AN INVESTIGATION into an ore train collision in Weipa has highlighted the importance of following published rules and procedures.
The Australian Transport Safety Bureau on Thursday released its final report on the 2019 incident. The report found 10 factors which either contributed to the accident or increased risk.
On 22 September 2019, an empty bauxite train collided with a rake of stationary wagons. The driver was unable to slow the train as it approached a bauxite loading station north of Weipa.
The ATSB said the locomotive and four wagons from the stationary rake derailed in the collision.
The modular driver’s cabin separated from the main body of the locomotive and was substantially damaged. The driver was initially trapped inside and sustained minor injuries.
The ATSB said the three safety issues in its investigation have now been addressed by operator RTA Weipa, the Rail Industry Safety and Standards Board (RISSB), and the locomotive’s design owner.
“The ATSB’s investigation found the driver was not able to slow the train as there was no continuity of air through the train’s brake pipe,” ATSB chief commissioner Angus Mitchell said.
“This was due to the brake pipe cock not being opened when the locomotive and rake were coupled together, prior to the accident journey.”
The ATSB found a brake continuity test was not performed during the pre-departure check, which it said was a missed opportunity to detect the issue.
“The coupling process being used was inconsistent with the published procedure, and routine audits conducted by the operator did not identify this inconsistency,” Mr Mitchell said.
The investigation also found management of change processes were not applied when the end of train telemetry system became inoperable, and the Lorim Point dump station became automated.
“This accident highlights the importance of ensuring that published rules and procedures are followed, through an effective monitoring and audit process, which is fundamental to rail safety,” Mr Mitchell said.
“Likewise, changes to rail operations need to be adequately managed to identify new or altered risks.”
As a result of the accident, according to the ATSB, the operator installed a revised telemetry system to allow drivers to perform brake continuity tests without relying on a second person.
It said the operator also introduced safety improvements to the manual brake continuity testing, and all relevant team members were re-trained in the test requirements.
The ATSB also found the design of the modular driver’s cabin mount was not resilient to frontal impact forces, and the industry standard did not provide design and/or performance standards for modular cabin resilience and retention for locomotive crashworthiness.
Since the accident, RISSB has included modular cabin retention within the update to Australian Standard 7520, which is underway, the ATSB said.
Separately, the locomotive’s design owner Progress Rail has re-engineered the modular cabin mounts to improve strength, to reduce the risk of cabin separation in the event of a collision.
“One of the ATSB’s primary goals is to encourage safety action to prevent reoccurrences when safety factors are identified, and I welcome the actions taken in response to this accident,” Mr Mitchell said.
