March 2015
This is a collation of some of the world’s railway formal inquiry reports. It includes a brief incident
synopsis, along with the main causes and recommendations from each investigation.
Readers may find some of the actions and recommendations useful to their own operations.
Co-ordinated by Greg Morse, Operational Feedback Specialist, RSSB
Contents: (Click to navigate)
Australia: Safeworking breaches at Blackheath (13
June 2013), Newcastle (13 July 2013) and
Wollstonecraft (17 July 2013)
Australia: Freight train fire near Snowtown, SA, 21
August 2014
Australia: Freight train derailment at Bonnie Vale,
WA, 14 May 2014
Snowtown
Some of the key issues raised and/or suggested by the stories in this edition:
Non-compliance with rules
Management check function
Safety critical communications
Lack of guidance
Lack of risk assessment
Dangerous goods (declaration of)
Dangerous goods (loading, and checking thereof)
Appreciation of derailment risk (wheel-rail interface)
Reporting of track irregularities
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
10 March
Australia: Safeworking breaches at Blackheath (13 June 2013), Newcastle (13
July 2013) and Wollstonecraft (17 July 2013)
For the full report, click here: LINK
During June and July 2013, three separate ‘safeworking’ breaches occurred on the Sydney Trains
Network in NSW, involving the application of Network Rule NWT 308 (Absolute Signal Blocking) and
Network Procedure NPR 703 (Using Absolute Signal blocking). The incidents occurred at Blackheath
on 13 June 2013, Newcastle on 13 July 2013 and Wollstonecraft on 17 July 2013.
In each case, trains were being excluded from worksites, as part of worksite protection
arrangements, using the Absolute Signal Blocking (ASB) rule and procedure. Neither were adhered to
during the authorisation of the ASB resulting in trains entering or passing through worksites from
which they should have been excluded.
The Australian Transport Safety Bureau (ATSB) found that the three incidents were the result of the
requirements of the Network Rule and Procedure not being complied with – particularly full train-insection checks were not being conducted or the location of worksites was not clearly identified. Also,
the systems used to monitor the application of ASB were not consolidated. Instead, they made a very
limited number of isolated and generally non-safety-related findings without identifying how the
findings or proposed corrective actions were to be recorded, analysed or implemented.
The ATSB’s report identified the following specific findings:
Contributing factors

The Protection Officers (POs) and signallers did not effectively communicate all information
that was critical to the implementation of ASB.

Rule NWT 308 Absolute Signal Blocking and procedure NPR703 Using Absolute Signal
Blocking did not provide any guidance on acceptable methods for determining the location of
rail traffic in the section or confirming the clearance of rail traffic past a proposed work
location.

There were no forms or checklists to provide practical guidance for completing the steps
required to implement ASB or to provide an auditable record of the process.

The worksites were established to accommodate the available time constraints and without
rigorous assessment of the likely hazards or risks associated with using ASB as a form of
‘safeworking’.
Other factors that increase risk

Differences exist in the way signallers and POs identify trains to each other.

Not all major infrastructure was marked on the screens for the North Shore pane.

POs are implementing generic hazard control measures for the ‘struck by train’ risk, without
understanding that ASB relies on the total exclusion of trains from the section where the
worksite is located.

The Sydney Trains regime for auditing worksite protection arrangements was not effective in
identifying emerging trends or safety critical issues when using ASB.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
Other findings

Although conditional, the re-introduction of ASB following a period of suspension, was not
subjected to any risk assessment or change management review for potential changes in risk.
Action taken
Immediately after the third incident, Sydney Trains suspended use of the ASB rule and procedure for
some categories of track work. The suspension was conditionally lifted on 23 July 2014 with some
additional procedural requirements and an emphasis on complying with existing requirements for
clear communications.
In September 2014, Sydney Trains began a trial of a ‘Coded Authorisation Process for Absolute Signal
Blocking’. The trial seeks to address the common types of errors identified in ASB incidents by testing
a ‘job aid’ which requires improved train-in-section checks, improved identification of work site
locations and consistency in the implementation process between the Signaller and the PO for any
ASB request. It also requires that a unique code number be issued to the Protection Officer by the
Signaller upon any request for ASB. Work cannot commence on track without this code and the code
is surrendered back to the Signaller when the ASB is fulfilled.
On the matter of the monitoring and assurance, the ATSB has recommended that Sydney Trains
undertake further work to improve its focus on the potential issues involving ASB and its continued
safety.
The ATSB notes that ASB is one of five methods of worksite protection which are designed to provide
workers with safe track access. It is paramount that track access using any of the methods is properly
planned with adequate defence(s) against error, has the Network Rules and Procedures applied
consistently and is constantly monitored for compliance.
For more about the ATSB’s ‘safe work on rail’ initiative, click here: LINK
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14 March
Australia: Freight train fire near Snowtown, SA, 21 August 2014
For the full report, click here: LINK
At around 10:55 (local time) on 21 August 2014, a train carrying containerised freight (including
dangerous goods), arrived at Snowtown, South Australia. While at Snowtown, the crew noticed
smoke coming from one of the containers conveying dangerous goods.
The crew contacted ARTC Network Control to arrange for the Country Fire Service to attend the site.
An exclusion zone was set up around the site and the fire was brought under control with minimal
damage sustained.
The ATSB found that freight within the affected container, including undeclared dangerous goods,
had been packed in a way that was not in accordance with the code of practice for Transport of
Dangerous Goods by Road or Rail, or the operator’s dangerous goods policy.
Said operator – Genesee & Wyoming Australia (GWA) – had a documented policy on the
transportation of dangerous goods, including a Standard Condition of Carriage, which documented
the obligations of GWA’s customers when providing freight for transportation. However, GWA had
no active verification processes in place to check and confirm compliance with those requirements
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
(either in total or in part through random selection). Such a process may have provided the
opportunity to detect any undeclared dangerous goods or inappropriately packed freight before an
incident or accident resulted.
GWA has undertaken an independent audit of their policies and procedures for consigning freight,
including the adequacy of training in receiving handling and storage of dangerous goods. GWA has
also undertaken to improve communications with customers at their Alice Springs and Darwin
terminals – to identify where deficiencies may exist and how they might be best addressed.
Safety message
This incident illustrates the importance of freight forwarders and rail operators ensuring that
dangerous goods freight accepted for carriage meets the relevant requirements of the Transport of
Dangerous Goods by Road or Rail code of practice. All rail operators should ensure that their policies
and procedures for the acceptance of dangerous goods are effective in ensuring that the goods
accepted have been appropriately packed to minimise the risk of incidents during transportation.
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27 March
Australia: Freight train derailment at Bonnie Vale, WA, 14 May 2014
For the full report, click here: LINK
On 14 May 2014, a bulk iron ore train derailed on
the Defined Interstate Rail Network (DIRN) between
Stewart and Bonnie Vale, Western Australia. As a
result, there was significant damage to track and
rolling stock, although there were no reported
injuries.
The ATSB determined that the derailment was most
likely initiated by lateral harmonic vehicle
oscillation induced by a combination of minor cyclic
cross-level and lateral track irregularities just in advance of the point of derailment. As a result of
these irregularities, it was likely that the roll of one of the wagons caused the left hand wheels to
unload at a time when the leading left wheel came into contact with the left rail face – resulting in
flange climb and derailment.
While the wagon type that derailed (WOE class) had passed prescribed dynamic performance testing,
and the wagons and track complied with mandated engineering requirements, post-derailment
computer modelling showed the onset of lateral harmonic wagon oscillation of sufficient magnitude
to increase the likelihood of derailment at this location. Simulations showed that iron ore wagons,
with their short length, react more severely to 22-metre wavelength cyclic irregularities (as evident
at this site) than do the typically longer intermodal wagons. The ATSB concluded that undertaking
computer modelling when changing rolling stock and/or track working conditions offers rail transport
operators an opportunity to identify potential areas of risk exposure before implementing new
service arrangements.
Track maintenance and inspection was found to be in compliance with engineering requirements,
however the track leading into the derailment site was known (to train drivers) as an area of rough
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
ride. It was found that the systems in place between the train operator and track maintainer for the
reporting of track irregularities (in particular the rough riding of trains) was ineffective, and hence
the opportunity was lost to check for uncharacteristic track qualities through the derailment site –
before such qualities contributed to a derailment.
While not influencing the derailment, it was also noted that the loss of the train’s brake pipe integrity
(loss of air), including activation of the end-of-train monitor, had not resulted in the immediate and
full automatic activation of the train brake.
Action taken
The operator has developed enhanced procedures for reporting track irregularities and have jointly
committed, through the Rail Industry Safety and Standards Board, to ongoing industry support and
research into the cause of this type of derailment. Aurizon is examining, with the intent of rectifying,
the train braking irregularity (brakes not activating) that occurred following the loss of brake pipe
integrity.
Safety message
To reduce the potential for unforeseen dynamic stability issues affecting the safety of rolling stock
operations, it is essential that train operators and track maintainers:

Appropriately test and model rolling stock dynamic characteristics and the effects of changed
track conditions before implementing new service arrangements.

Develop proactive interface management strategies that promote the prompt reporting,
capture and feedback of uncharacteristic track qualities.
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Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk