergency services personnel following the collision was both timely and adequately resourced. The evacuation of passengers from The Sunlander was also timely. However, some passengers expressed concern at being made to wait in an open field for about 2.5 hours7 and with the journey in buses south to Brisbane8 and points between.

The investigation concluded that the collision occurred because the driver of the waste disposal truck did not come to a halt at the ‘Stop’ sign and entered the level crossing while The Sunlander was approaching.

The investigation also found that the Aerodrome Road approach signage and road markings did not fully comply with the relevant standards. However, it is unlikely that this contributed to the collision as the truck driver was familiar with the route and would have been aware of the presence of the level crossing.

7 The accident happened on New Year’s Day which may have delayed the response of some emergency personnel. The CCRC were the first to respond with tarpaulins and portable facilities at the site.

8 QR had two General Managers meet the buses on arrival at Roma Street Station to help with accommodation, luggage and further travel arrangements for the passengers. page viii Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 The investigation concluded that the train crew’s actions were appropriate and that there was little effective action they could have taken to prevent or minimise the impact of the collision. The investigation also concluded that it was very likely that structural alterations and strengthening of the driver’s cabin of locomotive 2196 carried out by QR as a component of a ‘mid-life’ refurbishment were effective in minimising the failure of the cab structure and the associated risk to the train drivers.

As a result of the investigation, the Queensland Department of Transport and Main Roads has identified a number of safety issues concerning level crossing signage, road user attentional issues and seatbelt usage.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page ix 1 Factual information

1.1 Overview At 1118 on 1 January 2009 a laden waste disposal truck drove into the path of The Sunlander passenger train at the Aerodrome Road level crossing, Mundoo (near Innisfail) North Queensland. As a result of the collision the truck driver was fatally injured. Six passengers and six QR staff members (including both train drivers) were also injured. Of those injured, all six passengers and one QR staff member were taken to hospital for observation. Following the accident a further three passengers notified QR that they had required medical attention due to injuries received in the accident, thereby bringing the total number of injured passengers to nine.

The two lead locomotives and the following six carriages derailed in the collision. The truck was extensively damaged.

1.1.1 Location

The main north line9 between Townsville and Cairns substantially comprises a single line railway with crossing loops that facilitate the movement and passing of north and southbound trains.

Innisfail

Aerodrome Rd level crossing

Main north railway line

Figure 1: Location of Innisfail. Map - Geoscience Australia. Crown Copyright ©.

9 Main north line, the main railway line linking Brisbane and Cairns. page 1 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Innisfail10 (Figure 1) with a population of 8,83211 people is a regional Queensland town located approximately 260 km by road north of Townsville.

Direction of train travel Innisfail

Direction of truck travel Level crossing

Aerodrome Road N

Innisfail - Japoon Rd

Bruce Highway

Figure 2: Map view, Aerodrome Road level crossing, approx 5.6 km south of Innisfail, QLD. ©2009 Google – Map data ©2009 GBRMPA Sciences Pty Ltd, PSMA

The collision occurred on the Aerodrome Road level crossing in Mundoo where it crosses the main north line. The level crossing (Figure 2) is located about 5.6 km south of Innisfail off the Innisfail-Japoon Road.

The main north line, including the level crossing and the associated signage within the rail corridor, is managed and maintained by QR Network. Aerodrome Road and the level crossing approach warning signage (outside the rail corridor) are managed and maintained by the CCRC.

Aerodrome Road is a local road that also serves as an access route for the nearby airport. The road is bituminised and carries about 800 vehicles per day. When travelling in an easterly direction (Figure 3) along the road it crosses the railway line at an angle of about 95 degrees when looking to the north (left). After passing over the railway line the road crosses a ‘T’ intersection with Douglas Road (left side), then crosses a sugar cane railway line and shortly thereafter intersects with Sawmill Road (‘T’ intersection right side).

The level crossing is controlled by ‘Stop’ signs that require road users to ‘Stop and Give Way’ to trains. The speed limit for road traffic travelling along Aerodrome Road is 50 km/h. The maximum allowable speed for trains over this section of track is 80 km/h.

10 Innisfail is part of the Cassowary Coast Region Council which has a population of 33,940 people (2001 census data).

11 Queensland Department of Environment and Resource Management February 2009

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 2 Figure 3: Road user’s view of Aerodrome Road level crossing, travelling in an easterly direction (direction of truck travel).

1.1.2 Train information

QR Passenger is an accredited operator of passenger rail transport services in Queensland. As part of its regular activities it operates a diesel hauled train service, The Sunlander, on the main north line between Brisbane and Cairns.

The service operates three return trips a week over a distance of 1,681 km, with a scheduled journey time of about 31 hours.

On the day of the collision, The Sunlander was designated train number 3936. It comprised two diesel locomotives, 2196 leading with 2479 trailing, hauling 18 carriages including two Motorail12 wagons marshalled at the rear. The train had an overall length of 363.6 m with a gross weight of 737.3 t.

The train was crewed by two drivers and eight on-board staff. There were 122 passengers and staff members on the train at the time of the collision.

12 Wagon for transportation of private motor vehicles, etc. page 3 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Table 1: The Sunlander consist (train 3936) Thursday 1 January 2009.

Passenger Tare Length Sequence Number Type Capacity Weight m

1 2196 Locomotive Nil 94.4 t 18.1

2 2479 Locomotive Nil 91.6 t 18.1

3 1459 Baggage car Nil 27 t 17.6

4 1471 Crew car 8 33.7 t 17.6

5 1537 Sleeper car 14 33.7 t 17.6

6 1536 Sleeper car 14 29 t 17.6

7 1540 Sleeper car 14 29 t 17.6

8 1905 Sleeper car 14 32.7 t 17.6

9 1532 Sleeper car 24 35.2 t 17.6

10 1475 Sleeper car 21 34.6 t 17.6

11 1463 Dining car 24 35 t 17.6

12 1503 Club car 42 32 t 17.6

13 1878 Sitting car 36 30 t 17.6

14 1884 Sitting car 48 30 t 17.6

15 1931 Sitting car 48 30 t 17.6

16 1930 Sitting car 48 30 t 17.6

17 1880 Sitting car 48 30 t 17.6

18 1997 Power/baggage car Nil 44.5 t 17.6

Double deck motorail 19 45635 20.1 t gross 10 t 17.1 wagon

Single deck motorail 20 44839 14.8 t gross 10 t 16.8 wagon

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 4 Train drivers The lead locomotive was operated by two drivers who were based in Cairns. The operating driver at the time of the collision had 12 years train driving experience and had worked for QR in various roles since 1985 before becoming a train driver. The co-driver commenced employment with QR in 2002 and had six years train driving experience. Both train drivers were certified to drive the Cairns to Townsville route including the section of the line where the collision occurred. Both were appropriately qualified, assessed as competent and had a good service history.

QR uses the National Transport Commission National Standard for Health Assessment of Rail Safety Workers as a basis for health assessment of its ‘Safety Critical Workers’. At the time of the collision, both drivers were assessed as ‘Fit for Duty’ as prescribed in that standard.

QR ‘on-board staff’ At the time of the collision there were eight on-board staff, composed of a Passenger Service Supervisor (PSS), one cook, five catering attendants and one technician. Six of the on-board staff were based in Brisbane with the two remaining staff being based in Rockhampton and Toowoomba respectively. Duties for on-board staff include the preparation of meals, attending to passenger requirements, train servicing and cleaning, train security and emergency response.

The QR on-board staff were provided with emergency response/incident training that encompassed evacuation of passengers from a train, securing the site and assisting with train protection as required. All on-board staff at the time of the collision held appropriate and current certification for all aspects of their duties. Two members of the QR on-board staff were senior first aid qualified and could assist injured passengers. At the time of the collision, one member of the on-board staff, a catering attendant, was located in the crew car. The remainder of the on- board staff were working throughout the train.

Emergency response and first aid equipment on board The Sunlander includes items such as fire extinguishers and first aid kits.

1.1.3 Truck information

Subloo’s Pty Ltd (Subloo’s) was the owner and operator of the waste disposal truck involved in the collision at the Aerodrome Road level crossing. The company has significant business operations throughout Queensland, with its head office based in Innisfail and site offices located throughout the state. The company has a large fleet of specialised vehicles for the collection and transportation of waste material and also operates plant at various transfer stations throughout Australia. The truck involved in the collision, similar to that shown in Figure 4, was an ‘Iveco ACCO 2350G’, a dual control waste disposal truck with an automatic gearbox and no anti-lock braking system. It could be driven either as ‘left-hand drive’ while collecting waste or ‘right-hand drive’ while engaged in normal road movement activities. page 5 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Figure 4: Iveco ‘dual control’ waste disposal truck. Photograph – Subloo’s Pty Ltd Copyright ©

The truck had an overall length of 10.3 m with a statutory gross mass of 22.5 t and was just over 12 months old at the time of the collision. Maintenance of Subloo’s trucks at Innisfail was carried out at a licensed workshop on a regular basis. In addition, all Subloo’s trucks were examined and certified on a yearly basis by the Queensland Department of Transport (QT). The truck involved in the collision had undergone its first roadworthiness check by QT during July/August 2008.

Following the collision, the truck was inspected by the Queensland Police Service (QPS) for roadworthiness. There were no identified deficiencies that related to the mechanical condition of the truck.

The operating history of the truck operator, Subloo’s, gave no indication of factors likely to have contributed to the collision.

Truck driver information The driver of the truck was a 40 year old male from Innisfail, North Queensland. The truck driver had been employed by Subloo’s on a full time basis for approximately 18 months before the collision and had extensive truck and bus driving experience. The truck driver received induction and initial route training when first employed by Subloo’s and regularly drove the route on which the collision occurred.

Based on available police records and post mortem results, the truck driver had no known medical condition that would have precluded him from driving a heavy motor vehicle/truck of this class. The truck driver was appropriately licensed, had

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 6 extensive driving experience and had no prior convictions or traffic offences that would indicate an increased risk for this type of collision.

1.2 The occurrence On Thursday 1 January 2009 the two train drivers involved in the collision commenced duty at 0640. The train’s locomotives (2196 and 2479) were boarded at the locomotive maintenance depot at Portsmith and driven the short distance to where The Sunlander coaches were stabled. Once coupled to the coaches, a full brake examination was conducted and a brake examination certificate issued. The train then proceeded to the Cairns passenger station where the locomotives were detached and placed at the southern (head-end) of the train. A brake-pipe leakage and continuity test was conducted as passengers embarked and luggage and provisions were loaded.

The train departed the Cairns railway station at 0915 as scheduled, with locomotive 2196 leading. The passage of the train from Cairns to Innisfail was uneventful, although some time was lost whilst picking up passengers at Gordonvale and Babinda. The train arrived in Innisfail eight minutes late at about 1108 and departed 10 minutes late at 1115. The train was then 3.7 km from the Aerodrome Road level crossing.

On the same day, the truck driver involved in the collision booked on for duty at 043013 at the Subloo’s Depot located off Dickson Road, Innisfail. After completing requisite vehicle checks he departed the depot on his routine Thursday round to collect waste from residents located in the Mundoo area.

Evidence obtained from the truck driver’s manager indicates that the most likely route travelled would have been along Dickson Road, then into Goondi Mill Road before travelling along the Bruce Highway/Palmerston Drive. From there he would have started servicing the Mundoo area. The truck driver was scheduled to finish his round at about 1200, with the last segment being to complete the southern and northern pick-ups along Aerodrome Road. This segment entailed travel over the Aerodrome Road level crossing (the accident crossing) in both directions. Once the west run was complete he was to return along Aerodrome Road in an easterly direction.

At about the time The Sunlander departed Innisfail (1115) the waste disposal truck was probably completing the westerly run along Aerodrome Road. The truck would have then turned around and begun the easterly run collecting waste from houses located on the northern side of Aerodrome Road. The truck driver, who was sitting in the left-hand seat, was observed to stop at the last house (number 112) just before the level crossing at about 1117. He emptied the bin and then drove towards the level crossing, which was approximately 50 m away.

13 This was about one hour earlier than normal as the truck driver wanted to finish ahead of his scheduled finishing time as it was New Year’s Day. page 7 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 After departing Innisfail, the train driver steadily accelerated the train until a speed of about 74 km/h was reached. This speed was maintained as the train continued south towards the Aerodrome Road level crossing. The train driver said he sounded the locomotive horn when it was about 250 m from the level crossing, adjacent to the ‘whistle board’ and, shortly after, started braking to reduce speed for the 40 km/h speed limit at the Mundoo sugar cane railway crossing that is several hundred metres to the south of the Aerodrome Road level crossing. Shortly before traversing the level crossing, the train driver said that he saw a white truck on his right side, about 50 or 60 m from the level crossing14. The train driver, who still had his left hand on the brake operating handle, said he then realised a collision was imminent so he made an emergency brake application (moved the brake handle from the service zone to emergency) and, with his right hand, sounded the locomotive horn again. At the same time he called out to the co- driver “truck...truck (co-driver’s name)... he’s not going to stop!” He estimated the time from when he took this action until impact was no more than two or three seconds and that the truck was travelling at a constant speed he estimated to be between 15 and 20 km/h.

The co-driver, who was seated on the left-hand side of the locomotive and was looking for traffic on ‘his’ side of the level crossing, did not see the truck approaching. He only saw the truck when it was on the level crossing in front of him, when it was about 15 to 20 m away. He estimated, in the second or so that he was able to see the truck, that it was travelling at about 20 km/h. Neither the driver nor co-driver observed the truck driver before the collision.

Figure 5: Front view of waste disposal truck with The Sunlander passenger train in the background.

14 The operating train driver is seated on the right-hand side of the locomotive.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 8 The train’s lead locomotive collided with the left side of the truck’s waste collection bin directly above the double axle wheel set. The truck was catapulted to the left-hand side of the train in the direction of train travel and came to rest upside down about 20 m from the point of collision. The truck driver was not wearing a seatbelt15 and was ejected from the cab and struck the side of the locomotive.

The collision caused the lead locomotive to derail, it then rapidly decelerated as it ploughed through the steel sleepers, ballast and formation layer. The locomotive finally came to stop on its right-hand side with all wheels derailed, 120 m beyond the point of collision on the left-hand side of the track, facing 150 degrees to the direction of original travel (Figure 6).

The co-driver ended up on the driver’s (now bottom) side of the cabin. Both drivers said they were disorientated and took a number of seconds to realise the angle at which the locomotive was laying. The driver was able to exit via the left-hand (upper) side window, which had been smashed during the collision sequence. Once the driver was out, the co- driver handed up a hand held portable radio to the driver whereupon he radioed an emergency message to train control, who responded almost immediately. The co-driver exited through the same window as the driver.

Exit point for drivers

Figure 6: Lead locomotive 2196.

15 Section 267 of the Transport Operations (Road Use Management - Road Rules) Regulation 1999, clearly states that in general, drivers of waste collection vehicles do need to wear seatbelts. s267 Exemptions from wearing seatbelts (1) A person in or on a motor vehicle is exempt from wearing a seatbelt if— (a) the person is— (i) engaged in the door-to-door delivery or collection of goods, or in the collection of waste or garbage; and (ii) required to get in or out of the vehicle, or on or off the vehicle, at frequent intervals; and (b) the vehicle is not travelling over 25km/h. page 9 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 The second locomotive derailed all wheels but stayed upright and came to a stop on the right-hand side of the track (seen in the background of Figure 6). This locomotive, which had been marshalled ‘cab trailing’ as usual, did not rotate in the same manner as the lead locomotive and remained facing south. Six carriages of the train, behind the second locomotive, also derailed. The first five carriages (the baggage car, crew car and three public sleeping carriages) derailed all wheels but remained substantially upright. The sixth carriage (a public sleeping carriage) derailed the front bogie only. The remaining 10 carriages and two Motorail wagons were not derailed and were undamaged.

1.3 Post occurrence

Response The train controller, once notified of the collision, contacted the emergency services and requested the attendance of emergency services personnel and equipment. At about the same time the train’s PSS assumed site co-ordination for QR activities and directed on-board staff to start confirming the wellbeing of passengers. The PSS then made her way to the front of the train to check on the condition of the train drivers. After determining that the train drivers had not sustained any major injuries, she returned to attend to the needs of passengers and co-ordinating the efforts of on-board staff. During this process it was established that there were minor to moderate injuries to six passengers and six QR staff members (including the train drivers).

Police, ambulance and emergency services personnel arrived on site at 1129, just 11 minutes after the collision. The police took control of the site to ensure that it was appropriately protected and that evidence was preserved.

At about 1140, following some concern about a diesel spill and health risks associated with the waste disposal truck, passengers were assisted in detraining by QR staff and emergency services personnel. They were moved through the train to car ‘G’, ‘H’ and one first class door, that were located on or near the Aerodrome Road level crossing. Passengers got off the train by climbing backwards down the train steps onto Aerodrome Road. A staff member was at each door assisting the passengers to disembark. Passengers were then evacuated to an offsite field approximately 50 m to the east of the level crossing.

At 1150 the six injured passengers and one QR staff member were transported by ambulance to the local Innisfail Hospital for examination. The remaining passengers were subsequently relocated to a local community hall (the Wangan Community Centre) which was equipped with air-conditioning and ablution facilities. The transfer of the remaining passengers was completed by 1425.

Bus transportation for the passengers was despatched from Townsville at approximately 133016. The buses carrying passengers and QR onboard staff

16 It took QR just over two hours to organise buses and have them travelling to the accident site to transport passengers to their final destinations. This timeframe is very reasonable considering the accident happened on New Year’s Day.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 10 departed the Wangan Community Centre for Townsville/Brisbane at about 1850, seven hours after the collision. The on-board staff left the buses at Townsville and the passengers continued their journey unsupervised or chaperoned by QR staff. During the investigation it became evident that issues associated with the bus transportation south to Brisbane and points in between were a source of concern for some passengers (see section 2.5).

Injuries A total of nine passengers and six QR staff members sustained injuries of a minor to moderate nature in the collision. Of these, six passengers advised of their injuries at the accident site. These passengers and one QR staff member were taken to hospital for checks and observation. Since the accident, a further three passengers have contacted QR and reported they had been injured during the accident and had received medical help.

Site recovery There were no dangerous goods carried on the train at the time of the collision. However, there was concern regarding the public health risk associated with a diesel fuel spill from the truck and the refuse being carried by the waste disposal truck.

The waste disposal truck was held on-site at the request of the rail regulator to enable the investigation team to collect evidence. The truck was subsequently removed from the site by 1515 on 2 January 2009. The trailing part of the train, from the baggage car back, was recovered over the period 2 – 3 January 2009 with the track reopened for traffic on the afternoon of 4 January 2009. The two locomotives (2196/2479) and the baggage car remained on-site, clear of the tracks, and were recovered during the following week.

1.3.1 Loss and damage

Locomotive 2196 (Figure 7) sustained extensive damage to its front end, superstructure and both bogies (which had been dislodged) during the collision and subsequent roll over.

There was major damage to the second locomotive (2479), the baggage car and the crew car. Damage to the remainder of the rolling stock was minor17.

The main damage to QR fixed infrastructure comprised 150 m of track damage and the eastern side level crossing ‘Stop’ sign had been up-rooted.

The waste disposal truck (Figure 8) was extensively damaged.

17 See section 2.4.2 for a more detailed description of damage to vehicles. page 11 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Figure 7: Damage to locomotive 2196.

Figure 8: Damage to waste disposal truck cabin.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 12 1.4 Environmental information At the time of the collision the sun was high (altitude 74 degrees 36.9 minutes) with an orientation a little south of east (azimuth of 113 degrees 17.8 minutes).

Information obtained from the Bureau of Meteorology (Table 2) established that at the time of the collision the weather in Innisfail was fine, although there were showers earlier in the day. The temperature at the time of the collision was about 27 degrees Celsius, wind speed was low.

At the time of the collision visibility was good with the sky overcast.

Table 2: Weather details for Innisfail, 1 Jan 2009 (Source BoM).

Temp. Relative Cumulative Local Wind Wind Speed (degrees Humidity Rainfall (mm) Time Direction (km/h) Celsius) (%) from 9am

0900 NW 7 27 77 8.0

page 13 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 2 Analysis

On 1 January 2009 QT and the Australian Transport Safety Bureau (ATSB) despatched a team of investigators to the collision site at Aerodrome Road, Mundoo in Northern Queensland.

Evidence was sourced from the train drivers, on-board train staff, passengers, witnesses, QR, CCRC, QPS, Main Roads (MR) and QT. Evidence included interviews, photographs, train running information, event logs, engineering documentation, site surveys and other material.

Initial examination of this evidence established that there were no known mechanical defects or deficiencies with the train or truck which would have contributed to the collision, nor were there any deficiencies in relation to the qualifications of the truck driver, train drivers or on- board train staff.

2.1 Sequence of events analysis 2.1.1 Passage of train – train speed

At the time of the collision, The Sunlander was under the direction of the QR Network train controller located in Townsville. The train driver had the correct Direct Traffic Control18 (DTC) authority to occupy the block section between Innisfail to Boogan, the section of the line where the collision occurred.

The data logger on locomotive 2196 captured time, speed, distance, brake and horn activation data. The operation of the headlight was not recorded.

The speed recorded by the data logger was corrected for wheel diameter variation to accurately calculate the train’s speed. An examination of the data from locomotive 2196 was used to reconstruct events leading up to the collision. Based on this information the following was concluded:

The train’s locomotive horn was sounded at 1117:42 and 1117:51 on its approach to the Aerodrome Road level crossing when it was 250 m and 50 m from the level crossing respectively. The emergency brake application was made approximately three seconds before the train entered the Aerodrome Road level crossing, i.e. about 50 m before the point of impact. The speed of the train was 74 km/h when the emergency brake application was made. The collision occurred at 1117:53, just as the train entered Aerodrome Road level crossing at a recorded speed of 66 km/h19.

18 The DTC system of safe-working allows for the movement of trains on bidirectional single track and through stations. The movement of trains and on-track vehicles is governed by instructions contained in DTC authorities issued by the train controller to train drivers. DTC authorities are either computer generated or written and must be issued: for every moment of a train to enter a block or blocks; and for every moment by an on-track vehicle which is not protected by signals. The Sunlander had been issued with the correct DTC authority for this section of the journey.

19 The impact speed recorded appears to be erroneous. Given the time for a brake application to take effect, it would not be possible for the train speed to reduce by 8 km/h in three seconds.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 14 Figure 9: Locomotive 2196 ‘data logger’ extract.

The information from the data logger corroborates the account of the train driver in which he said that the locomotive horn was sounded at the whistle board and that the horn was again sounded and an emergency brake application made when he saw that a collision was imminent. However, the data does not quite match the operating train driver’s account of applying the train brake for the 40 km/h speed restriction between the first sounding of the locomotive horn and the emergency brake application. Given the short period of time between events (nine seconds), it seems likely that the service brake application was made split seconds before or almost at the time of the emergency brake application.

The data logger does not record headlight illumination and therefore cannot corroborate or disprove the account of the train driver who stated that the train’s headlight was on20. The position of the locomotive on-site meant that the position of the switches on the driver’s (right-hand) console were unable to be examined. These switches were examined some time after the locomotive was righted and the headlight switch was observed to be in the ‘on’ position at ‘low beam’. While this is a likely indicator that the headlight was illuminated at the time of the collision, this cannot be substantiated as a number of persons worked

20 The co-driver of this class of locomotive is unable to see the headlight switch on the driver’s console or other evidence that the headlight is on during daylight hours. page 15 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 on and around the locomotive during the recovery stages. An examination of the headlights themselves however, indicated that although one of the two sealed beams had been dislodged from its housing, both were intact as individual units and appeared to be in good condition.

2.1.2 Passage of truck – truck speed

The truck did not have an on-board data recorder21 that could be used to provide information regarding its movement or speed. However, the truck’s speedometer was jammed (Figure 10) at a speed of 22 km/h. This is consistent with the observation by the train driver who said that the truck approached the level crossing at a constant speed between 15 and 20 km/h and did not come to a halt at the ‘Stop’ sign. The co-driver estimated a truck speed of about 20 km/h. Calculations based on a police re-enactment of the accident show that the truck would have probably attained a speed of about 6 km/h had it been stationary at the ‘Stop’ sign and then accelerated over the crossing.

No tyre skid marks22 were found on the road surface approaching the level crossing, indicating that the truck driver probably did not apply the brakes. Given the evidence of the train driver and the lack of any indications of braking on the road surface, it is considered likely that the truck driver did not see the train or only saw the train moments before the collision.

Based on available evidence it is concluded that the truck did not come to a halt at the ‘Stop’ sign.

Figure 10: Waste disposal truck dashboard showing speedo jammed at 22 km/h.

21 Data loggers are generally not fitted/required on road vehicles. As a result, the truck speed and truck driver actions are based on available evidence and the police reconstruction of events.

22 The absence of skid marks could be for various reasons such as not being aware of the train or well controlled braking by the truck driver. The ‘Iveco ACCO 2350G’ involved in this collision did not have an anti-lock braking system (ABS).

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 16 2.1.3 Emergency response

The emergency response to the accident was rapid because of the early notification and the proximity of the site to Innisfail. The train was evacuated in a timely manner once the authorisation to evacuate was given by police officers.

There were two on-board train staff with current competencies in first aid. In this accident they were able to cope with the small number of casualties.

Movement of the passengers to an evacuation point (nearby vacant field) was undertaken so control could be maintained and to allow emergency response personnel to continue with their work. The delay incurred before the passengers and on-board staff were moved from the open field to a nearby hall was of concern to some train passengers questioned during the investigation. There was very limited shade in what was virtually the middle of the day. Notwithstanding this, the on-board staff minimised any discomfort by providing refreshments.

Movement of the passengers via buses through to Brisbane without the on-board staff or other QR representatives left some passengers upset. They said they felt abandoned without a responsible QR person or persons to manage and supervise their journey (see section 2.5). The investigation panel were advised by QR that on arrival at Roma Street, Brisbane, passengers were met by two senior managers who assisted with luggage and accommodation.

2.2 Traffic control system effectiveness 2.2.1 Level crossings in Australia

There are around 9,400 public level crossings in Australia. Control and warning of road (and pedestrian) users approaching a railway crossing can be by means of active or passive controls. These are supplemented, but not replaced by, both audible warnings (horns) and visual warnings (headlights) fitted to the trains and operated in accordance with the railway operator’s practice.

Active control level crossings regulate the movement of vehicular or pedestrian traffic using devices such as flashing lights, bells, gates or barriers, or a combination of these. These devices are activated by an approaching train and provide a visual, audible and/or physical warning that a train is approaching. Road users are required to stop at the stop lines at the crossing when these devices are activated and wait for the warnings to cease before proceeding. There are approximately 2,700 active control level crossings in Australia with 524 located in Queensland.23 Priority for the provision of active controls is usually given to high road speed and/or high road traffic volume railway crossings or to railway crossings where the sighting distances when stopped at the crossing are not sufficient for the applicable train speed.

Passive control level crossings regulate the movement of vehicular or pedestrian traffic using signs and devices (including ‘Give Way’ or ‘Stop’ signs), none of

23 At June 2009 there were 1,800 public railway level crossings in Queensland, excluding the sugar cane railways. page 17 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 which are activated during the approach or passage of a train and which rely on the road user or pedestrian perceiving the approaching train by direct observation. There are over 6,000 passive control level crossings in Australia, including the Aerodrome Road crossing in Mundoo. Of these, 1,276 are in Queensland.

The crossing at Aerodrome Road in Mundoo was fitted with ‘Stop’ sign traffic control. ‘Stop’ signs are used at level crossings where the sighting distance along the rail track from a road vehicle approaching the crossing is such that the road user does not have unobstructed/clear sighting as they approach the level crossing. ‘Stop’ sign traffic control requires a road user to stop at the crossing and visually search the rail track in both directions. If no train is seen or heard then the road user can proceed. If a train is seen or heard, the road user must remain stationary at the ‘Stop’ sign until it is safe to proceed.

Given the size and weight of most trains it is not possible for them to brake at the rate of a road vehicle. Heavy freight and passenger trains can take up to two kilometres to slow from high speeds.

In most circumstances a train driver is unlikely to sight an approaching motor vehicle and determine the driver’s intention to stop or continue, until the train is close to the level crossing. By this time a collision may be imminent. In such circumstances a train driver is unable to take any effective action to avoid the collision other than sounding the locomotive horn to warn the road user and, if time permits, apply the train brakes.

By comparison, road vehicles can stop relatively quickly. It is for this reason that, regardless of the type of level crossing traffic control, the onus to stop and give way to trains rests with the road user.24 Consequently, it is important that road signage is effective in warning a road user that they are approaching a level crossing and that the signage is located at a sufficient distance so road users can be prepared to observe and obey the active or passive controls at the crossing. For a passively controlled crossing with ‘Stop’ signs, it is important that from the stopped position there is sufficient sighting distance available for the road user to check for the approach of a train by direct observation and decide whether it is safe to proceed across the level crossing.

The remaining analysis will focus on issues including level crossing management, road alignment, sighting distances, placement of the ‘Stop’ signs, approach warning signs and the actions of the truck driver.

24 In accordance with the Transport Infrastructure Act 1994 section 254 and Transport Opertaion (Road Use Management - Road Rules) Regulation 1999 section 121, drivers of road vehicles must give way to rolling stock or other rail vehicles on railway tracks at level crossings.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 18 2.2.2 Railway level crossing management

Overview The responsibility for managing and maintaining public level crossings in Queensland is shared between QT, QR, other railway managers, MR and local governments. Since 1995, strategies to improve level crossing safety have been pursued in Queensland by committees that represent these agencies and managers. Within these committees is the technical, operational, governmental and local expertise considered necessary to ensure all issues are considered when developing strategies for level crossing safety in Queensland.

To ensure conformance with the applicable standards and individual funding responsibilities are clearly understood, a Memorandum of Understanding (MoU) was entered into on 24 October 2003 by the Local Government Association of Queensland (LGAQ), QR, MR and QT for the management of level crossing safety. Whilst the MoU expired 31 December 2008, there was an understanding that it would continue pending finalisation of a new MoU. The MoU contains a Statement of Institutional Responsibilities, which includes management responsibility for ensuring that level crossings conform to the applicable safety standards and a funding responsibility to pay for related work and maintenance at level crossings.

RX-2 assembly

Figure 11: Left photograph shows the approach to the Aerodrome Road level crossing, direction of truck travel, i.e. easterly direction. Right photograph (inset) shows close- up of RX-2/‘Stop’ assembly

Organisational context In 1995, the Queensland Level Crossing Safety Steering Group (LCSSG) was established to identify and manage rail level crossing issues and develop strategies to improve level crossing safety. The LCSSG comprises representatives from QT,

page 19 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 MR, QR, LGAQ, QPS, Australian Sugar Milling Council and Queensland Sugar Research Institute.

In 1999, the Queensland government established the Open Level Crossing Protection Strategy (OLCP) to upgrade all level crossings on the QR non- commercial rail network, which does not include the parts of the Queensland network predominately for the cartage of coal. The OLCP objectives were to undertake a risk assessment of all the public level crossings on the non- commercial network (approximately 1,500) and to fund any additional control measures necessary to achieve an acceptable risk threshold.

Local Review Committees (LRC) were established throughout Queensland, comprising representatives from QR, MR and local councils. LRC conduct the level crossing assessments and make recommendations regarding level crossing upgrades for funding approval by the Level Crossing Safety Technical Working Group (LCSTWG) established by the LCSSG.

Level crossing assessments have been completed using a Queensland Risk Scoring Matrix, which has evolved into the Australian Level Crossing Assessment Model (ALCAM),25 that was adopted by the Australian Transport Council in 2003 to be used as the national level crossing assessment tool.

Between 1999 and 2009 approximately $20 million has been spent throughout Queensland and by 2013 a further $10 million (approximately) will be spent by the state government under the second Transport Service Contract. This does not include the $10 million QR has allocated in 2008-09 or the federal government level crossing initiatives announced in 2009.

The Queensland Level Crossing Committee (QLCSC) has been established to develop the Queensland Level Crossing Safety Strategy. The QLCSC, comprised of representatives from QT, MR, QPS and the LGAQ, is currently investigating a range of state-wide initiatives to improve level crossing safety.

Level crossing traffic control Throughout Queensland the MR standard, Manual of Uniform Traffic Control Devices (MUTCD) Part 7 Railway Crossings (Issue 1) dated August 2003 is used to specify traffic control devices to regulate and warn road users and pedestrians at, and in advance of, public railway crossings. The MUTCD Part 7 is based on a previous version of Australian Standard AS 1742.7-2007 Manual of uniform traffic control devices - Railway crossings. The Australian Standard is used

25 ALCAM - The model has been used as a basis for determining level crossing risk and controls in determining an upgrade priority. While the ALCAM takes into account over 70 factors for each level crossing, including local characteristics and controls, it does not include near miss or collision history when calculating a risk score. Near miss and collision history has not been used as part of the ALCAM as these events are relatively infrequent and random in nature. Additionally, ‘near miss’ incident data has been found to be unreliable as it is subjective and may vary for different train drivers according to their perception of the risk. The process for assessing the overall risk at a level crossing is based on the risk score provided by the ALCAM model and a qualitative evaluation of each site with local knowledge and incident history brought into the process to influence recommended controls measures.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 20 nationally and was developed and is maintained by a committee of which the Queensland MR is a member.

The Aerodrome Road level crossing was reviewed using the Queensland Risk Scoring Matrix on or about the 16th June 2004. Based on the risk score and local assessment at the time it did not warrant the provision of active controls, i.e. flashing lights. Following the accident on 1 January 2009, a review of the crossing using ALCAM established that there has been a negligible direct increase in risk through traffic volumes or other factors. Passive protection using ‘Stop’ sign control remains the appropriate minimum level of protection at this crossing.

2.2.3 Level crossing compliance - Aerodrome Road

Signage control measures The MUTCD Part 7 and AS 1742.7-2007 specify the traffic control devices to be used to control and warn road traffic at and in advance of railway crossings throughout Queensland. They specify the way in which these devices are used to achieve the level of traffic control required for the safety of road users and pedestrians.

The specification and standard clearly define the configuration of approach warning signs and pavement markings that are required on roads that have passive ‘Stop’ sign controls. Warning signs are displayed at specific distances based on the nominal (85th percentile) approach speed of motor vehicles. Signage for Aerodrome Road, as a nominal 50 km/h bitumen road, is required to be erected in a specific order (Figure 12) as follows:

The advance warning sign - ‘Railway level crossing ahead’, (symbolic train) W7-7(R)26, on the left-hand side of the road and optionally a W7-7(L) sign on the right-hand side of the road for busy or multi-lane undivided roads. The ‘Stop sign ahead’, W3-1, sign positioned 50 m after the W7-7(R) sign and between 80 – 120 m before the ‘Railway level crossing stop assembly’ (RX-2) sign. The ‘Railway level crossing stop assembly’ (RX-2) sign positioned not less than 3.5 m from the nearest rail. The painted ‘RAIL’ and ‘X’ road markings are optional (MUTCD clause 7.2 and AS 1742.7-2007 clause 3.2) and may be used where the visibility of the level crossing is poor and on road approaches where road speeds are high. A local review committee which included the CCRC conducted a survey of the Aerodrome Road level crossing on 23 October 2001 and recommended the following upgrades to the crossing:

Install 2 x G9-48A ‘Look for trains’ signs on RX-2 assemblies at the crossing. Install 1 x W3-1 sign 50 m on the eastern side of the crossing.

26 The Manual of Uniform Traffic Control Devices 2003 (MUTCD) edition and AS 1742.7-2007 differ slightly in the use of W7- 7(L) and W7-7(R) terminology. The sign numbering in AS 1742.7-2007 has been modified to conform to road vehicle signage. The difference is minor and only involves terminology, in that sign numbering on the left-hand side of the road in the MUTCD is W7-7(L) whereas in AS1742.7-2007 the sign number is W7-7(R). However, the signs on site are physically the same sign. page 21 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Install 1 x W3-1 sign at location of existing W7-7 sign ie 40 m west of crossing. Install 1 x W7-7 sign 100 m on western side of crossing. Replace existing W7-7 sign and provide new post 160 m on eastern side of crossing. Provide road markings in accordance with the standard. The recommendation for funding was approved on 16 December 2002 by the LCSTWG. CCRC forwarded an invoice to the LCTWG confirming all works associated with the program, including the upgrade works associated with Aerodrome Road level crossing, had been completed.

Compliance at the time of the collision A review of the Aerodrome Road level crossing traffic control system was undertaken by the investigation panel on 2 January 2009 following the collision of the waste disposal truck and The Sunlander. The review established that the RX-2 assembly (Figure 11, see inset) on the western side of the crossing was compliant with the standard.

However, there were several non-conformances with the approach warning signage (maintained by the CCRC) in that it did not fully comply with MUTCD Part 7 (and/or AS1742.7-2007). These non-conformances are detailed as follows:

V85 A B Km/h m m V85 A B Km/h m m <75 80-120 50 75-90 120-180 60 <75 47 >90 180-250 70

Figure 12: Signage prescribed in MUTCD. Figure 13: Signage at Aerodrome Rd level W7-7(L) is optional. crossing on 01 Jan 09. Western approach to the level crossing: The W7-7(R) ‘Railway level crossing ahead - Passive control’ was not in place as prescribed. An examination of available evidence established that the sign was in place during a QR audit undertaken in June 2008, but was probably removed by persons unknown between the time of the audit and the collision. The absence of the sign whilst not considered a factor in this collision, could be

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 22 an issue for a road user who was unfamiliar with the local area, thereby failing to recognise the presence of the level crossing until almost upon it. MUTCD Part 7 and AS1742.7-2007 both specify that the ‘Stop sign ahead’, W3-1, sign should be positioned between 80 – 120 m before the ‘Railway level crossing stop assembly’ (RX-2) sign. It was noted that the sign was in fact located at a distance of 47 m before the crossing. The CCRC explained that the location of the sign was predicated on low residential traffic speed (50 km/h) and a need to fit both the W3-1 and W7-7 signs in a short section of road between the level crossing (western side) and the junction of Mundoo Road/Aerodrome Road. Available evidence indicates that the positioning of the signage at this location had been recommended by the LRC and accepted by the LCSTWG for this reason. The stop line was set back from the ‘Stop’ sign assembly (RX-2) by 1.4 m. For consistency, the stop line and RX-2 assembly should be adjacent one another. It was noted though that in this instance sighting from either the stop line or ‘Stop’ sign assembly was excellent. The barrier line and stop line were heavily faded. The approach to the level crossing did not have ‘RAIL’ and ‘X’ signs painted on the road surface. These markings are optional, based on road traffic volumes and vehicle speed as described within MUTCD Part 7/AS1742.7-2007. Based on the standards and a risk assessment by the LRC, the LCSTWG agreed that ‘RAIL’ and ‘X’ signs were not warranted at the Aerodrome Road level crossing. During the investigation it was noted however, that there were painted ‘STOP’ pavement markings on both sides of the crossing. These markings were heavily faded. The CCRC advised that these markings were a carry-over from a previous standard and would not be repainted.

Eastern approach to the level crossing The W7-7 sign on the eastern approach to the Aerodrome Road level crossing was obscured by foliage, making it difficult to see.

Sugar cane railway crossings in northern Queensland There was a mixture of signage on the eastern side of the crossing, in part associated with the nearby sugar cane railway. This mixture of signage could be confusing for road users. Cane trains in northern Queensland can become an issue for road users due to frequency of cane trains and the height of sugar cane obscuring the vision of road users. While the accident occured outside of the cane cutting season, it did happen near a sugar cane train level crossing. However, as the truck driver had a good local knowledge it was concluded that the proximity of the sugar cane line and associated signage were probably not factors in this collision.

Conclusion The lack of an advance warning ‘symbolic train’ W7-7 sign in conjunction with the badly faded barrier and stop lines were matters of concern. However, in this instance, due to the extensive local knowledge of the truck driver, it is almost certain that the non-conformances in signage were not factors that contributed to the collision.

page 23 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 The positioning of the ‘Stop sign ahead’ W3-1, although considered a minor non-conformance, was seen as a necessary placement of the sign because of the short distance between the level crossing and the junction of Aerodrome Road and Mundoo Road.

Although not mandated in the MUTCD (or AS 1742.7-2007) but to enhance the safety of the crossing, particularly for road users who are unfamiliar with the local area, it may be beneficial to give consideration to the installation of the ‘RAIL’ and ‘X’ pavement marking on both the eastern and western approaches to the level crossing. This may assist with the identification of the level crossing.

Sighting distance With respect to sighting distance, AS 1742.7-2007 clause 4.2.1(b) states that at a level crossing having ‘Stop’ sign control:

The sight distance shall be sufficient for the road vehicle driver stopped at the railway crossing stop line to be able to start off and clear the crossing before the arrival of a previously unseen train.

Using the formulae contained within AS 1742.7-2007 appendix D3, a truck of the class involved in the collision at Aerodrome Road when stopped on the stop line, 27 on the western approach, needs about 260 m sighting (S3 Figure 14) to safely traverse the crossing with a train approaching at 80 km/h.

The sighting distance to the left (S3) from the stop line, in the direction The Sunlander was approaching the crossing, was found to be well in excess of 500 m. The sighting distance exceeded the requirements of the standard for all vehicles authorised to use this level crossing.28

Australian Standard 1742.7-2007 appendix D4 also prescribes that the maximum viewing angle measured at the stop line when looking for an approaching train should not exceed 110 degrees, looking to the left. An assessment of the Aerodrome Road level crossing geometry revealed a viewing angle of 84 degrees for a vehicle stopped on the western side at the stop line. This is significantly better that the 110 degrees specified by the standard and indicates that the amount of ‘head twist’ required of the truck driver was not excessive in this instance and thus was unlikely to have been a factor in the collision.

Another important consideration that can impact on the available section sighting distance is the prevailing environmental conditions. As detailed at section 1.4 of this report, at the time of the collision the weather was overcast but fine and the sun’s azimuth was 113 degrees 17.8 minutes at an altitude of 74 degrees 36.9 minutes. Therefore, glare or other issues such as dust or rain were unlikely to have been factors that affected the visibility of the signs or conspicuity of the approaching train.

27 Calculation assumes a waste disposal truck of length 10.3 m having an acceleration of 0.5 m/sec.

28 Note: A semi-trailer of 19 m in length having an acceleration of 0.36 m/sec requires 340 m sighting. Therefore adequate sighting distance was available for all vehicle types that were allowed to use the Aerodrome Road level crossing.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 24 The QPS carried out re-enactments at the scene using a similar vehicle to that involved in the collision. The re-enactment showed that a truck having stopped at the stop sign and accelerating in a normal manner would reach a speed of approximately 6 km/h when traversing the level crossing. The same vehicle, when driven in a normal manner from the last rubbish bin pick-up point, would attain a speed of approximately 20 km/h when traversing the level crossing.

within AS1742.7

Figure 14: AS 1742.7-2007 approach distances and viewing angles sighting diagram.

Conclusion The Aerodrome Road level crossing exceeded the minimum requirements prescribed in AS 1742.7-2007 in terms of both the viewing angle and the sighting distance (to the north) for a road user whose vehicle was stationary at the ‘Stop’ sign on the western side of the level crossing.

Based on the evidence, had the truck driver come to a halt at the ‘Stop’ sign and visually searched the rail track, he should have been able to see and respond appropriately to the approaching train.

page 25 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 2.2.4 Level crossing occurrence history

A review of data held by the QPS, CCRC, QT and QR found only two recorded instances of near-miss/collision history between trains and motor vehicles at the Aerodrome Road level crossing. These were:

5 Aug 1999 at 2010. Collision - A vehicle drove into the side of a freight train. One person was severely injured. 12 June 2008 at 1549. Near miss - A vehicle crossed within 20 m of the front of a passing train.

2.3 Human factors 2.3.1 Truck driver behaviour

Human information processing Both active and passive control level crossing devices rely on the correct behaviour of the road user. Figure 15 shows a version of ‘Wickens’ model of human information processing (Wickens, 1984). In both active and passive control protected level crossings, the requirement on the road user is the same. Firstly, a stimulus, for example flashing lights or the presence of a ‘Stop’ sign, must be present.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 26 Attention resources

Stimuli Decision Response and Response Perception response execution selection

Working memory

Long-term memory

Memory

Feedback

Figure 15: Model of human information processing

The road user must then perceive the stimulus which requires attentional resources and their long-term memory. Next, the road user uses attentional resources and both their long-term and working memories to make a decision and decide on the response. Once the decision has been made and a response selected, the road user can execute the response and monitor the response through the feedback loop to ensure it was appropriate.

In an example of a road user approaching a passively controlled level crossing with a ‘Stop’ sign, the stimulus of the sign is present. The road user must perceive the sign by using their long-term memory and some attention resources. Based on their perception of the sign, the road user will make a decision to stop at the ‘Stop’ sign. The road user will then apply the brakes on the vehicle and, based on the response of the vehicle, will monitor that the vehicle stops at the sign. Driving is a skill-based behaviour and as such will often require minimal attentional resources. However, work such as collecting bins from the side of the road may be more task-based behaviour and require far more attentional resources.

page 27 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Unfortunately, due to a number of different possibilities, human information processing is not infallible and errors can occur. One of the issues with human information processing is that humans have a limited amount of attentional resource, which limits the amount of information that can be perceived, the number of decisions that can be made and the number of responses that can be executed.

Based on accounts from the train driver and other evidence, the truck did not stop at the ‘Stop’ sign before proceeding across the Aerodrome Road level crossing.

2.3.2 Factors unlikely to have affected truck driver behaviour

The following sections discuss the factors that appear unlikely to have affected the truck driver’s behaviour.

Toxicology The post-mortem examination of the truck driver established that he was not affected by alcohol or illicit drugs or medication likely to affect his driving performance.

Mobile telephone The investigation established that the truck driver was not receiving any incoming calls or using his mobile telephone at the time of the collision.

Misjudgement Road users are often unable to judge the speed and distance of an approaching train, which can result in the road user attempting to cross the tracks before a train arrives at the crossing.

There are two phenomena which relate to misjudgement of train speed and distance. The first relates to the fact that as an object approaches a viewer, the growth in size is not linear but hyperbolic, meaning that at distance an approaching object appears to grow quite slowly. As the object gets closer, it appears to grow much faster and looms. The result of this with a train approaching a level crossing is that road users are able to estimate the speed of a train more effectively when it is close because of the rapid change in visual angle. When the train is much further away, road users are more likely to underestimate the speed of the train due to the slow change in visual angle.

The second phenomenon relates to the human perceptual issue of the large object illusion. Leibowitz (1985) suggests that road users underestimate the speed of trains as, in general, human vision and perception underestimates the speed of large objects. Leibowitz gives the example of how a large aircraft approaching a runway appears to move slowly, while a small aircraft travelling at the same speed appears to moving much faster.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 28 In addition to these phenomena, when a road user is close to a crossing, they tend to view the train virtually head-on. This results in there being minimal lateral motion which is an important visual cue in the perception of the speed of the train.

Given these limitations of perception, it is possible that as the truck driver neared the crossing he saw the train approaching but misjudged the speed and distance of the train and felt able to make it over the crossing before the train arrived.

However, given the residential housing and vegetation that limited the sighting distance on the approach to the level crossing at Aerodrome Road, the train would have been quite close to the crossing before the truck driver would have been able to see it. Therefore it is unlikely that misjudgement of train speed and distance was a factor in the collision.

Fatigue Fatigue can have a profound effect on a road user’s performance. It can reduce attention, increase reaction time and affect memory. It can also affect a person’s ability to judge distance, speed and time. Sleep deprivation, even for one night, generally has negative influences on several aspects of human performance. Performance decrements from sleep loss include slowed reaction time, delayed responses, failure to respond when appropriate, false responses, slowed cognition, and diminished memory.

Performance decrements for cognitive psychomotor tasks have been shown to reduce for each hour of wakefulness between 10 and 16 hours to an equivalent performance decrement observed with a 0.004 percent rise in Blood Alcohol Concentration (BAC) per hour. After 17 hours of sustained wakefulness, performance decreased to a level equivalent to the performance impairment observed at a BAC of 0.05 percent. After 24 hours of sustained wakefulness, performance decreased to a level equivalent to the performance deficit observed at a BAC of roughly 0.10 percent29.

Research has also shown that partial sleep loss from going to sleep later or waking earlier can also influence behaviour. For instance, waking two hours earlier than normal has been shown to lead to a decline in performance on more difficult (but not easier) short-term memory tasks.30

The truck driver worked a fixed eight hour roster, Monday to Friday. He had adequate sleep opportunities including weekends off. Roster related fatigue is therefore not considered to be a factor in this collision. Although the evening preceding the collision was New Year’s Eve, it was established that he had an early night as he was rostered for work early the next morning. It is therefore highly unlikely that fatigue was a factor in the collision.

29 Dawson, D., & Reid, K. (1997). Fatigue, Alcohol and Performance Impairment. Nature, 388 (July-August), 235.

30 Campbell, S. S. (1992). Effects of sleep and circadian rhythms on performance. In A.P. Smith & D. M. Jones (Eds) Handbook of Human Performance, vol 3, 196-216. page 29 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Crossing awareness It was established that the truck driver lived and worked in the Innisfail – Mundoo area and had worked for Subloo’s for the previous 18 months. He regularly collected waste along Aerodrome Road and probably traversed the level crossing at least twice a week in that time.

Vegetation and residential housing on the northern side of Aerodrome Road completely obscures any train approaching the level crossing from the north for road users travelling in an easterly direction until close to, or stopped at the ‘Stop’ sign.

The truck driver’s familiarity with the crossing meant he would have been fully aware of this impediment to sighting a train and the consequent need to stop at the level crossing. It is considered highly unlikely that the truck driver’s actions in failing to stop at the crossing were due to a lack of awareness of the presence of the level crossing or the existence of the ‘Stop’ sign.

The absence of tyre skid marks on the pavement near the level crossing indicates that the truck driver probably did not make a brake application before entering or while traversing the crossing. In the event that he did see the train, once he was on the level crossing and had time to react, that reaction may have been to accelerate in an attempt to clear the crossing and move out of the path of the oncoming train. However, the short time between when the train driver saw the truck enter the level crossing and the collision would suggest there was only limited time for the truck driver to take such action.

Based on available evidence, it is concluded that the truck driver was familiar with the route and should have been aware of the presence of the level crossing. It is probable that his behaviour was influenced by factors other than a lack of awareness of the crossing.

2.3.3 Factors likely to have affected the truck driver’s behaviour

The following sections consider the factors that could have potentially affected the truck driver’s behaviour. While the factors are considered individually, it is important to note that they may not have happened in isolation and that they may be inter-linked. For example, the expectation of encountering a train affects the possibility of not looking or ‘looked but did not see’.

Expectation of encountering a train A factor which influences the behaviour of road users at level crossings is their expectation of encountering a train (NTSB31, 1998). If the road user does not expect to encounter a train they may simply not look for one and behave accordingly, or they may look but not see (discussed later) a train because they were not expecting to see one.

31 National Transportation Safety Board of the United States of America

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 30 The road user’s perception that a train is unlikely to be at a crossing is reinforced every time they use the crossing without seeing a train. Research has found that an individual’s response to a possible hazard is influenced by both the perceived probability of the adverse event occurring and their understanding of the severity of the consequence of the event. A person’s perception of the probability of a given event is strongly influenced by past experience (Schoppert and Hoyt, 1968 cited in NTSB, 1998) and the frequency with which they encounter a train at a level crossing will influence the likelihood of the road user stopping (NTSB, 1998).

It is known that the truck driver was familiar with the crossing and probably traversed it as often as twice a week. He had in fact traversed the crossing only minutes earlier before returning to collect waste on the northern side of the road. Approximately 41 trains use the line weekly, an average of six trains per day or about one train every four hours. On Thursdays (the day of the accident) only one train was scheduled between 0600 and 1200. Therefore the probability of seeing a train was relatively low.

Had the truck driver previously seen little or no rail traffic passing over the crossing, he may have had a low expectation of seeing a train at the crossing and this may have led to the development of a pattern of not looking for trains or looking but not seeing a train.

It was also established the truck driver started his shift approximately one hour earlier than normal to finish early on New Year’s Day. If the driver had not previously noticed trains during his regular time of operating on this route, it may have reinforced his low expectation of seeing a train, even though he was operating to a different time schedule.

Stop signs Section 121 of the Queensland ‘Transport Operations (Road Use Management— Road Rules) Regulation 1999’, stipulates: 121 Stopping and giving way at a stop sign at a level crossing A driver at a level crossing with a stop sign must - (a) stop at the stop line or, if there is no stop line, at the stop sign; and (b) give way to any train or tram on, approaching or entering the crossing. Maximum penalty - 20 penalty units.

In this context, the failure of a road user to stop at a level crossing ‘Stop’ sign may be explained by their expectation of being caught and the consequences if they are caught. If the road user does not expect to be caught and the consequences of being caught are low, there is a greater chance that they will flout the law.

The road user’s perception that they are unlikely to be caught is reinforced every time they break the law and do not get punished, either through the law, page 31 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 or socially through the stigma of unlawful behaviour. The road user’s response to a possible hazard is influenced by both the perceived probability of the adverse event (being caught by the police) occurring and of that individual’s understanding of the severity of the consequence (the size of the fine). A person’s perception of the probability of a given event is strongly influenced by past experience and the frequency with which they encounter enforcement will influence the likelihood of the road user obeying the law. If the level of enforcement is relatively low, this expectation is continually reaffirmed.

Road user confidence may also play a part in not stopping at the sign. Over half of Australian drivers rate themselves as above average drivers (Job, 1990). This over-confidence can result in road users believing they are superior drivers and therefore not at risk when passing a ‘Stop’ sign without coming to a complete stop.

Research has shown that ‘Stop’ sign behaviour can reflect risky decision-making rather than adherence to the law (McKelvie, 1986) and that upwards of 50 percent of road users do not come to a complete stop at signs (McKelvie, 1986 and DeVeauuse et al., 1999).

Another factor to consider is the type of vehicle that is being driven by the road user. Stopping and then restarting in a car does not require much ‘effort’. In a truck, coming to a complete stop and then restarting can be time consuming and require much more ‘effort’ on the part of the driver. It is possible that the ‘effort’ to stop and restart the truck influenced the driver’s behaviour.

Given these factors, it is clear that many road users do not feel compelled to come to a complete halt at a ‘Stop’ sign.

Audibility of the train horn The NTSB (1998), in cooperation with several Oklahoma based companies, conducted research on the audibility of train horns in different types of road vehicles. They measured the amount of insertion loss32 that occurred for each vehicle and also the audibility level of the train horn under different vehicle conditions (including windows up with engine at idle and air-conditioning fan on high). The train horn sound level used in the tests was 96 dB(A)33 30 m from the vehicle. In seven of the 13 vehicles tested the train horn was not audible over the fan and engine at idle noise. This study did not include other potential noise sources such as radio/music, engine noise above idle or road noise generated by a moving vehicle. The NTSB concluded that these results underestimated the level of interior noise that would be present under normal driving conditions and therefore overestimated the audibility of the train horn.

32 Insertion loss refers to the difference between the measured sound values from an exterior sound source taken outside the highway vehicle and inside the vehicle (NTSB, 1998).

33 The decibel (dB) is a logarithmic unit used to measure sound. The human ear does not respond equally to all frequencies. It is much more sensitive to sounds in the range of 1,000 to 4,000 Hz, than to very high or very low frequencies. The A scale is a filter that responds to frequency in a similar way to the human ear (http://www.phys.unsw.edu.au/jw/dB.html).

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 32 In the Mundoo collision sequence the first use of the train horn was recorded approximately 12 seconds before the collision. Given, the distance of the train from the crossing (approximately 250 m) and the presence of obstacles (residential housing and vegetation) between the truck and the train, and that the truck windows were closed (truck air conditioning probably operating), it is probable that the first sounding of the train horn did not alert the truck driver to the train’s presence. The horn was sounded for a second time, approximately two seconds before the collision, which would not have provided the truck driver with enough time to respond even if he did hear it.

It is probable that the truck driver did not hear the first sounding of the train horn or did not recognise it as the warning signal of an approaching train and failed to respond accordingly.

Looked but did not see The term ‘looked but did not see’ is generally used to cover two phenomena, change blindness and inattentional blindness. These two phenomena are related and closely fit with the model of human information processing in Figure 15.

As observers of a scene, individuals believe that they see the entire picture in great detail and can immediately notice any changes in it. However, this is not the case and change or inattentional blindness can occur with dramatic consequences.

Change blindness occurs when an individual viewing a visual scene apparently fails to perceive a change. Research has shown the effects of change blindness (Rensink et al., 1997) can have dramatic real world effects (Simons and Levin, 1998). In their research, Simons and Levin asked directions of a pedestrian. During the conversation, it was temporarily interrupted by two people carrying a door between the researcher and the pedestrian. While the pedestrian could not see the researcher, another researcher took their place and continued the interaction after the door had passed. In less than 50 percent of cases the pedestrians involved noticed the change of researcher. Given the nature of the Mundoo crossing and the fact that there was no perceptible change in the scene apparent to the truck driver until the train would have been visible to him just before he arrived at the crossing, it is unlikely that change blindness was a factor in this collision.

Inattentional blindness is the failure to perceive what would appear to others as an obvious visual stimulus. As all individuals have limited attentional resources they may simply miss vital visual stimuli if their attention is allocated on another task.

Research by Mack and Rock (1998) into the phenomenon of inattentional blindness has shown how a person may fail to perceive an object even though they were looking directly at it. Furthermore, research by Green and Senders (2004) has shown that in road accidents, critical or important information may have been detectible but the road user did not attend to or notice it because their mental resources were elsewhere. The truck driver was engaged in moving from

page 33 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 one point to another and lining up to collect and empty bins from the side of the road. It is probable that this activity was using a large portion of the driver’s mental resources leading up to the collision.

The human mind has limited resources for perceptual and memory processing. To cope with this limitation, a mechanism called ‘attention’ acts as a filter to focus this resource on specific tasks. Research and the model of human information processing Figure 15 suggests that inattentional or change blindness can occur when attention is mistakenly filtered away from important information and can be affected by mental workload, expectation, conspicuousness and capacity. As attentional resources are limited, if the viewer is attending to something else, which may be making a decision, executing a decision or another stimuli, it is possible that the road user may not notice a particular stimulus.

When considering the collision between the truck and train, it is possible that the driver of the truck ‘looked but did not see’ and suffered from inattentional blindness at two distinct points. The first point was on the approach to the crossing. Here it is possible that the driver of the truck did not perceive the ‘Stop’ sign and drove the truck accordingly. The second point was at or near the ‘Stop’ sign. Here it is possible that the driver did look along the track directly at the train, but failed to perceive the approaching train which would have been clearly visible (the locomotive headlight was illuminated and the front of the locomotive was bright yellow that would strongly contrast against the background environment) from his seat on the left-hand side of the truck’s cabin.

It is quite probable that at both points on this occasion, the truck driver was so pre-occupied with the task at hand that his attentional resources were allocated to the collection of bins/waste from residential properties along Aerodrome Road. As a result his attention was drawn away from either the ‘Stop’ sign or the approaching train, to the extent that he failed to perceive either of those visual stimuli or the risk associated with traversing the level crossing at that time.

2.4 Crashworthiness of the train Given the forces that the locomotive and carriages were subjected to, both at impact and during the subsequent derailment sequence, the chance of major injury (or worse) to the people on the train was high, especially for the train drivers. Therefore, the crashworthiness of The Sunlander should be considered.

2.4.1 Locomotives

The collision between locomotive 2196 and the waste disposal truck occurred at the front/buffer of the train and the left-hand side of the waste collection bin of the truck, directly above the double axle wheel set. Although the collision caused significant damage to the locomotive, the greatest threat to the wellbeing of the train drivers was from the subsequent roll-over of the locomotive after it derailed.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 34 Despite the extent of the damage to the locomotive, damage within the crew cabin was mainly confined to the displacement/damage of cabin fittings. The biggest risk to the drivers in this collision was probably being thrown around in the locomotive cab.

Locomotive 2196 was examined on 5 February 2009 after it had been recovered and transported to the QR Redbank workshops. This examination confirmed that although external damage to the locomotive was significant, the structural integrity of the driver’s cab was maintained (Figure 16). Discussions with QR engineering staff established that a large number of Clyde built locomotives have undergone a mid-life refit.

The lead locomotive (2196) was overhauled on 20 October 2000. The refit included reinforcing the driver’s cab with anti-intrusion bars (anti-collision beams, see Figure 17) and external plating/panels that have increased the thickness of the side walls and roof from an original 1.6 mm to 3.0 mm. The front panel of the driver’s cab has been increased to 10 mm and the roof thickness has also been increased substantially.

It is very likely that the extent and quality of this work was effective in maintaining the integrity of the locomotive cab and reducing the associated risk to the train drivers in this accident.

Figure 16 View of right-hand side of locomotive cab 2196 at QR Redbank workshop. This is the side the locomotive came to rest.

page 35 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Anti-intrusion bars welded into the front corners of the locomotives as part of the midlife refit.

Figure 17: View of intrusion bars being installed on a Clyde built locomotive undergoing refit at Redbank.

2.4.2 The Sunlander carriages

The protection afforded to on-board train staff and passengers is a key consideration in the event of a level crossing collision.

Four of the six carriages located behind the second locomotive 2479 that had derailed were public sleeper cars. An examination of these four carriages revealed that no fixtures such as doors, seating, fixed panels, windows etc had become dislodged during the collision or subsequent derailment.

Small items strewn within buffet car.

Figure 18: Buffet car showing evidence of minor items being thrown around.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 36 Dislodged table in sleeper carriage/ cabin.

Figure 19: Many of the sleeper cabins’ fold-away tables were strewn within the cabin.

It was also evident that in most of the sleeper cabins, semi-fixed tables located under the seat/bed were strewn around the compartment. It was also noted that many unsecured/smaller items such as glassware, crockery and cutlery had been thrown around in the ‘buffet car’34 (Figure 18).

Occupant safety was not compromised by failed carriage structural components. Any immediate danger to passengers or staff within the carriage saloons was mainly as a result of any unrestrained movement of persons and/or unsecured items (Figure 19).

34 The buffet car was the eleventh carriage behind the locomotives. This carriage did not derail. page 37 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 2.5 Passenger questionnaire

Response Following the collision a questionnaire was sent to passengers who were on The Sunlander at the time of the accident. The passenger questionnaire was designed to canvas a number of matters relevant to the collision and subsequent emergency response.

The safety investigation sought feedback from the train passengers with a view to establishing the circumstances surrounding the accident and what procedures or processes may be changed to improve rail safety in Queensland.

When reviewing passengers’ responses, consideration needs to be given to the circumstances of the incident. The accident occurred at 1118 on New Year’s Day, a public holiday, near a country town. CCRC organised council workers to open stores and supply tarpaulins, seats and portable toilets at the assembly site for use by the passengers. The State Emergency Service (SES) called in volunteers from surrounding districts to provide support and the QAS and Queensland Fire and Rescue Service (QFRS) had people on site at 1127 and 1129 respectively.

Of the 112 passengers on board, surveys were posted out to 70 passengers whose identity and address was known (63 percent). Responses were received from 25 passengers (a response rate of 22 percent), with eight being returned as undeliverable and one being returned due to the passenger not being on the train prior to the accident.

Due to the low response rate it was determined no data analysis would be conducted and that only qualitative comments would be reviewed. The results presented in this report represent the responses and experiences of only a limited number of passengers and are not necessarily representative of the majority. Individual responses have been treated confidentially with the key findings of interest to the investigation being included for completeness and are as detailed below:

The overriding comment from all passengers who responded was that the handling of the accident by QR staff and emergency services (including QPS, QFRS, SES and QAS was excellent). In relation to general safety instructions given onboard prior to the accident, comments were made that in one train car the safety instructions could not be heard and some passengers stated that they did not hear or were not given any safety instructions. There were comments made about general confusion in relation to exit doors not being able to be opened and some panic due to passengers being told of a fuel leakage whilst being asked to evacuate. Some passengers commented on the amount of time they had to spend waiting in the sun at Mundoo, with one passenger reporting severe sunburn as a consequence.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 38 A comment was made that some passengers had to go back to the train to collect their luggage when they had injuries and were in pain. A number of passengers stated that they appreciated the food and drink which was given to them from the train immediately after the accident and whilst waiting at Mundoo. A comment was made by some passengers that journalists had been given permission35 to take photos of distressed passengers inside the hall at Mundoo. Some comments were made about what passengers perceived to be the poor handling of both them and their luggage upon return to Roma Street via bus from Mundoo, with QR staff at Roma Street having no information about them or their luggage.36

Passenger manifest The attempt to survey passengers on The Sunlander has revealed that the known addresses or identity of passengers travelling on the train at the time of the accident was in the order of 54 percent (61 out of 112 passengers). There are many reasons why the passenger manifest of any passenger transport operation, be it road, rail or air, needs to be accurate. In particular, an incident, accident or service delay can make the need to contact either the passenger or a nominated relative a priority.

35 QR has confirmed that at no time had they given anyone the authority to take photos of the passengers inside the hall.

36 QR stated they had provided accommodation for passengers as required and had two senior managers available at Roma Street Station to answer questions and provide information to passengers. page 39 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 3 Conclusions

3.1 Context At 1118 on 1 January 2009 a laden waste disposal truck drove into the path of The Sunlander passenger train at the Aerodrome Road level crossing, Mundoo, near Innisfail, North Queensland. As a result of the collision, the truck driver was fatally injured.

Based on the available evidence, the following findings are made with respect to the collision. They should not be read as apportioning blame or liability to any particular individual or organisation.

3.2 Findings 1. The truck driver was fatally injured as a result of the collision.

2. Of the train occupants, nine passengers and six QR staff (including both train drivers) suffered minor to moderate injuries in the collision.

3. The train crew were appropriately trained, qualified and medically fit at the time of the collision.

4. Breath testing of the train drivers for alcohol returned zero readings.

5. The truck driver was appropriately trained and qualified at the time of the collision and based on available police records and post mortem results, did not have any known medical condition that would have precluded him from driving a heavy motor vehicle/truck of this class.

6. Toxicology testing of the truck driver for alcohol and illicit drugs returned zero readings.

7. There were two on-board staff with current senior first aid competencies.

8. There were no mechanical deficiencies of the train that contributed to the collision.

9. There were no mechanical deficiencies of the truck that contributed to the collision.

10. It is very likely that the mid-life refit structural alterations to the driver’s cabin of locomotive 2196 were effective in minimising the failure of the cab and the associated risk to the train drivers.

11. At the time of the collision train 3936 had the appropriate authorisation to occupy the section of track that includes the Aerodrome Road level crossing.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 40 12. The operation of the train in terms of speed, sounding of the locomotive horn and braking was appropriate. It is probable that the locomotive headlight was illuminated.

13. A review of the Aerodrome Road level crossing geometry revealed that the available sighting distance and viewing angle at the ‘Stop’ sign on the western side of the level crossing more than met the requirements in Australian Standard 1742.7-2007.

14. The approach warning signage for the Aerodrome Road level crossing was not fully compliant with MUTCD Part 7/AS1742.7-2007 and the road markings were in poor condition.

15. There were no ‘RAIL’ and ‘X’ pavement markings on either the eastern or western approaches to the Aerodrome Road level crossing. These signs are not mandatory under MUTCD Part 7/AS1742.7-2007 for all circumstances. They are not mandatory for the Aerodrome Road level crossing.

16. The truck driver regularly traversed the Aerodrome Road level crossing and would have been well aware of its presence.

17. It is probable that the initial sounding of the locomotive horn failed to alert the truck driver to the presence of the train.

18. Had the truck driver come to a halt at the ‘Stop’ sign/line as prescribed, he should have been able to perceive the train.

19. The emergency response to the collision was prompt and effective. The evacuation of the train was effective and occurred soon after the emergency responders arrived.

20. The passengers and on-board staff were left in an open field without suitable facilitates for approximately 2.5 hours and there were delays in transportation by bus south to Brisbane and points in between37.

21. The lack of supervision by QR staff on the buses south of Townsville was of concern for some passengers.

22. The manifest detailing the addresses and identities of passengers travelling on The Sunlander at the time of the accident was in the order of 54 percent (61 out of 112 passengers).

23. The lack of a data recorder on the truck meant that analysis was based on the observations on the train drivers and a reconstruction of events.

24. During the investigation, it was noted there were some minor inconsistencies between MUTCD Part 7 2003 and the current AS 1742.7 2007.

37 This needs to be considered against the organisational factors required by all parties to arrange amenities and transport on New Year’s Day holiday. page 41 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 3.3 Contributing factors 1. The driver of the waste disposal truck did not come to a halt at the ‘Stop’ sign, entered the level crossing at an estimated speed of approximately 20 km/h and drove into the path of The Sunlander train (3936) which was approaching the crossing.

2. It is probable that the truck driver’s failure to recognise the presence of the train was a result of his low expectation of seeing a train at the crossing and/ or not feeling compelled to come to a complete halt at the level crossing ‘Stop’ sign and/or his attention being drawn away from either the ‘Stop’ sign or the approaching train due to his concentration on the collection of refuse bins.

3. The truck driver was legally required to wear a seatbelt but was not doing so at the time of the collision. This probably contributed to the driver being ejected from the truck cab. The driver then impacted against the side of the locomotive and sustained fatal injuries.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 42 4 Safety actions

The safety issues identified during this investigation are listed in the Findings and Contributing factors sections of this report. The Department of Transport and Main Roads (DTMR) expects that all safety issues identified by the investigation should be addressed by the relevant organisations.

All of the organisations responsible for the safety issues identified during this investigation were given the opportunity to review the draft report and invited to provide comment. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or proposed in relation to each safety issue, relevant to their organisation.

Depending on the level of risk of the safety issue, the extent of corrective action taken by the relevant organisation, or the desirability of directing a broad safety message to the transport industry, DTMR may issue safety recommendations or safety advisory notices as part of the final report.

4.1 Subloo’s Pty Ltd 4.1.1 Truck driver’s attention

Safety Issue It is probable that the truck driver’s failure to recognise the presence of the train was a result of his low expectation of seeing a train at the crossing and/or not feeling compelled to come to a complete halt at the level crossing ‘Stop’ sign and/ or his attention being drawn away from either the ‘Stop’ sign or the approaching train due to his concentration on the collection of refuse bins.

Contributing factor 1 and 2 Safety action already completed In consultation with Queensland Workplace Health and Safety (WH&S), Subloo’s Pty Ltd have raised their employees’ awareness of, and compliance with, level crossing traffic control measures.

4.1.2 Seatbelt usage

Safety Issue The driver of the waste disposal truck was not wearing a seatbelt at the time of the accident. This probably contributed to him being ejected from the truck cab resulting in fatal injuries.

Contributing factor 3 Safety action already completed In consultation with WH&S, Subloo’s Pty Ltd have reviewed their work procedures for wearing of seatbelts and ensured their drivers are aware of the statutory requirements of wearing seatbelts. page 43 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 4.2 QR Passenger Pty Ltd. 4.2.1 Train passenger contact details

Safety issue The manifest detailing the addresses and identities of passengers travelling on The Sunlander at the time of the accident was in the order of 54 percent (61 out of 112 passengers).

Finding 22 Recommended safety action That QR Passenger ensures that, as far as possible, passenger manifests are accurate in terms of passenger identities and nominated contact details.

4.2.2 Passenger transportation post-accident

Safety issue The lack of supervision by QR staff on the buses south of Townsville were areas of concern for some passengers.

Finding 21 Recommended safety action That QR Passenger review the procedures for response to collisions of passenger trains and the subsequent transportation procedures.

4.3 Cassowary Coast Regional Council 4.3.1 Level crossing signage

Safety issue The approach warning signage for the Aerodrome Road level crossing was not fully compliant with MUTCD Part 7/AS1742.7-2007 and the road markings were in poor condition.

Finding 14 Safety action already completed Cassowary Coast Regional Council has implemented a maintenance program to periodically visit and review the level crossings in its area and program maintenance to repair and replace missing or deteriorated controls.

4.4 Queensland Level Crossing Safety Committee 4.4.1 Level crossing signage

Safety issue The approach warning signage for the Aerodrome Road level crossing was not fully compliant with MUTCD Part 7/AS1742.7-2007 and the road markings were in poor condition.

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 44 Finding 14 Recommended safety action That the Queensland Level Crossing Safety Committee recommends its members review current level crossing maintenance programs.

4.4.2 Level crossing road markings

Safety issue There were no ‘RAIL’ and ‘X’ pavement markings on either the eastern or western approaches to the Aerodrome Road level crossing. However, these are not prescribed for all circumstances.

Finding 15 Recommended safety action That the Queensland Level Crossing Safety Committee consider the placement of ‘RAIL’ and ‘X’ marking on level crossings where they are not already installed.

4.5 Department of Transport and Main Roads 4.5.1 MUTCD Part 7, 2003 and AS1742.7

Safety issue During the investigation, it was noted there were some minor inconsistencies between MUTCD Part 7 2003 and the current AS 1742.7 2007.

Finding 24 Safety action already underway That the Department of Transport and Main Roads review the MUTCD Part 7, 2003 with a view to updating to match the current Australian Standard.

4.5.2 Queensland Rail Regulator

Recommended safety action The Queensland Rail Regulator monitors the implementation of recommended safety actions.

page 45 Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 Appendix A : Sources and submissions

Sources of information Passengers, witnesses and next of kin QR Limited Queensland Police Service Department of Transport and Main Roads The Cassowary Coast Regional Council The train drivers and on-board train staff Queensland Ambulance Service Queensland Fire and Rescue Service

References Australian Level Crossing Assessment Model. Australian Standard 1742.7-2007: Manual of uniform traffic control devices. Part 7: Railway crossings DeVeauuse, N., Kim, K., Peek-Asa, C., McArthur, D. and Kraus, J. (1999). Driver compliance with stop signs at pedestrian crosswalks on a university campus. Journal of American College Health. 47 (6), 269-274. Green, M., Senders, J., 2004. Human error in road accidents. Visual Expert. (http://www.visualexpert.com/Resources/roadaccidents.html#Green91S) Job, R.F.S. (1990). The application of learning theory to driving confidence: The effect of age and the impact of random breath testing. Accident Analysis and Prevention, 22, 97-107. Leibowitz, H.W. (1985). Grade crossing accidents and human factors engineering. American Scientist, 73, 558-562. Mack, A. And Rock, I. (1998). Inattentional Blindness. Cambridge: MIT Press. Manual of Uniform Traffic Control Devices Part 7 Railway Crossings, 2003 Edition McKelvie, S.J. (1986). An opinion survey and longitudinal study of driver behaviour at stop signs. Canadian Journal of Behavioural Science, 18 (1). National Transportation Safety Board (1998a). Safety at passive grade crossing. Volume 1: Analysis. Safety study NTSB/SS-98/02. Washington DC. Rensik, R.A., O’Regan, J.K. and Clark, J.J. (1997). To see or not to see: The need for attention to perceive changes in scenes. Psychological Science, 8, 368-373. Simons, D.J. and Levin, D.T. (1998). Failure to detect changes to people during a real-world interaction. Psychonomic Bulletin and Review, 5 (4), 644-649. Wickens, C. (1984). Engineering psychology and human performance. Columbus, OH: Merrill

Department of Transport and Main Roads, Rail Safety Investigation QT2493, 2009 page 46 Notes

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