THE AUSTRALIAN Transport Safety Bureau has urged training organisations to review rail safety worker competency assessments in response to a grain-train collision investigation.
ATSB on Tuesday (20 August) released the final report into the January 2022 incident, following an investigation by the Office of Transport Safety Investigations (OTSI).
The report details how three banking locomotives were added to the rear of a loaded grain train at Werris Creek (near Tamworth) to assist it up a steep uphill gradient later in its journey.
The banking locomotives separated from the train while it was in transit. The train stopped shortly afterwards, and the locomotives collided with the rear of the train, resulting in significant damage to the rear wagon and the front banking locomotive.
The investigation found the train separation was likely due to the knuckle on the bottom operated coupler of the lead banking locomotive remaining unlocked after coupling.
It also found the train crew had not performed a “stretch test” after attaching the banking locomotives.
OTSI acting chief investigator Jim Modrouvanos said a stretch test would have revealed that the knuckle was unlocked.
“It was also found that while the train crew had been assessed as competent in shunting during both vocational education and training and enterprise-based assessments on several occasions, the supporting evidence collected was usually limited to a single check box that the task had been ‘performed correctly’,” Mr Modrouvanos said.
The ATSB has issued a Safety Advisory Notice to rail transport operators, and registered training organisations acting on their behalf, to review and validate their rail safety worker competency assessments.
“The competence of rail safety workers is critical to safe railway operations,” Mr Modrouvanos said.
“Relevant industry members should validate their competency assessments to ensure their assessment tools, processes and judgements are reliably meeting the principles and requirements of competency-based training and assessment.”
OTSI’s investigation also found that, after the separation, the banking locomotive’s driver’s response was consistent with their training and operator Southern Shorthaul Railroad’s emergency response procedures, despite “being inappropriate for the situation”.
“It was also found the operator’s risk assessments for this operation were mostly performed by members of the management team,” Mr Modrouvanos said.
“While the team had varying levels of operational experience, consultation with operational staff directly affected by the operation did not occur.
“During assessment of risk, consultation consisting of effective and meaningful engagement becomes critical in identifying novel risks which may not be immediately apparent,” he continued.
“Particular attention should be given to procedures utilised in past operational environments, to ensure their ongoing appropriateness in these unique operational circumstances.”
ATSB said Southern Shorthaul Railroad has taken “a range of safety actions” since the accident, including providing train crew with reference materials related to coupler functionality, defining the process for a stretch test after coupling, and contextualising emergency response procedures for banking operations.
The investigation report is available here.
