RAIL SAFETY

ISSUE 7 JUNE 2012 Chris McKeown Director Rail Safety

Welcome to issue 7 of Rail Safety News

Readers will be aware that new rail safety is in the South Australian Parliament. Once this legislation is passed it’s expected to be enacted by most in , with a commencement date of December 2012. This is a challenging time frame for legislators and regulators, including Safety (TSV). Inevitably, the of rail safety will change when State parliaments pass enacting legislation. TSV is working with the National Project Office to ensure that the regulatory processes will transition smoothly and, importantly, that there is no reduction in safety oversight.

If you are interested in reading more about the National Rail Safety Regulator project, please visit http://www.nrsrproject. sa.gov.au

This edition of Rail Safety News highlights TSV’s current activities regarding track side worker safety and management of risks to safety associated with hi-rail vehicles. The risks related to fatigue and our usual update on rail accident investigations from around the world are features in this newsletter. I hope you will find them useful. Thank you and farewell

I would like to also take this opportunity to announce that this will be my last Rail Safety News column as TSV’s Director, Rail Safety. I have accepted a new position in the Office of the Chief Investigator as the Chief Investigator, Transport Safety and commence on 3 July. In this new role, I will continue to have a strong safety focus – something that I am very passionate about.

As much as I am excited about the prospect of embarking on this new challenge, I am equally proud of my time at TSV, where I have had the pleasure of working with the and other stakeholders to deliver and uphold important and tangible rail safety initiatives.

By the time you receive this newsletter, Andrew Doery will be acting in the position of Director, Rail Safety. Andrew comes to the role with a wealth of experience in the area, having held the role of Deputy Director, Rail Safety Operations, for some time now. I am confident that he will continue the good work accomplished by TSV and the industry thus far.

It has been a pleasure working with you in our joint quest to improve safety in the rail industry.

2 Safeworking – track side worker safety

A focus of TSV’s Rail Safety Compliance Program in 2011/2012 The more significant occurrences relate to: includes track side worker safety. This has translated into a number of targeted safety audits focusing on safeworking rules ●● near misses with track workers/equipment for infrastructure work and rail operators’ occupational health ●● work commencing prior to correct protection in place and safety requirements. ●● conflicting train/track authorities

This focus resulted from TSV’s analysis of reportable incidents, ●● protection removed prior to work completion. where an increasing trend of occurrences within the Occurrence Notification – Standard One (ON-S1) category ‘Safeworking Irregularity/Breach’ was identified. Closer examination of this trend revealed an increase in track side worker safety breaches.

Total 250

Years Quarters Total 2010 Qtr1 141 Qtr2 150 200 Qtr3 177 Qtr4 124

2011 Qtr1 146 Number of incidents

Qtr2 195 Count of Incidents Qtr3 206 150 Qtr4 184

10 0 Years Quarters Total 2010 Qtr1 26 Qtr2 22 Qtr3 53 50 Qtr4 33 2011 Qtr1 26 Qtr2 54 Qtr3 73 Qtr4 63 0 2010 2011 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Figure 1: ON-S1 category “Safeworking irregularity/breach”. Track Side Worker Safety Safeworking Occurrences > 3

80

70

60 Count of Incidents 50

40

30

20

10

0 2010 2011 Total 250

Years Quarters Total 2010 Qtr1 141 Qtr2 150 200 Qtr3 177 Qtr4 124 2011 Qtr1 146

Qtr2 195 Count of Incidents Qtr3 206 150 ¼¼ For more information about TSV’s Rail Qtr4 184 The increase in near misses with track TSV reinforces the importance for all rail workers/equipment is of particular operators and contractor staff to comply Safety Compliance Program or reporting concern. These incidents regularly at all times to safeworking standards, as rail incidents visit www.transportsafety. 100 Years Quarters Total involved work being undertaken where documented in their safety management vic.gov.au. 2010 Qtr1 26 only lookout protection (administrative systems. While it may be tempting Qtr2 22 control to treat risks) was in place. for staff to deviate from the systems Qtr3 53 50 Qtr4 33 In some of these cases equipment and procedures on site, any deviation 2011 Qtr1 26 was operated immediately adjacent increases safety risks. It is also important Qtr2 54 Qtr3 73 to the track with the potential to foul for rail operators and contractor staff to Qtr4 63 the mainline. ensure clarity for and appropriateness 0 2010 of risk treatment owners,2011 including the roles and responsibilities of all workers Data analysis has been a key input to to ensure safety. TSV’s Rail Safety Compliance Program.

Targeted safety audits are currently Track Side Worker Safety Safeworking Occurrences underway with heavy rail infrastructure managers in Victoria.

80

70

60 Number of incidents Count of Incidents 50

40

30

20

10

0

2010 2011 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Figure 2: Safeworking occurrences related to track side worker safety.

4 Mobile phones a distraction in safety critical tasks

Submitted by: Nic Doncaster, Office of the Rail Safety Regulator, .

Recent rail accidents have highlighted mobile phone use as a source of distraction in rail safety work.

On 12 September 2008, in Chatsworth, California, a passenger train collided head-on with a freight train. The passenger train locomotive and lead passenger car derailed and the freight train’s two locomotives and 10 of 17 cars also derailed. This resulted in 25 fatalities, including the driver of the passenger train. More than 100 passengers were hospitalised and other damage was estimated at greater than $US12 million.

After an extensive investigation, the National Transportation Safety Board (NTSB) determined that the probable cause of the collision was the failure of the driver of a passenger train to observe and appropriately respond to a red signal aspect. This was found to be because he was engaging in text messaging on his mobile phone at the time of the incident, which distracted him from his duties.

This is not the first occasion when mobile phone use has been found to have contributed to a train collision in the USA. A report on the impact of distraction caused by electronic devices in the US rail industry (Federal Rail Administration (FRA) 2008) identified possibly the first clearly documented accident.

On 28 May 2002, near Clarendon, Texas, two trains collided, resulting in two fatalities. The NTSB investigation report indicated the driver of one of the trains was conducting a personal call at the time the train exited the siding. The NTSB concluded that the driver may have been so distracted that he was unaware of the dispatcher’s instructions to stop the train at a designated point. Three other collisions involving mobile phones have been documented between 2000 and 2006.

…because he was engaging in text messaging on his mobile phone at the time of the incident which distracted him from his duties

5 While driving activities are typically There is extensive literature about the For those tempted to dismiss mobile cited, other activities on and around impact on safety of distraction due to phone distraction as a part of the driving safety critical areas also require the use of electronic devices, mostly experience, it is sobering to understand extensive vigilance from rail safety in the in-car driving environment. the misconception that conversation workers and their managers. The risk Typically, when considering the issue on a mobile phone while driving is is not restricted to drivers of trains. For of distraction, people think of holding equivalent to talking with an adult, sober example, on 8 June 2008, a brakeman in and using mobile phones while driving. and traffic-experienced passenger. This the US was struck and killed by the train However, there are other activities that has not been found to be true. Kircher, to which he was assigned (Federal Rail may also lead to distraction to a greater Patten and Ahlström (2011), reported Administration, 2008). The preliminary or lesser extent. Activities that have that passengers with traffic knowledge findings indicated that he had instructed been found to lead to distraction include, adapt their conversation patterns to the driver via radio to back the train according to Young, Regan & Hammer, the traffic situation at hand, such as up and subsequently walked across the 2003: stopping talking when the driver needs track, into the path of the moving train. to concentrate, and therefore can help in It is most likely that he was talking on his ●● hands free mobile phone use has regulating the driver’s workload. This is mobile phone. been found to be no safer than using usually not the case for telephone calls. a hand-held device In another similar incident in September 2010, a railway maintenance worker ●● mobile phone use has been found in Minneapolis stepped from behind a to be more distracting than holding stationary train on to tracks and was hit an intelligent conversation with a both experienced by another train. He was on his mobile passenger, but no more distracting phone at the time and may have been than eating a cheese burger and novice drivers standing near a “loud maintenance ●● smoking while driving has been found restricted their vehicle” (Levy, 2010). to increase the risk of being involved in a crash visual scanning The dangers of distraction ●● for younger drivers, the presence of while driving using Distraction can be dangerous because a peers increases crash risk a mobile phone person’s attention is diverted away from a central activity to other competing ●● reaching for a moving object and activities. For instance, in train driving applying make-up may expose the this could be distraction from any tasks driver to up to three times the risk of critical to the safe operation of the train. crash involvement (Robertson, 2011). In the rail environment, distraction can lead a person to miss a critical piece of information, such as a signal or warning, an approaching train or vehicle, or a passenger or pedestrian.

6 > References Federal Railroad Administration (2008). The Impact of Distracting Electronic Devices on the Safe Performance of Duties by Railroad Operating Employees: Initial Report of the Study Required by Section 405 of the Rail Safety Improvement Act of 2008. U.S. Department of Transportation Federal Railroad Administration. Accessed on: 29 February 2012 at: http://www.fra.dot.gov/downloads/safety/ CellPhoneReport4510.pdf

Federal Railroad Administration (2010). Restrictions on railroad operating employees’ use of cellular telephones and other electronic devices late season; final rule. Federal Register - Part V, 49 CFR Can we really multi-task? Action by regulators and Part 220. Department of Transportation, Federal In our modern world, people like to think Railroad Administration. Accessed on 29 February that they can multi-task. Unfortunately, In response to these types of events, 2012 at: http://edocket.access.gpo.gov/2010/ this is not the case. Research indicates the United States Federal Railroad pdf/2010-23916.pdf ). that humans are “serial processors of Administration (FRA) amended its information”. This means that even railroad communications , though we may feel as though we are restricting the use of mobile telephones Kircher, K. Patten, C. and Ahlström C. (2011). Mobile multi-tasking we are really switching and other potentially distracting telephones and other communication devices our attention rapidly back and forth electronic devices by railroad operating and their impact on traffic safety: A review of the between tasks. As a result, none of the employees. TSV has also recognised the literature. Report No. VTI rapport 729A. Swedish tasks being performed is likely to receive risks associated with mobile phone use Government: Stockholm. Accessed on 28 February optimal attention (Smiley, 2005 cited in and in June 2011, issued a safety alert 2012 at: www.vti.se/publications. Robertson 2011). Here our biology limits about the risk associated with the use of our ability to multi-task. mobile telephones and other electronic devices. This was preceded by an earlier As the amount of information that safety alert on driver distraction in 2008. Levy, P. (2010). Rail worker struck, killed by requires attention increases, the Northstar train. Star Tribune: Minneapolis, US. brain must decide where to focus TSV considers that the use of mobile Accessed on 29 February 2012 at: http://www. attention. Some of this can be phones and other electronic devices startribune.com/local/north/101967018.html?page= consciously controlled, but much may affect a rail safety worker’s ability all&prepage=1&c=y#continue of it is not (Tromblay, 2010, cited in to carry out safety critical work. It could Robertson, 2011). lead to loss of situational awareness, failure to detect hazards and critical For example, Strayer, 2007 (cited in National Transportation Safety Board (2010). information, and increased mental Collision of Metrolink Train 111 With Union Pacific Robertson, 2011) estimated that mobile workload and error. phone use by drivers leads them to Train LOF65–12, Chatsworth, California, September fail to see up to 50 per cent of the TSV suggests that operators consider 12, 2008. Railroad Accident Report NTSB/RAR-10/01. available information. This is because reviewing: Washington, DC. Accessed on 28 February 2012 at: the driver’s effective field of vision http://www.ntsb.gov/doclib/reports/2010/rar1001. shrinks as the load of verbal information ●● risk registers with regard to the risks pdf increases (Tromblay, 2010, cited in associated with distraction for drivers Robertson, 2011). and other rail safety workers Robertson, R. (2011). Distracted driving: So what’s While experienced drivers perform ●● existing controls for these risks, for the big picture? Canada: Traffic Injury Research better than novice drivers, studies have example, procedures controlling the Foundation. found that the abilities of both groups use of electronic devices to maintain their vigilance are affected. ●● their approach to monitoring and For example, Smiley, 2008 (cited in enforcing these controls. – Robertson, 2011) found that both experienced and novice drivers restricted If you have further queries about Transport Safety Victoria (2011). Restrictions on the their visual scanning while driving using distraction associated with rail safety use of electronic devices. Safety Alert (SA. No. 2011- a mobile phone. work, please contact Elizabeth Grey, 01). Available at: www.transportsafety.vic.gov.au/ Manager Human Factors at TSV on rail-safety/newsroom/safety-alerts (03) 9655 6892.

7 Protecting our track workers

Protection arrangements on track are aimed at preventing workers being struck by approaching trains and to prevent entry of trains onto unsafe areas of track. Safeworking rules also apply to protect workers from injury through contact with electrical wiring or equipment. Apart from the devastating loss of life or serious physical injuries sustained by those involved in such events, incidents and near misses involving track workers can result in significant trauma to train crews and co-workers involved.

Many types of rail safety workers are involved in applying safeworking rules to manage risks working around the track. They include track protection coordinators/supervisors, hand signallers/ flagmen, maintenance workers, network controllers, signallers and train drivers.

Incidents can occur when rules and procedures are not followed, or when other factors combine to result in a hazardous situation. A review of safeworking incident reports provided to TSV from accredited operators during 2011 identified a number of actions and circumstances. >

8 “… the driver saw the The following examples of errors and ●● failure of track workers to move to violations occurred during work site a position of safety and give the ‘all four workers standing in protection tasks: clear’ hand signal to approaching the middle of the track train ●● a hand signaller observed placing with their backs to the protection on track while a train was ●● a flagman away from his post (e.g. train. He immediately approaching observed to be in a car) and/or flags left unattended on or next to the applied the emergency ●● a flagman positioned too close to track brake and sounded the worksite providing insufficient warning time for the train crew to ●● a flagman giving an inappropriate the horn…the workers respond hand signal (e.g. showing the ‘all clear’ hand signal when workers were moved very quickly ● ● a flagman positioned in a way that still on track) in a disorganised caused confusion as to which track the warning applied ●● multiple work groups within an fashion to clear off absolute occupation without ●● no Audible Track Warning (ATW) individual permits to foul the track. Expecting devices in place on approach to a the train would strike worksite ●● workers observed walking underneath overhead electrical wiring while it one or more of the ● ● ATWs placed on wrong track was being maintained workers, the driver ●● failure to obtain appropriate ●● workers observed standing on an ducked underneath the authorisation for electrical works adjacent, unprotected line dashboard and waited ●● work group observed without a ●● ATWs left in place following work and for the train to come to lookout in place removal of the flagman 1 ●● heavy machinery operating close to a stand... ●● a supervisor failing to inform a a running line without protection in flagman of works being completed place and inner flagman protection having 1 Office of Transport Safety been removed. Investigations (2010). Rail Safety ●● workers placed where no position of Investigation Report: Near Strike with Signal safety was available (e.g. on a bridge) Maintenance Staff, Strathfield, 1 April 2010. Available from: http://www.otsi.nsw.gov.au/ > rail/Investigation-Report-Near-Strike-Track- Worker-Strathfield.pdf

9 > While these actions involve some form of Rail operators are required to eliminate procedures and training to reduce these error or violation by individuals, it is also or reduce risks to safety so far as is risks. TSV promotes consideration of important to think systemically about reasonably practicable. This includes the hierarchy of control when reviewing what might have led to the occurrence. the risks and hazards associated with and selecting control measures. As such, Such actions are influenced by the local work on the track. Operators should operators should first consider where workplace environment and factors in review their risk registers regularly and there are opportunities to eliminate the organisational system. Rail operators ensure controls are appropriate and risks associated with track work through and infrastructure managers experiencing implemented correctly. This includes design and engineering controls such as such events need to consider what keeping abreast of new technologies the use of physical barriers. measures can be applied to minimise and methods of work and adopting these the likelihood of these behaviours and where they are reasonably practicable. The table below lists potential factors accidents arising as a consequence. known to be involved in track worker Most operators rely heavily on protection incidents, as well as potential administrative controls such as rules, safety measures.

Potential Example worker behaviour Potential safety measures contributing factor

Knowledge and Worker responsible for positioning ●● Improved training/on-going awareness sessions. experience flagman lacks experience calculating the ●● Implement non-technical skills training (e.g. rail resource appropriate distance where there are management) as this encourages double checking and asking differences in train operating speeds and for assistance if in doubt. track gradients.

Fatigue Workers are slow to detect an ●● Alarms to alert track workers of approaching trains. approaching train or to move to a ●● Sufficient resourcing is provided to complete the work within position of safety. scheduled, rather than relying on over-time.

●● Improved rostering practices.

●● Fatigue self-reporting systems.

Time pressure Workers choose lower form of protection ●● Realistic timeframes used for planning of work including to avoid significant train running delays. project works.

●● Legitimacy and importance of track work is promoted by senior management in the organisation.

●● Implement non-technical skills training. This can help to promote understanding between different work groups in terms of their roles and the operational pressures they face.

Distraction Person with safeworking responsibilities ●● Sufficient resourcing is provided to complete the work. becomes involved in, or distracted by, the ●● Alarms to alert track workers of approaching trains. work being undertaken on track.

Noise Lookouts and workers unable to hear ●● Alarms to alert track workers of approaching trains. approaching trains due to being in a noisy environment.

Poor visibility Lookout warning to workers delayed due ●● Improve visibility of trains. to difficulties detecting the presence of ●● Improve visibility of track workers. the train. ●● Alarms to alert track workers of approaching trains.

Complacency/ Flagman working in hot conditions leaves ●● Safety culture improvement initiatives. social norms his position to rest in his car nearby ●● Implement non-technical skills training (e.g. rail resource between timetabled trains. He is aware management). of other flagmen who do the same when working in adverse weather conditions. ●● Increased supervision/monitoring of protection arrangements.

●● Ongoing awareness sessions about risks.

Lack of co- Train crew would have approached the ●● Improving communications practices among different track ordination between area more cautiously and may have been worker groups, between network controllers and track different groups more vigilant looking for track gangs, had workers and between network controllers and train crews they been informed that work was being (regarding the position of track workers). undertaken in that area. ●● Implement non-technical skills training (e.g. rail resource management).

10 Good practice rostering

Rostering is typically a rail operator’s ●● minimise the occasions on which ●● monitor actual hours against planned primary control for eliminating or rail safety workers are required to hours, as well as the impact of reducing the risks to safety associated undertake rail safety duties for long changes from planned rosters due with fatigue. Shift patterns have a direct periods (i.e. from sign on to sign off) to shift swapping, overtime or on- impact on an individual’s fatigue levels, call working which can increase the potential for ●● ensure adequate rest and recovery human errors that can lead to accidents. periods after night shift work ●● consider fatigue related risks immediately outside work (e.g. Rostering should be underpinned by ●● ensure that any rostered period of commuting demands, secondary good practice rostering principles which extended hours is compensated with employment, etc) which have include roster design and management a longer break before resuming a shift foreseeable impacts on fatigue of work patterns. Rostering principles at work. ●● avoid rapid shift changes that do not should be applied to minimise features provide opportunity for adequate of working patterns that could give rise If bio-mathematical tools are utilised to sleep (especially from night shift to assist with rostering it is important that to fatigue-related risks, or increase the day shift) risk of accidents arising from fatigue. those using the tool fully understand the model behind the software, including Rostering principles should also be ●● ensure rail safety workers have developed in consultation with rail safety a minimum number of hours free the limits to its validity and use the workers (particularly those expected to of work in a 14-day period to aid tool for its designed purposes only. be most susceptible to fatigue-related in fatigue recovery, including two Bio-mathematical tools do not amount risks) and their representatives. The nights sleep to a fatigue management system and rostering principles developed should should not be used on their own. also be explicitly documented in the ●● minimise consecutive night shifts Rather they can be used in conjunction operator’s safety management system. in order to limit reductions in with good practice rostering principles performance levels caused by and the other elements of a fatigue There is a range of factors that may circadian disruption, fatigue and management system. constrain the rostering practices of a rail reduced alertness, and organisation. This may include operating In the event of an audit, inspection or schedules, resources, information ●● take into account the process of investigation, a rail organisation should management systems, and industrial circadian rhythm adaptation when be able to demonstrate how its rostering agreements. Nonetheless, rostering must rail safety workers return to work practices help manage the risk of a consider the impact of work schedules after a period of extended leave. fatigue related incident or accident. on the potential for fatigue. A common In addition, those responsible for For further information, see: challenge is the impact of terms and rostering should: conditions of employment contracts ¼¼ 1National Rail Safety Guideline - (which are often a result of enterprise ●● build in flexibility for rostering to Management of Fatigue in Rail Safety bargaining agreements). Rostering optimise recovery from varying Workers, June 2008, National Transport cannot be solely based on limits from work conditions and unforeseeable Commission. Available at: http://www. enterprise agreements unless these are events, which may include the ntc.gov.au/filemedia/Reports/NRSG_ consistent with good practice roster consideration of: FatigueManagement_June2008.pdf design to minimise fatigue. If work hours ●● the nature of work undertaken are not consistent with good practice, ¼¼ Transport Safety Alert Number 34 - Use of bio-mathematical models in managing then additional controls may be required ●● variations in shifts and rest to manage increased fatigue related risk. periods as a result of emergencies risks of human fatigue in the workplace, 27 July 2010, Independent Transport

The National Transport Commission’s ●● degraded or abnormal conditions Safety Regulator. Available at: http:// Guideline on the Management of Fatigue www.transportregulator.nsw.gov.au/rail/ 1 in Rail Safety Workers , is based on the ●● different environments and routes, publications/tsas/all-tsas advice of fatigue experts. It specifies that and the following principles be considered in ●● varying quality of rest roster design: environments

11 Management of risks to safety associated with operation of hi-rail vehicles

Hi-rail vehicles (also known as road rail vehicles) are widely > A number of investigation reports have used in the inspection and maintenance of track infrastructure. been produced about incidents involving Hi-rail vehicles exist in a number of forms, including vehicles hi-rail vehicles. These include: that tow trailers or vehicles that have boom arms required to reach infrastructure or vegetation above the rail. ●● Road-rail vehicle runaway incidents at Brentwood, Essex and at There are numerous hazards associated with the operation of Birmingham Snow Hill that occurred hi-rail vehicles, and an extensive history of incidents associated on 4 November and 31 October with hi-rail vehicles in Australia and overseas exists. 2007, produced by the Rail Accident Investigation Branch (RAIB) in On 30 December 2011 a hi-rail vehicle rolled over a track side the United Kingdom. worker at a rail construction site in Perth, , http://www.raib.gov.uk/cms_ resulting in a fatality. While this incident is still under resources.cfm?file=/090527_ investigation, preliminary advice suggests that there may have R112009_Brentwood.pdf been a problem during the off tracking of the hi-rail vehicle, causing it to roll and hit the track side worker. ●● Derailment of a road rail vehicle at Terryhoogan, near Scarva, Northern Ireland that occurred on 9 March 2008, produced by the RAIB. http://www.raib.gov.uk/cms_ an extensive history resources.cfm?file=/090211_ R032009_Terryhoogan.pdf of incidents associated ●● Runaway of a road-rail vehicle at Glen with hi-rail vehicles in Garry that occurred on 5 December 2007, produced by the RAIB. Australia and overseas http://www.raib.gov.uk/cms_ resources.cfm?file=/090225_ R052009_Glen_Garry.pdf

12 ●● Investigation into runaways of road- The investigations into these incidents Network Rail in the United Kingdom has rail vehicles and their trailers on highlighted the following contributing launched a national road rail vehicle Network Rail, produced by the RAIB. factors: safety improvement program and a http://www.raib.gov.uk/cms_ campaign for road rail vehicle safety, resources.cfm?file=/091029_ ●● prevailing environmental conditions to highlight the dangers posed by R272009_RRV.pdf road rail vehicles. ●● track contamination

●● Collision between hi-rail and the Rail Accredited rail operators and rail ●● visibility on track Motor Zig Zag Railway that occurred contractors are encouraged to consider at Clarence on 1 April 2011, produced ●● design and configuration of the hi- the following information and take by the Office of Transport Safety rail vehicle (for example friction drive appropriate steps to manage the risks Investigations (OTSI) in NSW. versus rubber tyre drive) to safety associated with the operation http://www.otsi.nsw.gov.au/rail/ of hi-rail vehicles. Interim-Factual-Statement-Zig-Zag- ●● maintenance of the hi-rail vehicle Collision-2011-04-01.pdf http://www.safety.networkrail.co.uk/#s1 ●● braking performance of the hi- rail vehicle (given prevailing http://www.safety.networkrail.co.uk/ ●● Following an incident involving a heavy duty rail mounted mobile flash environmental conditions and load) Information-Centre/Safety-365- welder truck, the Western Australian Campaigns/RRV-2011 ●● hi-rail vehicle speed rail safety regulator issued a safety alert (Notice No: RSN 2011 – 01) on ●● training and experience of staff 10 January 2011 regarding the braking ●● track gradient and curvature systems of hi-rail vehicles.

http://www.transport.wa.gov.au/ ●● knowledge of operating rules and rail_sa_rsn_2011_01.pdf procedures on the network and at the work site

●● failure to prepare emergency plans.

13 Your fatigue > management responsibilities as a rail safety worker

Rail safety worker fatigue is widely accepted as a safety issue in the rail industry. To address this issue, Victorian rail safety legislation imposes obligations on rail operators to develop and implement strategies for controlling risks associated with the fatigue of rail safety workers.

Fatigue can have serious short term and long term effect on health as well as work performance. It is important to understand these effects and work towards minimising their impact.

The long-term effects on health associated with ongoing fatigue and lack of sleep may include heart disease, diabetes, high blood pressure, gastrointestinal disorders, depression, and anxiety.

In the short term, fatigue can lead to a reduced ability to:

●● concentrate and avoid distraction

●● think laterally and analyse problems and situations

●● make decisions

●● remember and recall events

●● maintain vigilance

●● control emotions

●● appreciate complex situations

●● recognise threats and risks

●● coordinate hand-eye movements, and

●● communicate effectively.

The nature of these effects means that people who are fatigued are more likely to make errors and be involved in accidents. Fatigue can also cause uncontrollable sleep onset which is particularly dangerous in the high risk rail environment.

It is important to understand that some people may not “feel tired” before their performance is impaired by fatigue. Once fatigued, people are less able to make this kind of assessment. Therefore, it is important to know what can cause fatigue and to plan ahead to minimise the chance of being impaired by fatigue when working. >

14 > Contributing factors to fatigue

Loss of sleep and ●● Being awake for extended periods of time takes a toll on a person physically and mentally and reduces the cumulative fatigue opportunity for restorative sleep.

●● Demands and activities in a person’s work (eg.workload) extended hours/overtime, staff and resource shortages, commuting demands, plus demands in personal life (eg. family/social commitments and responsibilities, secondary employment, significant and stressful personal events) can result in loss of sleep.

Extended working ●● Generally speaking, longer time spent working increases physiological and mental fatigue and reduces the hours opportunity for sleep.

Time of day ●● Everyone is biologically inclined to sleep between midnight and 6am, and (to a lesser extent) between 2pm and 4pm. These are the danger times for fatigue-related accidents.

●● Working and commuting at night is likely to expose a person to greater risk of fatigue.

Irregularity of sleep ●● Over time, a person’s body clock adjusts to the typical day-to-day schedule of being awake and asleep. patterns Therefore, maintaining a regular and predictable sleep pattern is very important for achieving consistently good quality rest.

●● Any change to regular sleeping patterns such as those caused by unpredictable disruptions (eg. being on- call or on-duty, call-outs, changes between day to night shift, overtime, significant stress and other life events) is likely to increase the risk of fatigue.

●● Returning from extended leave can result in the body clock being inconsistent with regular working hours.

Task demands and ●● Tasks that are particularly difficult, demanding, or extended over long periods of time can result in overload work environment of physiological and mental processes. This may cause a person to become fatigued more quickly.

●● Fatigue can also be brought about by tasks or environments that do not provide enough mental stimulation. This is often the case when tasks are prolonged and monotonous (eg. driving long distances).

●● The immediate work environment can also affect fatigue levels. For instance, uncomfortable conditions such as temperature, noise, vibration, glare, and lighting can place extra strain on a person.

Health and fitness ●● Fatigue can be a symptom of an underlying medical or health problem.

●● Health conditions such as sleep apnoea and chronic fatigue syndrome may cause a person to be excessively sleepy or tired.

●● Increased fatigue and drowsiness can also be brought on by acute illness and poor health, as well as certain medications, drugs, and alcohol.

To reduce your risk of being involved in ●● assess your own fatigue levels and fitness ●● advise your supervisor or manager if you a fatigue related incident or accident at for duty before commencing work foresee or experience being impaired by fatigue that may mean you are work, you should: ●● monitor your fatigue levels while you are at work unfit to work ●● comply with your organisation’s ●● seek medical advice and assistance if you and procedures relating to fatigue ●● assess your fatigue levels after work and take appropriate commuting and have or are concerned that you might ●● attend work in a fit state to undertake accommodation options, such as avoiding have a health condition that affects your your duties driving if fatigued sleep and fatigue. ●● be aware of what might contribute to your being fatigued

●● understand your sleep/rest/recovery requirements and ensure you obtain appropriate rest and sleep away from work

15 Rail incidents review

The following is a summary Common themes in these reports include: of the investigation reports ●● the importance of controls to prevent train into rail safety incidents that runaways (Poland, NSW) occurred in Victoria, NSW, ●● risks associated with the failure of cuttings New Zealand, Europe and (UK, Canada) Canada in recent months. ●● risks associated with bearing failures (South Australia, Victoria, Canada)

●● inappropriate operations of plant equipment on the railway (NSW, Netherlands)

●● risks and effectiveness of controls associated with overruns (Victoria, UK).

16 OCI (VIC) http://www.transport.vic.gov.au/about- us/oci/safety-investigations#Rail

Platform overruns Siemens have contributed to the onset of Derailment Train, End-of-track overrun MTM Train, Nexas EMU Connex/Metro Trains wheelslide and an overrun event. points 127D, South Dynon Carrum Siding (PDF, 496 KB, 25 pp.) Theme 5) network - Occurrence date 15 Oct 2010 the investigation concluded that at Occurrence date Feb-Mar 2009 Investigation release date 9 Jan 2012 Occurrence date 3 Mar 2011 Investigation release date 14 Sep 2011 the time of the Ormond incident Investigation release date 13 Feb 2012 there remained the potential for The locomotives and the leading The report noted that the Siemens- severe consequences and that the wagon of a Pacific National A Comeng train being driven into manufactured Nexas has been network risk management systems Mildura to Appleton Dock freight Carrum 3 siding could not be involved in a relatively high number that were in place were inadequate. train derailed at points at South stopped before reaching the end of Dynon Junction. The set of points of reported overrun events when The investigation also found the line, causing it to overrun the connected the recently constructed compared to other types of trains deficiencies in procurement and end of-line baulks, derail and collide North Dock Line to the existing operating on the network. The acceptance testing processes. with a steel stanchion supporting Australian Rail Track six platform overruns between Recommendations were made to the the overhead contact wire. As a network and the derailment occurred 8 February and 3 March 2009 operator and infrastructure manager consequence, the stanchion was during commissioning works. The suggested that systemic issues in the areas of train performance uprooted and the overhead contact train was the first revenue train to remained unresolved and triggered monitoring, track condition wire parted. The stanchion fouled operate through the commissioning this investigation. Another event monitoring and driver training. the adjoining main line causing area and was doing so under the at Ormond Railway Station on 25 Recommendations were made to rail services between Carrum and local signaller’s authorisation. As a February 2009 involved a train the Department of Transport and Frankston to be suspended. There consequence of the derailment, rail overrunning the platform by about operator in terms of procurement was also considerable damage to the traffic was disrupted and Dock Link 250 metres and entering the North and acceptance testing. leading car of the train. Road before the boom Road was closed to road traffic for The investigation found that the barriers had fully lowered. several hours. two drivers involved did not follow It was concluded that the End-of-track overrun Metro Trains The investigation found that the standard operating procedures when predominant condition associated Melbourne, Macleod broad-gauge blade of the points changing driving ends, resulting with the overrun events was the was not connected to the dual- in the train being driven into the Occurrence date 24 Mar 2011 presence of low levels of adhesion control point machine and that it siding without the braking system Investigation release date 21 Oct 2011 between wheel and rail. In was secured against movement for correctly set up. Since the incident considering this condition and other An X’Trapolis train collided with the broad-gauge route towards the the operator has issued a bulletin factors potentially contributing to the end-of-track baulks at Macleod North Dock Line. The derailment advising drivers to “fully and platform overruns, the investigation Railway Station and subsequently was caused by the left-hand point correctly” comply with documented explored the following five themes: the station wire boundary fence. blade of the points being in the procedures at all times and outlining reverse position while the right-hand the likely consequences of not Theme 1) the environment - the The train was fully loaded but there broad-gauge point blade was secured complying. investigation concluded that was no injury to any occupant or against the standard-gauge rail in moisture combined in a particular other person. The leading car of the The investigation found that the normal position. This resulted proportion with rail head train sustained minor damage with Comeng trains can be operated in the locomotives and lead wagon contaminants produces a liquid the baulks being destroyed and the without normal braking being attempting to traverse two routes. suspension sufficient to result in low fencing damaged. available and recommended that The derailment was a consequence coefficient of friction conditions the operator consider the provision The investigation determined that of the failure of the commissioning of a suitable intervention system to Theme 2) the track - while unlikely low-adhesion conditions were planning, operations and safe prevent such occurrence. to have been highly contributory present at the wheel-rail interface, working processes to identify the to the frequency of overrun events, contributed to by vegetation matter condition of the points and the the investigation concluded that from surrounding foliage and moss signallers not ensuring the integrity maintaining track in ideal condition from the platform that had been of the route set for the train. would contribute to maintaining a washed onto the track during the The investigation made good wheel-rail contact interface platform cleaning process. The recommendations in the areas of the with the potential to optimise end-of-track baulks were poorly processes for identifying the position braking performance. maintained and not fit for purpose. of field equipment prior to train Theme 3) the train - the investigation Recommendations were made to movements and the practices applied concluded that there was no the rail operator concerning the by signallers. identified defect on Nexas trains maintenance of infrastructure as The investigation also recommended involved in the overrun events it relates to vegetation and end-of- that Victorian Network Managers but that as an integrated system, track baulks, and for the operator to review the rules in relation to the was more prone to overrun than conduct a review of the adequacy of operation and working of dual- other types of train running on the end-of-track protection. control point machines when in the network. hand mode. Theme 4) train handling- the investigation concluded that driving techniques could in some instances > 17 The Office of Transport Australian Transport Investigation, NSW Safety Bureau http://www.otsi.nsw.gov.au www.atsb.gov.au

Collision between hi-rail and rail Runaway of rolling stock, Parting of train 9827 near he has left wagons behind’. The motor, Zig Zag Railway Enfield Yard Gunning, NSW driver observed four wagons sitting stationary on the down main line. Occurrence date 1 April 2011 Occurrence date 3 May 2011 Occurrence date 30 Mar 2011 Investigation release date 2012 Investigation release date 2012 Investigation release date 23 Nov 2011 As a result of the operators own investigation, the operator expects A Zig Zag Railway maintenance A Pacific National Terminal operator A southbound Port Kembla to to make changes to training vehicle (the hi-rail), collided with a was changing brake blocks on a Parkes empty bulk grain train packages and in cab resources for two-car rail motor on a viaduct. The rake of 28 loaded aggregate wagons. experienced a train parting event use in emergencies. The investigation hi-rail, with a driver and passenger When he released the air pressure in near Gunning (Oolong), NSW, on identified two safety issues in on board, was freewheeling down the braking system on a wagon in the down main Sydney to Melbourne relation to: the hill in reverse. The rail motor, the centre of the rake, the remaining rail line. There were no injuries or ●● the in-service condition operated by a driver, was travelling brakes applied to the rake did not damage as a result of the incident. monitoring of the wheel bearing empty in the opposite direction. hold it on the prevailing grade. It ran The driver felt a series of mud which was ineffective in detecting The rail motor driver saw the away through the yard and collided holes in the track, followed shortly the failing bearing before it led to approaching vehicle and applied the with another stabled rake consisting thereafter by a loss of brake pipe the derailment, and, brakes. However, the two persons of 15 empty fuel tanker wagons and pressure. The train was travelling at a onboard the hi-rail, facing the three flat bed wagons. The force of ●● bulk hopper wagons loaded speed of about 75 km/h at the time. opposite direction, did not see the the collision caused the tanker bogie with limestone which have been rail motor before the collision. The closest to the point of collision to Once the train came to a stop, the regularly operated at speeds force of the collision compacted the derail. driver notified the network controller up to 15 km/h higher than the body of the hi-rail such that neither at Junee while he placed track circuit mandated limit for some classes The combined rakes continued, cab door would open. The two shorting clips onto the up main line of track. and two of the tankers derailed and occupants of the hi-rail were injured adjacent to the train. He then walked slewed across the track, carrying in the collision and were assisted out towards and placed audible warning away two shunting signals and an of the hi-rail and onto the rail motor devices on the up main track near the Derailment of freight train 4DA2 overhead wiring portal stanchion. by the rail motor driver who was first approaching signal. near Cadney Park, South Australia The two rakes came to rest uninjured. The force of the collision approximately 460 metres from the During this time the second person Occurrence date 25 Nov 2010 caused a minor misalignment of the point of collision with the derailed walked back to the rear of train Investigation release date 20 Dec 2011 track. tankers foul of the up and down 9827 looking for an air leak and The investigation found the main lines. The rake of aggregate found an open air cock on what he Freight train 4DA2 derailed on collision resulted from the driver wagons ran away for a total of 1085 thought was the end of the train. He the Central Australia Railway line, of the rail motor and the driver metres. contacted the driver and advised him about 5 km south of Cadney Park of the hi-rail not being aware that the air pipe was blowing, the in South Australia. There were no The investigation established that that they were travelling towards tap was open and that he had closed injuries as a result of the derailment too few handbrakes had been each other on the same track as it. The driver then noted that the but there was significant damage to applied to the rake in order to hold a result of procedural errors. The brake pipe pressure had returned to rolling stock and about 300 m of it on the prevailing grade, and that rail motor driver departed without normal. The driver recalled asking track required replacement. Pacific National’s maintenance communicating his intention to the second person if he was at the regime and training of terminal The investigation determined that his guard or the hi-rail crew, and back of the train, ‘the wagon with operators was not adequate for the a severe weather event involving the rail motor guard exceeded the light’. After the event, the second effective maintenance of brakes on very strong winds associated with his authority by authorising the person did not recall this particular rolling stock that did not have slack thunderstorm activity, was of hi-rail driver to leave a worksite. communication. adjusters. The investigation also sufficient magnitude to initiate the A number of other factors were found that Pacific National did not The driver then contacted the rollover and subsequent derailment found to have contributed to the comply with network controller and advised of a group of lightly loaded double- collision, particularly a lack of radio them of the findings. When the stacked container wagons. communications and operational ●● the Safety Interface Plan and second person returned to the cab, The train had parted at the 18th safe working errors. Other safety Management Agreement with the driver recalled confirming with wagon and the 19th wagon through issues identified included delayed RailCorp in regard to controlling him that there was an end of train to the 32nd wagon were rolled over notification of the accident; poor the risk of runaways marker in place, following which he and located to the eastern side of maintenance of train register ●● its own procedures for risk surmised that the hose must have the track. The last three wagons books; passengers travelling in the assessments to test the efficacy flicked up, as a result of the series were upright although the leading rail motor driver’s cab; rail motor of its minimum requirement of mud holes, and hit the air cock. bogie of the 5-unit wagon FQAY driver’s fatigue and excess speed of for handbrake application at In his statement, the second person 0009R (Unit 1) was derailed. An ISO the hi-rail. Enfield Yard. recalled a conversation about closing container of methanol on this wagon the tap but not the exact words. As a result of its investigation, The investigation identified had become separated from the Based on the information from the OTSI recommended that Zig Zag a number of safety issues for wagon and was lying on its side. Railway review current operational second person, the driver contacted improvement including Pacific Wind induced lateral forces, procedures for the implementation the network controller, removed National’s non-conformance with its especially those acting on the side of of safeworking systems, improve the track circuit clips and audible own procedures for undertaking risk wagons, can contribute significantly monitoring and auditing of warning devices and departed. assessments, and gaps in training to body roll and may cause wagons safeworking procedures, ensure and procedures in relation to brake After train 9827 cleared the section, to rollover as identified by the ATSB that the train register books are maintenance. the track circuit remained occupied. in two of its previous reports (Mt maintained, review the structure The network controller noticed the Christie in South Australia on 1 and staffing of safety operational anomaly and immediately contacted September 2008 (RO-2008-010) positions and reinforce reporting train 8114, on the up main line, and Loongana in Western Australia requirements following an incident. to be very cautious and check the on 11 November 2008 (RO-2008- condition of the track ‘just in case 013)).

18 New Zealand http://www.taic.org.nz

The investigation found that double Menindee section of track. The road- Collision of grain train 3234 with Metro passenger train derailment, stacked container wagons are at rail vehicle, a Toyota Landcruiser grain train 8922 at Yass Junction, Sylvia Park, 14 April 2008 and higher risk of wind induced rollover. station wagon, was extensively NSW diesel motor fires on board As a result the operator has adopted damaged. There were no injuries and Metro Passenger Trains, 3 June Occurrence date 9 Dec 2010 a loading protocol which is designed no damage to fixed infrastructure. 2008 and 25 July 2008 to minimise the risk by requiring Investigation release date 30 Jan 2012 The investigation concluded that the that the heaviest container in any available evidence indicated that in Up (northbound) loaded grain train Occurrence date 14 Apr 2008 double stacked configuration is Investigation release date 29 Sep 2011 this instance the road-rail vehicle 3234N collided at low speed with loaded on the bottom. had accessed the track without the the rear of another up (northbound) A brake pad calliper fell from a The investigation also found knowledge of, or authority from, loaded grain train 8922N at Yass wheel set on the fourth car of a that train drivers receive no the network controller, even after Junction NSW. The intended DMU passenger train and derailed formal training with respect to the operator was advised of the operation had been for both trains one wheel set on the train. The understanding severe weather events, need to get a separate authority. to wait, one behind the other, on the train was stopped, but not before the associated derailment risk and After accessing the track the vehicle down main line at Yass Junction to the wheel set, plus another that mitigation strategies. As a result the travelled on towards a worksite enable a third northbound goods subsequently derailed, had re-railed. operator advised it will engage a without authority and was struck by train, 4MB2, to pass them both on The brake calliper fell because specialist service provider to monitor the freight train. the adjacent up main line. the securing key had either failed and issue warnings of the formation Train 3234N proceeded as intended or worked loose. Damage to the of severe weather events which past a signal which indicated that train was minimal and no one was have the potential to impact on the Derailment of train 3PW4, the route was not clear and that injured. railway network and operations. Wodonga, Victoria the train should proceed with On Tuesday 3 June 2008 and Occurrence date 23 Oct 2010 caution. Train 3234N braked as again on Friday 25 July 2008, fires Derailment of freight train 5MP5 Investigation release date 19 Oct 2011 soon as train 8922N was sighted broke out in the area of the diesel but a collision nevertheless ensued. auxiliary motors fitted on DMU near Keith, South Australia Fifteen wagons on freight train The investigation highlighted that passenger trains while running 3PW4 derailed near Wodonga Occurrence date 08 Oct 2010 the definition of restricted speed scheduled services. On each occasion Victoria. There were no injuries Investigation release date 28 Sep 2011 application in these cases requires the train was stopped and the but serious damage to rolling-stock considerable judgement on the part fire extinguished. Both fires were Freight train 5MP5 travelling from and rail track (including a bridge of train drivers. seated on the top of the under-slung Melbourne to Perth derailed on the structure) was sustained during the auxiliary motors. Defined Interstate Rail Network derailment. The calling on indication given (DIRN) between Wirrega and to 3234 N required the driver to The cause of all three incidents The investigation concluded that an Keith in South Australia. Four assume that the line ahead was in this report stemmed from axle bearing on a wagon failed and hundred metres of track required occupied and to operate the train inadequate service and maintenance completely seized. The most likely repairs before services could resume accordingly, at restricted speed. The practices at the maintenance depot. cause of bearing seizure was a loss and 2900 concrete sleepers were ARTC glossary defines restricted The maintenance depot was not of interference fit between the inner subsequently replaced to restore speed as ‘A speed that allows rail delivering a maintenance regime rings and journal. This allowed the track integrity. It was established traffic to stop short of an obstruction that was in line with sound railway inner rings to turn or spin on the that the derailment was the result within the distance of a clear line engineering practices. Although the axle journal leading to increased of a screwed journal on the twelfth that is visible ahead’. maintenance depot had to cope with wear and ultimately generating wagon in the consist behind the more and longer trains than those significant heat and damage until The Rail Industry Safety and locomotives. for which it had originally been the bearing completely seized. It was Standards Board (RISSB) of designed, it might have delivered a Inspection of data showed that possible that fretting and rotational Australia is currently developing better level of maintenance if better there was a growing problem with creep contributed to the loss of standards for the rail industry in systems had been in place. the 2L axle-box that was identified interference fit. Australia to adopt. The current draft by a trackside bearing acoustic document ANRP glossary defines Under the Railways Act 2005 Examination of data recorded by the monitor. Wheel impact data also restricted speed as “a speed that (NZ) and according to the rail ARTC Bearing Acoustic Monitoring identified a growing wheel impact allows rail traffic to stop short of an participant’s safety cases, KiwiRail system (RailBAM) found that, over problem. Under the operators obstruction within half the distance was responsible for maintaining the previous 12 months, the system existing maintenance guidelines of clear line that is visible ahead. the Auckland metro trains and the detected potential looseness or there was no requirement to take Restricted speed must not exceed 25 operator Veolia was responsible for fretting defects on the wagon but wagon RQJW 22034D out of km/h.” This is consistent with rules monitoring KiwiRail’s performance did not record any apparent fault service. The investigation advised currently in force in Victoria. to ensure that the trains were being trend. Nor did the system record any that the operator should consider maintained in accordance with bearing defect on the wagon when the implications of these safety issues sound railway engineering practices. train 3PW4 passed through the and take action where considered system on 21 October 2010. The investigation found contractual appropriate. arrangements between ARTA (the The investigation made a safety owner of the trains), Veolia (the action based on the fact that there operator of the trains) and KiwiRail Collision between freight train was no documented evidence that (the maintainer of the trains) were 3SP7 and road-rail vehicle near the operator actively in-service consistent with the Railways Act monitors the risk of looseness Menindee, NSW 2005 and the National Rail System and fretting damage to bearing Standard (NRSS). A blurring of Occurrence date 13 Jul 2011 components. The investigation stated responsibilities around the contracts Investigation release date 22 Nov 2011 that a review and documentation and a breakdown of relationships of processes for managing bearing Freight train 3SP7 collided with a at that time at a senior management failure due to looseness or fretting road-rail vehicle in the Kaleentha to level in all three entities was found to may be warranted. > 19 U.K. - Rail Accident Investigation Bureau, http://www.raib.gov.uk/publications/ investigation_reports/reports_2011.cfm

be hampering the effective execution Derailment of a passenger overrun at Stonegate, Train passed over Lydney level of those contracts. near Dryclough Junction, Halifax East Sussex crossing with crossing barriers raised Insufficient investment had been Occurrence date 5 Feb 2011 Occurrence date 8 Nov 2010 put into expanding and improving Investigation release date 20 Oct 2011 Investigation release date 17 Nov 2011 Occurrence date 23 Mar 2011 the efficiency of the then current Investigation release date 15 Dec 2011 maintenance facility to cope with A two-car passenger train derailed A passenger train failed to stop at the planned increase in passenger when the train ran into stone rubble Stonegate station in East Sussex. The A train passed over a manually rolling stock. on the track. The rubble had fallen train ran for a further 3.94 km with controlled barrier level crossing from a retaining wall beside the the emergency brake applied, passing The report states that KiwiRail while the barriers were in the line which had collapsed during a level crossing before coming to a has taken safety actions to address raised position. The railway signal the night. The collapse of the wall stop 5.18 km after first applying the the specific maintenance issues protecting the level crossing was followed a period of heavy rain. brakes. No one was hurt and there contributing to the incidents, and has showing green, and the train was was no damage to the train or to the also made significant modifications The local authority highways travelling at 94km/h. The red track. to the maintenance depot to improve department had reported cracks in flashing lights intended to instruct its efficiency and level of safety. the pavement behind the wall to the Rail adhesion conditions were road users to stop were operating railway infrastructure manager on poor on that day due to high winds and there were no road vehicles on several occasions, most recently in causing fresh leaf fall, and the onset the crossing. No injuries or damage October 2010, and had closed the of rain. The line had been treated resulted from the incident. footpath as a precaution. to improve adhesion the previous The crossing keeper had raised the evening. The investigation found The investigation found deficiencies up side barrier manually during that it is likely that the train failed in the examination of the wall by the 90 minutes before the incident, to stop because there was almost the railway infrastructure manager’s due to a defect in the equipment certainly no sand in the sand examination contractor and in the controlling the barrier motors. hoppers at the leading end. If sand way in which Network Rail handled Shortly before the incident, the had been present, the train braking reports from the local authority crossing keeper lowered the barriers system would have deposited sand concerning problems with the wall. for a train approaching from the onto the rail head, improving the The limited extent of repairs made to east. He then raised both barriers available adhesion and allowing the wall in 2006 also contributed to manually just before the westbound the train to stop in a much shorter its failure. train arrived at the crossing. An distance. annunciator (buzzer) intended to The investigation made five The investigation made three warn the crossing keeper about recommendations to the railway recommendations to the operator approaching trains did not give the infrastructure manager, relating to covering improvements in usual warning. the structures examination process, maintenance processes, restrictions the control of minor civil engineering The railway signals protecting the on the use of trains that need construction works and the system for crossing should have been placed at servicing, driver awareness of dealing with reports from third parties. danger before the barriers could be low sand conditions and the raised safely. The crossing keeper responsiveness of the sand had no facility to control these Passenger accident at Brentwood replenishment regime. signals, and did not inform the station neighbouring signallers who could have kept the signals at danger while Occurrence date 28 Jan 2011 the barriers were raised. Several Investigation release date 28 Nov 2011 possible reasons for not informing the signaller have been identified. A passenger alighting from the last coach of a train fell between the side The investigation made of the train and the platform. The recommendations to the driver of the train did not see this infrastructure manager relating to happen and the train departed from the adequacy of instructions and the station with the passenger still training given to crossing keepers in the gap between the train and the and signallers and the process used platform. The passenger sustained for on-going assessment of staff injuries to her leg and head in the competencies. The investigation also accident. recommended the modification of standards for new and upgraded The investigation made three crossings so that protecting signals recommendations to the operator always display a stop aspect when relating to driver training and the crossing barriers are raised. assessment, risk assessment reviews and the availability of CCTV equipment on trains. A recommendation was made to the infrastructure manager relating to working with train operators to assess periodically the suitability of equipment provided at unstaffed platforms to assist train drivers to dispatch trains.

20 Germany The Netherlands Poland www.ntsb.gov www.safetyboard.nl State Commission on Rail Accident Investigation

Collision between trains at Accident involving a rail grinding a result the train driver did not Uncontrolled runaway of freight Hordorf crossover train in Stavoren, Netherlands receive an alert upon passing the wagons downhill, Linie No 426 approach marker, no warning signal section Strzelce Krajeńskie Occurrence date 15 March 2010 Occurrence date 25 Jul 2010 was subsequently sounded when the Wchód - Strzelce Krajeńskie Investigation release date 14 Sep 2011 Investigation release date Sep 2011 braking system was not manually A collision between freight train A rail grinding train travelling at operated and no automatic braking Occurrence date 26 Jul 2011 Investigation release date 2012 DGS 69192 and passenger train high speed ploughed through a intervention occurred when the driver failed to brake manually. DPN 80876 occurred at the Hordorf buffer stop located at the end of the During the unloading operations Because the rail grinding train’s crossover (double to single line railway track at Stavoren Station. of a freight wagons from a train, trainborne ATB equipment was junction), resulting in the passenger The train then crashed into a parked seven freight wagons (for coal switched off, the train was able to train becoming completely derailed. tanker and drove straight through a transportation) ran away without travel faster than 40km/h despite the Both trains were occupied by a shop. The accident occurred while the locomotive in the direction of incompatibility of the ATB systems. single driver. Ten people were fatally the rail grinding train was being the station at Strzelce KrajeDskie. injured. Twenty-three people were transferred to Stavoren Station. The wagons hit the station building injured, some seriously, including the The intention was to take the track Train to train collision Amsterdam at high speed. As a result of the driver of the freight train. section out of service after the train collision with the building two had arrived and to subsequently The investigation revealed that of Occurrence date 25 April 2012 persons living in the flat located in commence the rail grinding activities. Investigation release date the signals passed by freight train the station building were killed and another person in the area of the DGS 69192, the signal in advance The crew on board the train On 21 April 2012, two trains station was also killed. showed an ‘expect stop’ aspect, and consisted of four people, two of collided in Amsterdam resulting the block signal showed a ‘stop’ whom were slightly injured. As there in one fatality and more than 100 The investigation found that aspect. The Hordorf crossover had was no one near the station at the injured passengers. separation of wagons from the been run through. The freight train time of the accident, there were no locomotive was undertaken by The 24 hour reporting of Prorail entered an occupied section and other casualties. However, the rail unauthorised persons and shunting (managers of the rail network) and as a consequence collided with the grinding train was severely damaged conducted in an unauthorised Inspectie Leefomgeving en Transport passenger train approaching from and the tanker and the shop manner. the opposite direction on the single premises were completely destroyed. (The Human Environment and line. The material damage incurred as a Transport Inspectorate) indicated result of the accident is estimated to that the driver of the ‘Sprinter’ train The investigation found the passing be over EUR 20 million. passed a signal at stop. The Sprinter of the repeater signal showing travelled for another 350 metres ‘expect stop’ and the stop signal B The accident occurred because along the track and drove through showing ‘stop’ was due to human the rail grinding train braked too and opened up a set of points. The error (though the type of error was late when approaching the end of train ended up on a track where the not identified). the line, the train driver failed to intercity double-decker train was obey a signal (in the form of an The investigation concluded that the travelling in the opposite direction. approach marker) and the automatic event would not have occurred had train protection system (ATB) was The signal was fitted with a train there been a track- and train-based inoperative. protection system known as the ATB automatic train control system. first generation, and not with the The investigation concluded that the The investigation recommended ATB improved version. The ATB signal was not obeyed on account of updating all lines with automatic first generation does not intervene the following: train control by means of which with trains passing a red signal at a train which passes a signal at ●● the train driver had inaccurate speeds below 40 km/h. danger without authorisation can be expectations of the signals/signs These findings are reported in the 24 automatically brought to a halt. along the line and his attention hour reports which are considered had been diverted The investigation also recommended to be preliminary. In-depth that until sections of line are ●● the signal (approach marker) was investigation by multiple parties is updated with automatic train an unusual signal, unfamiliar to still ongoing. control in accordance with the the train driver, which during first recommendation, additional darkness moreover is visible for measures should be taken to reduce a shorter period of time and was the probability of occurrence and/ less noticeable than a light signal or extent of the consequences of ●● it was more difficult for the train passing a signal at danger without driver to determine the position authorisation. of the train because some location markers along the track were missing or illegible. The investigation also found that the train driver’s poor route knowledge played a role in respect of his inaccurate expectations of the signals/signs along the route. The ATB system was inoperative because the trainborne ATB equipment was incompatible with the trackside ATB equipment. As > 21 Canada www.tsb.gc.ca

Main-track derailment, Canadian Incorrect roller bearing locking grade, the brakes were not as Pacific Railway freight train plate stamping presents a risk that effective as on the leading portion 220-24, Mile 105.1, MacTier potentially defective wheel sets composed of mainly empty cars. Subdivision, Buckskin, Ontario may not be correctly identified Consequently, the trailing portion of in the field and removed before the train decelerated at a slower rate Occurrence date 26 Jan 2011 component failure. and collided with the leading portion Investigation release date 18 Jan 2012 of the train.

Canadian Pacific Railway freight Main-track derailment, Canadian Findings were made in regards to the replacement of components train 220 was travelling southward National freight train M36831-18, subject to interchange rules and the at about 45mph when one of its cars Mile 58.20, Kingston Subdivision, derailed. The train continued 1.4 marshalling of trains. Lancaster, Ontario miles where an additional 20 cars, including a dangerous goods tank Occurrence date 18 Oct 2010 car, loaded with non-odorized Investigation release date 21 Oct 2011 Main-track derailment, Canadian liquefied petroleum gas (UN 1075), Pacific Railway freight train 159-23 derailed. Some of the derailed cars An eastward Canadian National Mile 22.2, Winchester side-swiped northbound Canadian freight train M36831-18 subdivision, Saint-Lazare, Quebec Pacific Railway (CP) freight train, derailed 18 cars, including 6 cars which was stationary in a siding, containing dangerous goods. Occurrence date 23 Sep 2010 Investigation release date 23 Nov 2011 derailing its lead locomotive and The damage to sleepers at damaging the second locomotive and Mile 58.33 was consistent with Canadian Pacific Railway freight the first nine cars. impact marks caused by the train 159-23 derailed 2 locomotives Inspection of the track revealed that coupler of wagon car CNIS 623151 and 11 loaded cars. While the train a roller bearing from a wagon on (the 68th car) hitting the ground was travelling at 50mph, it passed train 220 had overheated, seized and after being pulled away from the the 221 signal (Mile 22.1), which failed causing the axle journal stub yoke and separating the train. The was showing a clear indication, to burn off and sever from the axle. coupler was ejected and fell in and the crew noticed that the track The car remained on the rails until the ditch outside the path of the ahead was obstructed by debris. it derailed at a snowmobile crossing. trailing cars. The engineer reduced the throttle and initiated an emergency brake The car continued southward with The coupler and the yoke of the application. The train was unable one wheel set derailed until the trailing end of car CNIS 623151 to stop before hitting the debris wheel set contacted siding points at did not exhibit any fracture surfaces. derailing approximately 200 feet Mile 103.7 and became dislodged, Instead, the train separation was wide in the wooded section north thus causing the following 20 cars found to be caused by the failure of the track, sliding onto the track to derail. of the connection joining the two and covering it with a layer of clay components together. The retaining The roller bearing on the wagon and plant material approximately bolt of the connection had been initiated a low level alert on a hot six feet deep. axle box detector. CN low level identified as being prone to fatigue alerts did not require any action. failure and subject to an interchange The investigation found that an requirement. Nevertheless, the asphalt storage scrap pile rendered Four of the previous five hot axle retaining bolt was not changed. the ground unstable, causing a box detectors that train 220 thick layer of sensitive clay to slide In this occurrence, the retaining bolt encountered recorded temperature onto the tracks. Since municipal was not found. However, it is likely readings that initiated a low level regulations did not require a that the bolt fractured causing the alert for the roller bearing that geotechnical analysis of the load- retaining block to fall to the ground. subsequently failed. Since each bearing capacity of the ground, the With no redundancy built into of the readings was below an landslide risk caused by the overload the coupler design, the connecting alarm threshold the alerts were imposed by the storage scrap pile pin had worked its way out of the not communicated to CP or to was not anticipated. train 220’s crew, nor were they assembly, no longer securing the required to be. coupler to the yoke. As the coupler was pulled away from the yoke, the The investigation also found that train separated between the 68th and two derailments had taken place at 69th cars. the same approximate location since 2006 and that both derailments Train M36831-18 was marshalled resulted from progressive equipment with a block of loaded cars on the failure which wayside inspection tail end trailing mainly empty cars. systems (WIS) are designed to detect. This marshalling configuration is Principal main line WIS spacing is susceptible to a derailment through generally less than 25 miles, but in the generation of high in-train forces. the vicinity of the derailment WIS When the train experienced an spacing is 54 miles. emergency application of the brakes after the separation between the The investigation also found that 68th and 69th cars, both portions reconditioned roller bearings which of the train began to slow. Because contain repaired raceway spalls the trailing portion of the train was have an increased risk of premature composed of mainly loaded cars and failure when returned to service. was situated on a steeper descending

22 *This article has been provided by ARTC. Industry show case: The views and opinions expressed herein are those of the author and do ARTC – rail safety not necessarily reflect the views of TSV. worker competency management system

The Rail Safety Act 2006 and Rail Safety Regulations 2006 Australia Post has been established to facilitate an independent in Victoria require operators to ensure, so far identification check to be carried out on all rail safety workers. as is reasonably practicable, their rail safety workers do not undertake rail safety work unless they are competent to do ARTC is well advanced in the development of its competency so. This extends to having in place a system of identifying and management system. The roll out has commenced in Victoria managing the competency levels of all rail safety workers, with , a major partner to ARTC. It is including a profile of rail safety work requirements and a system expected compliance with a competency and identification for recording the qualifications that each worker holds. management system will be achieved by December 2012.

In response to these requirements, Australian Rail Track ¼¼ For queries or information about ARTC’s rail safety worker Corporation (ARTC) designated a team in 2010 to commence the competency management system, please email development of an appropriate rail safety worker competency [email protected] management system.

In accordance with their accreditation, ARTC has defined rail safety work into nine functional categories. Minimum competency matrices linked to the Australian Qualifications Framework have been created, detailing the units of competence required to perform each specific rail safety worker role.

The implementation of these matrices has been completed in NSW. Rail safety workers who conduct work in track and civil, plant and equipment, safe working, structures, and network control are compliant and had their associated Rail Safety Worker card issued by 2 March 2012. The suite of minimum competencies required to perform rail safety work is available on the ARTC website at www.artc.com.au

ARTC has further determined communications, engineering, project management and signals procedures as categories of rail safety work. Minimum competency matrices for these categories are currently being finalised with a compliance date to be determined.

The maintenance of competency data, associated competency management system, and the issuing of Rail Safety Worker cards have been externally sourced to Pegasus Safety Ltd.

A new website has also been established for all external contractors to enable them to access information about the competency management system and upload their information to the portal. Please visit www.railsafetyworker.com.au for more information.

The ARTC competency management system not only links rail safety workers to competency information, it is associated with a stringent 100 point identification check. A partnership with > 23 Tourist and heritage corner – management of infrastructure assets

Tourist and heritage (T&H) rail operators railway staff lack the competencies to TSV periodically conducts safety audits face the challenge of preserving the undertake detailed inspections of their on an operator’s management of heritage of the railway, as well as infrastructure. A reliance on suitably infrastructure assets. These safety audits ensuring the safety of rail operations. qualified external parties may therefore may include a review of the following This is particularly so when T&H railways be necessary in these circumstances. aspects of the operator’s SMS: are located in arduous terrain. It is the responsibility of the operator to ●● risk register It is important that track and structures, ensure that such external parties have including bridges and retaining walls, the necessary competencies and capacity ●● relevant procedures and the surrounding environment, are to undertake this work. ●● compliance with procedures routinely monitored to ensure that early It is also important that appropriate signs of defects or potential failures are ●● records of compliance with identified. records of all inspections are retained. procedures and condition of assets A periodical review of the inspection Asset inspection regimes should take ●● management of identified issues, and into consideration the risk profile of regime should be undertaken to ensure the railway and have different levels of the effectiveness of the inspection ●● ongoing internal review of the inspection types and detail depending on schedule. This should include reviewing inspection regime. the risks associated. The type, condition any incidents that have occurred and and age of the assets and prevailing adjusting the inspection regime to environmental conditions, together with respond to incident investigation findings details of the asset inspection regime, or asset condition. should be documented in the operator’s It is also the responsibility of the safety management system (SMS). operator to ensure any infrastructure Inspections should be undertaken defects or failures are assessed by a by personnel who have the relevant suitably qualified person and appropriate competency and capacity. Some T&H rectification works are carried out to the prescribed specification. > 24 25 Institute of Rail Signal Engineers – International Technical Convention Singapore and Malaysia

TSV’s signal engineer, Stephen Backway, As part of the convention, members countries and to exchange lessons learnt, was awarded the Frank Hewlett/Alan participated in various technical site while experiencing the local culture. Fisher Travelling Bursary to attend the visits, technical presentations and social Institute of Rail Signal Engineers (IRSE) events. The technical presentations This opportunity has benefited Stephen International Technical Convention (ITC) provided details on past and current and TSV by showing how rail safety in Singapore and Malaysia in October developments in the respective countries, risks are managed in other countries. 2011. The Frank Hewlett/Alan Fisher lessons learnt from recent projects This included the application of new Travelling Bursary is provided by the IRSE and future technologies and trends in technologies and practices to improve to support its younger members (under rail signals. As part of the site visits, the efficiency and safety of railways and 35 years old). Stephen was one of 10 members were given the opportunity the influence of cultural factors on how recipients of the bursary for 2011, which to observe rail control centres, train railways operate. This assists TSV to was valued at ₤1,000. This allowed him maintenance facilities, signalling understand the risks to safety associated to attend the ITC from 9-14 October with equipment rooms and systems onboard with technologies and practices, which support from TSV. the train. Social events enabled members may be introduced into Victoria. to develop contacts from different The 2012 IRSE ITC (ASPECT 2012) will be held in London in September. For information about this and previous international events see www.irse.org. The local chapter of the IRSE conducts free monthly meetings with technical presentations. More information about these local meetings can be found at www.irse.org.au

26 countries and to exchange lessons learnt, while experiencing the local culture.

This opportunity has benefited Stephen and TSV by showing how rail safety risks are managed in other countries. This included the application of new technologies and practices to improve the efficiency and safety of railways and the influence of cultural factors on how railways operate. This assists TSV to understand the risks to safety associated with technologies and practices, which may be introduced into Victoria.

The 2012 IRSE ITC (ASPECT 2012) will be held in London in September. For information about this and previous international events see www.irse.org. The local chapter of the IRSE conducts free monthly meetings with technical presentations. More information about these local meetings can be found at www.irse.org.au

27 Rail accreditation – > rail operators intending to operate in Victoria

Accreditation is the formal process undertaken by Transport Safety Victoria (TSV) to allow an operator to carry out rail operations in Victoria under the Rail Safety Act 2006 (Vic) (RSA). The purpose of accreditation is to attest that the rail operator has demonstrated the competency and capacity to manage the risk to safety associated with the proposed rail operations for which accreditation is sought.

Under the RSA, a rail operator may be accredited as a rail infrastructure manager (RIM) and/or rolling stock operator (RSO).

Under section 36 RSA, a RIM must not operate or be allowed to operate rolling stock on the rail infrastructure under its control, unless the RIM is accredited or is exempted from accreditation either as a private siding operator or is exempted pursuant to the regulations (if operating an emergency response vehicle).

Similarly, under section 37 RSA, an RSO must not operate rolling stock on rail infrastructure unless the RSO is accredited or is exempted from accreditation either as a private siding operator or is exempted pursuant to the regulations (if operating an emergency response vehicle).

Recently, TSV has become aware of rail operators who may be carrying out rail operations either outside their accreditation or without being accredited by TSV.

Operating rolling stock on rail infrastructure without or outside accreditation or without holding an exemption attracts substantial penalties in Victoria. In addition, TSV’s transport safety officers have enforcement powers which include prohibition notices to prohibit any rail operations that The accreditation process involve an immediate risk to safety. TSV conducts a rigorous process when Exemption from accreditation: granting an operator accreditation Rail operators can apply for exemption from accreditation in as an RSO or RIM, or exemption from Victoria if the operator is: accreditation. In order to grant accreditations, ●● a RIM who carries out rail infrastructure operations using or in relation to a private siding TSV conducts reviews of at least the following: ●● an RSO who carries out rolling stock operations in a private siding. ●● ABN and other company information

●● the nature, character and scope of the Exempt rail operators (EROs), however, still have obligations under rail infrastructure manager’s proposed the RSA to have systems and arrangements that comply with rail infrastructure operations Schedule 3 of the Rail Safety Regulations 2006 (Vic) (RSR).

28 >

●● the risk management steps taken by ●● documents evidencing the scale/ After the required information has been the operator complexity of private siding and provided, TSV undertakes a number of the extent of track and other reviews against legislative requirements ●● safety management system (SMS) infrastructure layout that result in a response being given to provided by RIM or RSO applicants the applicant. (as required by schedule 2 of the RSR, ●● evidence of systems and including risk registers) arrangements provided by ERO Applicants are encouraged to meet with applicants (as required by Schedule 3 TSV before submitting their application ●● evidence of consultation on the SMS of the RSR, including risk registers) for accreditation or exemption, and if required, seek additional guidance ●● financial and ●● the safety interface agreements documentation. from suitably qualified persons in order provided. to meet the requirements of the RSA In order to grant exemptions from TSV may issue points of clarification to and RSR. accreditation, TSV conducts reviews of at applicants requesting further information least the following: to clarify any issue or address any > omission associated with the application. ●● ABN and other company information > 29 Track safety awareness training

Track Safety Awareness is a competency- METRO TRAINS based training course developed for the rail industry. It ensures people Metro Academy conducts train who work on or about the railway track safety awareness courses and track environment have the skills is Metro’s preferred trainer. Metro and knowledge to conduct their Academy can be contacted by email on activities safely. [email protected] Rail operators are responsible for arranging track safety awareness training ARTC where appropriate. This is one way to demonstrate to TSV that operators are The training organisations which ARTC ensuring that a person is competent to endorses are: carry out rail safety work, so far as is ●● Centre for Excellence in Rail Training reasonably practicable. - http://www.certrail.com/default. Each rail operator has their own aspx?MenuID=357 processes and systems for maintaining ●● Skilled Rail Services - http://skilled. track safety awareness. If a person is com.au/Common/PDF/Train_Track_ employed by, or providing services for, Safety_Awareness_Level_1.pdf a rail operator through a contractor, he or she should speak with the relevant ●● The Instruction Company - http:// operator about track safety awareness www.instructionco.com.au/rail- training. A worker can also seek further training/track-safety-awareness-risi information by contacting the relevant track manager. Other useful links: http://www.railsafetyworker.com.au/ Below are the contact details for each of the major track managers: V/LINE

For all V/Line track safety awareness training requirements contact: Rupert Capper Manager Systems & Safeworking T 03 8414 8643 E [email protected] W www.vline.com.au

30 31 Comments, ideas, feedback? Need this publication in a more accessible format (such as large print or audio)? Please telephone TSV on 1800 223 022, or email [email protected]. gov.au

Report a rail safety incident (accredited rail operators only): 1800 931 937 Stay informed. Subscribe to TSV’s email alerts service: Go to the news alert subscription form on the TSV website and tick the ‘rail’ box.

View previous editions of this newsletter: Go to the TSV website homepage, then click on ‘publications and forms’ (top right-hand corner).

Copyright in this publication resides with the State of Victoria. No reproduction is permitted without written authorisation. The material in this publication may contain the views or recommendations of third parties, which do not necessarily reflect the views of the State of Victoria. This publication is intended as a general information source. While every effort has been made to ensure that the material contained therein is accurate and up to date, the State of Victoria accepts no responsibility or legal liability for the accuracy or completeness of the information contained in this publication. This publication does not contain legal advice or professional advice, and should not be treated as such. ISSN: 1835-4483 © Copyright Transport Safety Victoria 2012