Best practice rail safety:

Lessons from safety investigations

Rail 2007

Kym Bills

Executive Director ATSB

3 April 2007

Overview

‘Best practice rail safety: lessons from safety investigations’

�Background regarding the ATSB’s role and operations

�Recent rail safety data and the inter-modal context

�Developments to enhance rail safety data and its use

�ATSB investigations and key safety lessons from reports

�Concluding remarks on safety and sustainability

Rail

Marine

Aviation

Road

http://www.atsb.gov.au

ATSB role and operations

�ATSB approximately 111 staff, mostly in Canberra and

mostly dealing with aviation (Commonwealth sole role)

�Aviation and marine investigation recognised as among

best in world (ICAO, ISASI, IMO, MAIIF, ITSA activities)

�Road safety - similar recognition based on a dozen staff

�Rail safety – seeking to build a top reputation with 9

investigators and professional staff (4 in Adelaide HQ).

Via MOUs with jurisdictions, our focus is on the DIRN.

Defined Interstate Rail Network (DIRN)

Transport Safety Investigation Act 2003

�ATSB investigations do not apportion blame or liability

�Investigation reports cannot be used as evidence in civil or

criminal proceedings

�All investigation reports must be publicly released

�The Act gives the ATSB considerable investigative powers

�Independence, but cooperation with other investigations

and minimise unnecessary disruption to industry

Recent Rail Safety Data

�ATSB-published national regulator data for 2005-06:

-45 non-suicide deaths and 479 serious injuries

-121 running line derailments

-206 running line collisions (112 with infrastructure, 54 with

persons, 16 with rollingstock, 14 other trains, 10 road vehicle)

- 78 level crossing collisions (71 of which with road vehicles)

-457 signals passed at danger

-519 loading irregularities

-1084 track/civil infrastructure irregularities.

Inter-modal context

�Annual rail deaths about the same as in aviation and marine

�Road deaths by comparison are now around 1600 annually

�Rail, bus and low capacity regular public transport air travel are about equally safe based on passenger kilometres travelled and about 5 times safer than car travel

�High capacity regular public transport air travel in Australia has zero fatal accidents in the jet age

�Motorcycle travel is 28 times less safe than car travel (ie about 140 times less safe than rail).

Enhancing Rail Safety Data

�Rail regulators in jurisdictions will provide the ATSB with rail

safety data for calendar 2001 to calendar 2006 for publication

before the end of June 2007

�Regulators are working with the ATSB and NTC on broader,

more strategic and useful data including with causal factors to

enable pro-active analysis

�After some false-starts, there appears to be goodwill to make

substantial progress as required by Ministers and COAG

Levels of analysis

Investigation report findings

�Contributing safety factors

�Other safety factors

–Other safety factors identified during investigation which are considered important

�Other key findings

–Resolve significant ambiguity or controversy

–Discuss potential scenarios

–Positive factors which ‘saved the day’

ATSB safety action activities

�Critical safety issue:

–Communicate concern immediately

– If safety action not prompt, issue recommendation

�Significant safety issue:

–Communicate concern as soon as reasonable

�Minor safety issue: communicate with operator via

regular liaison and if safety action taken, record results

ATSB Recommendations

� Not enforceable (we do not place ourselves in the

position of a quasi regulator)

� Close liaison with regulators and operators for periodic

updates of implementation progress

� Non-prescriptive - ie identify the safety issues and

recommend “review” so that the organisation which

carries the risk is selecting/implementing the “fix”

� Early communication of safety issues so that “good

news” may be included in final report – a win/win.

Pre – July 2003

�ATSB investigation by invitation from State governments

�Usually the more serious accidents and provides more independence

�Conducted under State Legislation provided ‘no blame’ (could only help Waterfall Commission obtain investigation experts)

�Phased out when TSI Act in place (DIRN focus) and NSW developing capacity

Beresfield (NSW) – 23 Oct 1997 Zanthus (WA) – 18 Aug 1999

Ararat (VIC) – 26 Nov 1999

Key safety findings: Beresfield

�coal train collision with rear of another

coal train after failed to comply with

caution & stop signals

�3 locos & ten coal wagons derailed

�3 serious injuries (2 crew; 1 @ station)

�fatigue, system intolerant of human

error, inadequate safety defences

Key safety findings: Zanthus

�Indian Pacific directed into standing

freight train at low speed

�crew member of freight train pushed

a button which moved the points

and couldn’t reverse the mistake

�systemic vulnerability & human error

�safety action: interlock system &

new procedures to prevent repeat

Key safety findings: Ararat

�In this case a Freight Victoria employee

moved points diverting grain train into yard to

collide with stationary ballast train

�unsafe & unauthorised: ‘trying to be helpful’

�system vulnerability & human error

�training, control, system design, hazard

identification and risk management needed

Wodonga (VIC) – 25 Apr 2001 Footscray (VIC) – 5 June 2001

Black Mountain (QLD) – 1 Jul 2001

Key safety findings: Wodonga

�Countrylink XPT derailment on sharpest curve on

Sydney-to-Melbourne main line in Wodonga

�condition of high rail fasteners resulted in gauge

widening of up to 49mm at point of derailment

�also bogie thin wheel flange & issues with yaw

friction pads

�the combination led to derailment

Key safety findings: Footscray

�empty suburban electric express train collided with back of a suburban passenger train when driver impaired by medical condition/asleep

�‘deadman’s handle’ could be bypassed

intentionally or by weight of lower leg

�health standards to assess driver health were deficient (chronic sleep problems, medication)

�also signal & train stop system issues and train system radio network reliability

Key safety findings: Black Mountain

� QR runaway coal train hauling 120 wagons

during steep descent of Connors Range

�At 93 km/h front of consist with 28 wagons

separated & 74 wagons, 2 remote locos & the

electric locomotive control unit derailed

�extra errant O-ring reduced braking by over half

�also issues re communications & dataloggers

Epping (VIC) – 18 Jun 2002

Benalla (VIC) – 13 Oct 2002

Salisbury (SA) – 24 Oct 2002

Key safety findings: Epping

�scheduled suburban electric passenger train 60 km/h

on up journey SPAD - collided with scheduled

suburban empty train 12 km/h on a down journey

�up driver unwell (migraine, stress) - no recall 1 minute

�signalling system couldn’t maintain minimum safety

margin to prevent the collision

�deadman’s handle (pilot valves) ineffective again

Key safety findings: Benalla

�passive level crossing accident involving a loaded B-double and a passenger steam train

�B-Double driver didn’t see train before crossing

�train driver, fireman, and a footplate visitor died, one serious injury

�Victoria’s TOR focus on rail not B-Double

�recommendations included reviewing level crossings on B-double routes, track sighting, and education program

Key safety findings: Salisbury

�passenger train collided with a car and Serco

bus in which 4 killed and 26 injured

�road vehicles had queued across an active

level crossing and could not exit tracks

�this was forseeable as it occurred regularly

Spencer Street (VIC) – 3 Feb 2003

Chiltern (VIC) – 16 Mar 2003

Aloomba (QLD) – 23 May 2003

Key safety findings: Spencer Street

�driverless empty suburban train rolled away

while driver using the amenities and travelled

about 17 kms at speeds of over 100 km/h

�after near miss with previous passenger train

and at many level and pedestrian crossings,

finally collided with stationary passenger train

at Spencer Street station at 75 km/h

�safety action included park brake and

procedures when changing ends

Key safety findings: Chiltern

�PN freight train carrying steel etc derailed as a result

of a ‘screwed journal’ on a wagon that had been in

storage for several years

�a V/Line passenger train on the broad gauge

collided with the wreckage

�maintenance schedules for the journal bearing on

the failed axle were based on distance travelled not

both distance and time

�deficiencies in comms between control centres

Key safety findings: Aloomba

�passive level crossing accident when a local woman

stopped her car ‘in automation’ mode and drove in

front of 80km/h Sunlander passenger train

�7 year old killed and 5 year old seriously injured

�safety recommendations included reassess level

crossing upgrade program

Post – July 2003

�Increasing number of DIRN-only investigations:

Budget resourced for about 10 new per annum

�Now do non-DIRN if Ministerial request & under TSI

Act; eg because no assured funding from

jurisdictions to enable training of extra staff

�OTSI followed best practice independent model

after Waterfall changes; & VIC subsequently

�legislation review likely by other jurisdictions/NTC

Bates (SA) – 9 Nov 2003

Ararat (VIC) – 28 Nov 2003

Sandgate (NSW) – 25 Feb 2004

Key safety findings: Bates

�PN derailment at 77 km/h after axle separated

and ‘screwed off’ due to heat plasticising roller

bearing

�probable water ingress via suboptimum storage

�radius of roller bearing unit at opposite end of

failed axle was out of specification and rusty

Key safety findings: Ararat

�PN freight train derailed 2 wagons after

traversing buckled rail which was made

progressively worse as train passed over it

�found probably tamping a week before altered

geometry of track and lowered stress free

temperature to below 38C

Key safety findings: Sandgate

�empty Endeavour passenger train stopped 75m

short of collision with stationary loaded coal train

after points placed in wrong position

�signaller distracted and did not apply blocking

facilities or check route thoroughly

Alumatta (VIC) – 15 Mar 2004

Murarrie (QLD) – 28 June 2004

Fisherman Islands (QLD) – 20 Sep 2004

Key safety findings: Alumatta

�derailment of trailing bogie of 2nd to last wagon of

Freight Australia train departing crossing loop due

to combined track geometry and excessive speed

�travelled almost 5km in derailed state through 4

level crossings and a bridge at up to 69 km/h

�issue of broad gauge only metres from standard but

operated independently and poor communications

Key safety findings: Murarrie

�freight train SPAD when driver passed stop

while said retrieving a dropped radio hand-set

�train controller absent from workstation so 16

second delay while colleague dealt

�driver had a history of SPADs and died of

severe coronary 4 months after this one

�issue that not monitored or supervised after

previous SPADs, and QR medical standards

Key safety findings: Fisherman Islands

�freight train SPAD when driver fell asleep

and half woke and applied full power

�realised signal red and cars on level crossing but only stopped 74 metres beyond

�unclear if microsleep episodes based on

personal or task induced fatigue

�system vulnerable to such error in terms of

track and train secondary protection and

fatigue management standards and policy

Benalla (VIC) – 23 Sep 2004

Thornton (NSW) – 11 Oct 2004

Berajondo (QLD) – 15 Nov 2004

Key safety findings: Benalla

�4 of 15 Freight Australia wagons carrying dry

bulk cement derailed

�80km/h temporary speed restriction in place

due to weak track structure and geometry

was still too high given deteriorated track

Key safety findings: Thornton

�derailment of last 7 of 54 loaded coal wagons

due to combination with track

�gauge widening due to poor rail fastener

condition and asymmetric wheel wear

Key safety findings: Berajondo

�tilt train with 150 pax and 7 staff derailment at 112km/h on 60km/h curve

�lead car and 7 trailer cars derailed and only trailing power car remained upright

�driver distracted and lost position awareness while co-driver in adjacent vestibule

�QR was in process of reviewing advance speed boards to give drivers warning of speed reductions of over 40 km/h; and intended to expand use of Automatic Train Protection

Glenalta (SA) – 21 Nov 2004

South Dynon (VIC) – 19 Jan 2005

Koolyanobbing (WA) – 30 Jan 2005

Key safety findings: Glenalta

�PN freight train 10 wagons derailed in Adelaide

Hills with 5 obstructing broad gauge passenger

track and 4 down into residential properties

�likely triggered when wheel made contact with

check rail at entrance to Belair crossing loop

�4 factors combined including 3 empty wagons

behind locos; followed by 2900 tonnes; use only of

dynamic braking down descent; track geometry

Key safety findings: South Dynon

�two wagons of a PN freight train propelled at 9

km/h into the side of an XPT passenger train

running on the main line at about 13 km/h

�trainee marshalling freight wagons did not have

a clearly specified task or role or supervision

�also issue with performance of catch points

Key safety findings: Koolyanobbing/Booraan

�two PN freight train derailments (23 & 19

wagons) within an hour of each other 200 &

360km west of Kalgoorlie when track 18-21

degrees hotter than 40C design neutral temp

�both in vicinity of rural road level crossings

�track misalignment via buckle worsened by

passage of trains �for Koolyanobbing, track tamping on morning

probably contributed

Booraan (WA) – 30 Jan 2005

Regency Park (SA) – 2 Feb 2005

Horsham (VIC) – 11 Aug 2005

Key safety findings: Regency Park

�SCT employee directing shunting of a

locomotive and 9 wagons seriously injured

�either shunter fell from wagon end step or

slipped as trying to get on step

�procedures allowed this with no confirmation

by driver that shunter safe before starting

Key safety findings: Horsham

�active level crossing collision fatally injuring car

driver hit by PN locomotive which then derailed

�local driver probably did not expect train, and

possible personal distraction issues

�intersection after crossing may also have

distracted the driver

�recommendations included education and

awareness of level crossing safety and risk

Greenbank (QLD) – 25 Aug 2005

Eden Hills (SA) – 30 Sep 2005

Lismore (VIC) – 25 May 2006

Key safety findings: Greenbank

�freight train collided at 22km/h with a stationary

track vehicle at take-off point in station yard

�QR controller had not expected simultaneous

arrival because of trainee teaching distractions,

and ambiguous communication re departure

�track workers saw and heard train but thought

they would reach the take-off point and remove

the track vehicle before the train arrived

Key safety findings: Eden Hills

�out of gauge steel plate on PN freight train had

shifted from at least Murray Bridge before hitting

a TransAdelaide passenger train in Adelaide Hills

�ARTC track at Eden Hills station platform 140mm

closer to TransAdelaide track than design

�safety recommendations included steel tensile

strapping and improved load audit procedures

Key safety findings: Lismore

�passive level crossing accident between a rigid

tipper truck with quad axle trailer loaded with

citrus pulp and freight train travelling at 112km/h

�heavy fog, truck driver killed, and 41 of 64

wagons derailed

�truck not being driven according to conditions but

if it had stopped, longer time to cross so risk

remained unless active crossing greater warning

Inverleigh (VIC) – 25 Sep 2006

�26km/h impact by train

due to outer flag

position & late braking

Ongoing Investigations

� NT

– Elizabeth River

– Ban Ban Springs

� SA – Adelaide

– Tailem Bend

– Tarcoola

� VIC – Benalla

– North Geelong

– Seymour

– Wingeel

� NSW – Albury

– Harden

– Illabo

– Yerong Creek

– Back Creek

Yerong Creek (NSW) – 4 Jan 2006

Harden (NSW) – 9 Feb 2006

Adelaide (SA) – 28 Mar 2006

Ongoing investigations

�Yerong Creek – 9 wagons derailed,

track damage and closed 48 hours

�Harden – XPT derailment & power

car axle broken; 8 others cracked

�Adelaide – SPAD in yard damaging

54 points and potential collision with

Indian Pacific on DIRN

Benalla (VIC) – 2 Jun 2006

Albury (NSW) – 5 Jun 2006

Seymour (VIC) – 12 Sep 2006

Ongoing investigations

�Benalla – Interail freight train derailment

�Albury – car driver killed in active level

crossing accident involving XPT

�Seymour – derailment involving a Patrick

train

Tailem Bend (SA) – 4 Oct 2006

Elizabeth River (NT) – 20 Oct 2006

Ongoing investigations

�Tailem Bend – level crossing with stop

sign: train collision with prime mover/low

loader

�Elizabeth River – level crossing collision

between south bound freight train and

double-trailer road train

North Geelong (VIC) – 26 Oct 2006

Tarcoola (SA) – 1 Nov 2006

Illabo (NSW) – 2 Nov 2006

Ongoing investigations

�North Geelong – PN freight train collision with

‘bucket truck’ doing bridge works

�Tarcoola – Freightlink derailment after brake

pipe air lost

�Illabo – level crossing collision when train

collided with overturned semi trailer loaded

with wool bales

Wingeel (VIC) – 15 Nov 2006

Ban Ban Springs (NT) – 12 Dec 2006

Ongoing investigations

�Wingeel – level crossing collision: rigid tipper

truck and ‘dog’ trailer at passive crossing with

GSR Overland hauled by PN. Truck driver fatal.

�Ban Ban Springs – level crossing collision:

empty double-trailer road train drove into path of

Ghan derailing both locomotives & 10 wagons

Back Creek (NSW) – 10 Mar 2007

Ongoing investigations: Back Creek

�level crossing collision

�semi-trailer loaded with hay hit by

PN grain train at passive crossing

�truck driver fatality, one train driver

broken ribs, other minor injuries

�truck, 3 locomotives and ten span

bridge destroyed/burnt out

Conclusion re safety investigations

�I hope that this quick review has demonstrated a substantial

record of safety investigations and action, especially given

the dearth of other publicly reported investigations from 1999

�particularly proud of my team’s work on medical standards,

pilot valves, the need for better and standardised

communications, human error-tolerant systems, and level

crossing risk-based treatments and broader education

Rail Safety and Sustainability

�In conclusion, many lessons from best practice investigation

�Important these publicised to enable learning and change

�Good safety practices make good business sense

�A robust safety management system is key (safety culture)

�Australia’s rail safety record is good but can be improved

�One major accident can have disastrous consequences.

Further information

www.atsb.gov.au

Thank you for your attention

Rail 2007

Kym Bills Executive

Director ATSB

3 April 2007