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Final Report > > Rail Safety Investigation 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: 4 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 4 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: 4 Clearly establish the factual circumstances of both occurrences; 4 Identify the direct cause or causes of these occurrences and any other contributing factors; 4 Assess human factors to identify any underlying matters which may have caused or contributed to the occurrences; 4 Clearly indentify any systemic issues; and 4 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.
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