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Collision of Passenger Train T842 with Station Platform, Cleveland

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Collision of Passenger Train T842 with Station Platform, Cleveland Collision of passenger train Insert document title T842 with station platform LocationCleveland, | Date Queensland | 31 January 2013 ATSB Transport Safety Report Investigation [InsertRail Occurrence Mode] Occurrence Investigation Investigation XX-YYYY-####RO-2013-005 Final – 20 December 2013 Front cover: Photo supplied by Queensland Police Service. Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Publishing information Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office: 62 Northbourne Avenue Canberra, Australian Capital Territory 2601 Telephone: 1800 020 616, from overseas +61 2 6257 4150 (24 hours) Accident and incident notification: 1800 011 034 (24 hours) Facsimile: 02 6247 3117, from overseas +61 2 6247 3117 Email: [email protected] Internet: www.atsb.gov.au © Commonwealth of Australia 2013 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form license agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. Addendum Page Change Date 54 Figure 24: Row 5 - Track section location amended 7 Jan 2014 76 Buffer stop design criterion – QR response 255 t 5 March 2014 Safety summary What happened At about 0940 on 31 January 2013, a Queensland Rail Train T842 at Cleveland station passenger train (T842) failed to stop at the Cleveland station platform and collided with the end-of-line buffer stop, the platform and the station building at a speed of about 31 km/h. There were 19 people on board the train (including the driver and a guard); three people were on the platform and five were in the station building. A number of people were treated for minor injuries and transported to hospital for further examination. At the request of the Queensland Government, the ATSB Source: Dept of Transport and Main initiated an investigation into the accident. Roads, Queensland What the ATSB found The ATSB’s investigation found that local environmental conditions had resulted in the formation of a contaminant substance on the rail running surface. This caused poor adhesion at the contact point between the train’s wheels and the rail head. The braking effectiveness of train T842 was reduced as a result of reduced adhesion and the train was unable to stop before hitting the end-of- line buffer stop. The ATSB concluded that Queensland Rail’s risk management processes prior to the accident had not adequately assessed, recorded, managed and communicated the risks associated with operating trains on their network under low adhesion conditions. In addition, Queensland Rail had not undertaken exercises to test the preparedness and effectiveness of their emergency management system. Shortfalls were identified in the response to the accident with respect to internal communications within train control and between staff at Cleveland station which resulted in incomplete information being provided to key personnel. What's been done as a result Queensland Rail initiated a risk mitigation strategy in response to the collision of train T842 at Cleveland station on 31 January 2013. The strategy included the formation of a Wheel Rail Interface Working Group that identified the wheel/rail interface risks, particularly for Queensland Rail’s fleet of IMU160/SMU260 class trains being operated under certain conditions. Queensland Rail have also implemented a series of risk controls including identifying localised black spot locations and applying vegetation control measures, treating rail-head contaminants, reviewing and updating driver training with enhanced train handling advice about wheel slide and the trialling of sanding equipment on IMU160/SMU260 class trains. Queensland Rail have now undertaken emergency exercises to test the effectiveness of their emergency response arrangements and are implementing new communication protocols for emergency incident response. Safety message Rail operators should recognise that train braking performance may be significantly impaired when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion. Rail operators should put appropriate measures in place to assess and mitigate the risk to the safe operation of trains under these conditions. Contents The occurrence ........................................................................................................................1 Events prior to collision 1 Service T842 1 The collision 2 Post collision 5 Emergency response coordination 5 Vehicle recovery 6 Infrastructure repairs 7 Context ......................................................................................................................................8 Location 8 Organisation 8 Infrastructure 8 Track 8 Overhead traction system 9 Buffer stop 9 Slippery track conditions 10 Track adhesion and friction 11 Rail head and train wheel contaminants 11 Rail head and train wheel profiles 14 Train driver 16 Driver’s actions 16 Train information 16 Braking system 17 Brake inspection and tests 19 Pre-service brake conformance testing (IMU160 class) 21 Brake software changes 21 Test train SMU292 21 Wheel tread dressing 22 Train crashworthiness 23 Station overruns 27 Frequency by train class 27 Locations where trains have higher incidence of overrun 28 Previous Queensland Rail train wheel slide occurrences 33 Beerwah 9 January 2009 33 Beerwah 9 March 2009 36 Narangba and Morayfield 28 January 2013 36 Caboolture - test train 37 Train testing and data irregularities 38 BCU 38 VCU 39 Brake test methodology 39 Investigations of slide occurrences by other organisations 40 Siemens Nexas train overruns - Melbourne 40 Derailment of CityRail train 312A - Thirroul, NSW 11 September 2006 41 Rail slide occurrences - United Kingdom 42 Reference documents for the management of wheel slide 42 Train driver training 43 Training and qualifications 43 Emergency response management 44 Documented emergency management procedures 44 Emergency management training of involved Queensland Rail staff 45 Exercising emergency management procedures 45 Roles and responsibilities of train control personnel 46 Procedures for the assurance of Overhead Line Equipment (OHLE) safety 47 Actions of Queensland Rail staff at the emergency site 48 Communications between network control and Cleveland station 49 Train operations internal emergency debrief 49 Management of safety risks 50 Regulatory oversight of Queensland Rail 51 Confidential reporting system 55 Safety analysis ...................................................................................................................... 56 Organisational risk management 56 Beerwah 57 Other occurrences 58 Buffer stop collision risk 58 Regulatory oversight 59 Beerwah 60 Investigation report reviews 61 DTMR spot and compliance safety audits 62 National Rail Safety Regulator (NRSR) 62 Driver training for braking under conditions of low adhesion 62 Effectiveness of emergency management response 64 Design and accessibility of the Emergency Management Specification: 64 Preparedness and role of customer service staff in emergency response 65 Exercising simulated emergencies 66 Actions and interactions of train control personnel 66 Managing and communicating OHLE status 68 Criticality of efficient and standard communication protocols 68 Opportunities for organisational learning about emergency management 69 Findings ................................................................................................................................. 70 Contributing factors 70 Other factors that increased risk 70 Other findings 71 Safety issues and actions ................................................................................................... 72 Management of risk associated with poor adhesion 72 Safety issue description: 72 Current status of the safety issue: 73 Assessment and recording of rail safety risks 73 Safety issue description: 73 Cross divisional recognition of rail safety risks 74 Safety issue description: 74 Current status of the safety issue: 74 Application of safety actions from internal investigations 75 Safety issue description: 75 Awareness of rail safety occurrences in other jurisdictions affecting rail fleet type 76 Safety issue description: 76 Current status of the safety issue: 76 Buffer stop design criterion 76 Safety issue description: 76 Driver’s manual explanation of effects and control of low adhesion 77 Safety issue description: 77 Effective coordination of emergency communications 78 Safety issue description: 78 Emergency management exercises 78 Safety issue description: 78 Post emergency debrief and findings 79 Safety issue description: 79 Occurrence
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