Figure 9:
Mindi accident site layout
Unaware of the collision, the Front Tower Operator continued reversing MMA59
toward signal MI27 at 20 km/h9 until urgently advised to stop by the Middle Cab
Operator who had sighted the Systems Maintenance crew members on the track
beneath MMA59. The Front Tower Operator brought MMA59 to a stop by closing
the throttle, applying pneumatic braking and deselecting the train transmission.
After taking this action, MMA59 came to a stop in 2 seconds and travelled a
further 5.5 metres.
The Front Tower Operator immediately reported the collision by radio to Mackay
Network Control and requested assistance. Network Control responded and
initiated the dispatch of an ambulance to Mindi.
A QR response crew from the Coppabella Depot arrived onsite at 1120 at about the
same time as the ambulance. The Systems Maintenance personnel were confirmed
deceased at 1141 by the ambulance crew.
Police attended the accident site at 1230 and conducted initial investigation and
analysis until 1725.
The Resurfacing crew was taken by bus to the QR Coppabella Depot where breath
testing was conducted by Police. Each crew member returned a zero reading.
Testing for drugs that may have affected the crew’s ability to perform safely was
not conducted.
9
Validated by datalogger evidence.
Queensland Transport, Rail Safety Investigation QT2140, 2008
page 11
Rail Safety Officers from QT (Rail Safety Unit) were informed of the accident at
1124 and attended onsite at 1840 to conduct preliminary investigations. At 2055,
the QT Rail Safety Officers approved the relocation of MMA59 to Coppabella
siding and quarantined it, pending further investigations. All personnel were clear
of the site at 2140.
Unoccupied Broom
Trailer cab
Direction during “reversing
movement”
Groundperson
Front Tower Operator position
Switch Tamper cab
Two Middle Seat Operators
(Middle Cab) facing towards
Broom Trailer
Figure 10: Resurfacing crew positions for the reversing movement (Switch Tamper facing)
Switch Tamper cab –
location of Front Tower
Operator & Groundperson
Two Middle Seat Operators
(Middle Cab) facing towards
Broom Trailer
Unoccupied Broom
Trailer cab
Direction during “reversing”
movement
Figure 11: Resurfacing crew positions for the reversing movement (Broom Trailer facing)
page 12
Queensland Transport, Rail Safety Investigation QT2140, 2008
1.5
Environment
1.5.1
Weather
The accident occurred at approximately 1056 on Friday 7 December 2007.
Visibility at the time of the accident was assessed as good.
Information obtained from the Bureau of Meteorology (BoM) as detailed in Table
1 was recorded at the Moranbah Water Treatment Plant, Queensland. Mindi is
approximately 59 km east north east of the township of Moranbah.
Local Time
Wind
Direction
Compass
Wind Speed
(km/hr)
Temperature
(degrees
Celsius)
Relative
Humidity (%)
Rainfall from
9am (mm)
0900
NE
6
25.6
70
2
Table 1:
1.5.2
Weather details for Moranbah on 7 December 2007 (Source BoM)
Noise
The Systems Maintenance crew used hand tools to commence reassembly of Points
12 C/D at the time of the accident. Primary noise sources were generated by the
passing coal train. Tests carried out onsite indicated noise levels for the Systems
Maintenance crew, in a working position, would have been approximately 94 dBA
as the loaded coal train passed on the adjacent Up line. No hearing protection was
utilised, nor required to be utilised by the Systems Maintenance crew.
The Switch Tamper and Broom Trailer of MMA59 were each equipped with roof
mounted pneumatic horns. The independent functional engineering assessment10
of MMA59 determined that activating the pneumatic horns whilst operating
MMA59 from the Switch Tamper cab, would only sound the horns in a forward
direction. The audible level of the forward horns was measured as 103.5 dBA at
a distance of 20 metres in front of the cab. The rear horns located above the cab
of the Broom Trailer and directed toward the Systems Maintenance crew did not
sound as they were incapable of being activated from the trailing Switch Tamper
(driving) cab.
10 Performed at Coppabella 12/13 December 2007.
Queensland Transport, Rail Safety Investigation QT2140, 2008
page 13
Figure 12: Coal train passing at Mindi during the measurement of noise levels – showing
proximity of train to location of track workers
1.6
Personnel
1.6.1
Systems maintenance crew
Two Systems Maintenance personnel were fatally injured in the collision. They
were employed at the QR Moranbah Trackside Systems Depot and formed a team
that comprised a qualified Systems Maintainer and a Trainee Systems Maintainer.
The primary function of a Systems Maintainer is to carry out the installation,
maintenance and repair of mechanical signalling equipment and report on the
performance and condition of signalling and other trackside systems to ensure
it is safe and in effective operation. The role also includes providing support to
resurfacing operations as needed.
The Operational Systems Coordinator based at the Moranbah Depot allocates
maintenance tasks through a PDA11 process which enables the tracking
and monitoring of outstanding work. Each Systems Maintainer is assigned
responsibility for specific geographical areas within the Goonyella System.
At the time of the collision the Coordinator was rostered for a Leisure Day Off
and was therefore unaware of either the disposition or location of the Systems
Maintenance crew.
11
Personal Digital Assistant or hand held computer with wireless communication and GPS locational capacity.
page 14
Queensland Transport, Rail Safety Investigation QT2140, 2008
1.6.1.1
Relevant systems maintenance crew competencies
Competencies
Systems Maintainer
Trainee Systems Maintainer
Medical Fitness to QR Standards
Fit for Duty
Fit for Duty
Date Commenced with QR
28/01/97
01/08/05
Basic Electrification Awareness
Current
Current
Trackside Safety Induction
Current
Current
Eye Protection
Expired (27/10/07)
Current
Fire and Emergency Procedures
Current
Current
Occupational Health and Safety
Induction
Current
Current
Hearing Protection
Expired (27/10/07)
Current
Heat Stress Understanding/
Preventing
Current
Current
Lookout Duties
Current
Current
Low Voltage Rescue
Current
Expired (23/07/07)
STD 37 Communication Protocols
Current
Current
Track Protection Officer
(Track Occupancy Authority)
Expired (04/10/07)
Not required*
Track Protection Officer
(No Authority Required)
Expired (04/10/07)
Not required*
Workplace First Aid Level 1 (CPR)
Current
Current
General Safety Induction
(Construction Industry)
Not held**
Current
Risk Assessment Awareness
Current
Current
Job Safety Analysis (JSA)
Current
Current
Look Out For Your Mates
Current
Current
Certificate III in Transport and
Distribution (Rail Infrastructure)
Current
Not applicable***
Table 2:
Systems maintenance crew competencies
*
QR advised that the Trainee Systems Maintainer did not require track protection training as this
qualification is held by the Systems Maintainer overseeing the work.
**
Under the Workplace Health and Safety Regulation 1997 a person must hold a general Safety Induction
(Construction Industry) Card (also known as a blue card) when undertaking work in any construction
activity.
***
The Trainee Systems Maintainer had one capstone assessment12 to complete before being issued with this
qualification.
12 Capstone Assessment is a verification of learning outcomes over the Trainee Systems Maintainer’s training. There are
approximately 13 capstone assessments, with each assessment being completed over a one week period. Each capstone test
is competed after 12 weeks of theory and practical training. The capstone assessments are equipment specific assessments.
The Certificate III in Transport and Distribution (Rail Infrastructure) is issued after the successful completion of the
13 capstone tests.
Queensland Transport, Rail Safety Investigation QT2140, 2008
page 15
1.6.1.2
Systems maintenance crew roster
Mon
Tue
Wed
Thur
Fri
Sat
Sun
19/11
20/11
21/11
22/11
23/11
24/11
25/11
Systems
Maintainer
0600-1500
0600-1500
0600-1500
0600-1745
1800-1845
1915-1945
0600-1730
1800-2200
0500-0700
1430-1900
Total hours
8.5
8.5
8.5
12.5
15
2
4.5
Trainee
Systems
Maintainer
0600-1500
0600-1500
0600-1500
0600-1500
0600-1430
0
0
Total hours
8.5
8.5
8.5
8.5
8
0
0
Mon
Tue
Wed
Thu
Fri
Sat + Sun
26/11
27/11
28/11
29/11
30/11
1 + 2/12
Systems
Maintainer
0445-0830
0600-1500
1645-2015
0615-1500
1530-2000
2030-2330
0930-1600
0600-1430
0
Total hours
3.75
13
15.75
6
8
0
Trainee
Systems
Maintainer
0600-1500
0600-1500
0600-1500
0600-1600
0600-1430
0
Total hours
8.5
8.5
8.5
9.5
8
0
Mon
Tue
Wed
Thu
Fri
03/12
04/12
05/12
06/12
07/12
Systems
Maintainer
LDO
0330-1500
0330-1915
0600-1800
0600 -
Total hours
N/A
11
15.25
11.5
Trainee
Systems
Maintainer
LDO
0330-1500
0330-1915
0600-1800
Total hours
N/A
11
15.25
11.5
Table 3:
0600 -
Systems maintenance crew roster
LDO – Leisure Day Off
Note: Roster is inclusive of all travel time.
Analysis of this rostering cycle appears at Section 2.3 of this report.
page 16
Queensland Transport, Rail Safety Investigation QT2140, 2008
1.6.2
Resurfacing workers
1.6.2.1
Relevant resurfacing crew competencies
Competencies
Resurfacing
Supervisor
Team
Leader
Plant
Fitter/
Operator
Operator
Maintainer
1
Operator
Maintainer
2
Medical Fitness to QR Standards
Fit for Duty
Fit for Duty
Fit for Duty
Fit for Duty
Fit for Duty
Date Commenced with QR
06/06/94
29/09/97
3/10/88
21/06/82
23/08/06
Blue Certificate Switch Tamper
MMA59
Current
Current
Current
Current
Current
Blue Certificate Plasser Broom
Trailer MMB59
Current
Current
Current
Current
Current
Category 3 Train Driver
Current
Current
Current
Current
Nil
Tag Out Procedures for Plant
Maintainers
Current
Current
Current
Current
Current
Route Competency C3 NonSpecified Corridors
Current
Current
Current
Current
Not
required*
STD 37 Communication Protocols
Current
Current
Current
Current
Current
Safety Foundation Training
Not held
Not held
Current
Not held
Not held
Basic Electrification Awareness
Current
Current
Current
Current
Current
Trackside Safety Induction
Current
Current
Current
Current
Current
Eye Protection
Current
Current
Current
Current
Current
Fire and Emergency Procedures
Current
Current
Current
Current
Current
OH&S Induction
Current
Current
Current
Current
Current
Hearing Protection
Current
Current
Current
Current
Current
Heat Stress Understanding/
Preventing
Current
Current
Current
Current
Current
Lookout Duties
Current
Current
Current
Current
Current
Workplace First Aid Level 1 (CPR)
Expired**
(05/04/07)
Current
Current
Expired**
(10/09/07)
Expired**
(14/08/07)
General Safety Induction
(Construction Industry)
Current
Current
Current
Current
Current
Risk Assessment Awareness
Current
Current
Current
Current
Current
Job Safety Analysis (JSA)
Current
Current
Current
Current
Current
Look Out For Your Mates
Current
Current
Current
Current
Current
Table 4:
Resurfacing crew competencies
*
This competency was not required as Category 3 Train Driver Competency was not held.
**
Workplace First Aid is not a mandatory competency for every worker to hold.
Note: Track Protection Officer Training for “Proceed Authority” is covered under Category 3 training.
Queensland Transport, Rail Safety Investigation QT2140, 2008
page 17
1.6.2.2
Resurfacing crew roster
Mon
Tue
Wed
Thur
Fri
Sat
Sun
Mon
Tue
19/11
20/11
21/11
22/11
23/11
24/11
25/11
26/11
27/11
0700-1700
0700-1900*
Resurfacing
Supervisor
RDO
Total Hours
N/A
12
0700-1730
0700-1630
Total Hours
10.5
9.5
11.5
11.5
Plant Fitter/
Operator
0700-1730
0700-1630
RDO
Total Hours
10.5
9.5
N/A
Operator
Maintainer 1
RDO
Total Hours
N/A
Operator
Maintainer 2
RDO
Total Hours
N/A
Team Leader
Table 5:
0700-1900* 0700-1900* 0900-2200* 0800-1800* 0700-1900* 0700-1900*
12
13
10
12
12
10
12
RDO
RDO
0700-1800*
0700-1700
11.5
N/A
N/A
11
10
RDO
RDO
RDO
RDO
0700-1800*
0700-1700
N/A
N/A
N/A
N/A
11
10
0700-1700
0700-1900*
0700-1830* 0600-1730* 0600-1730*
0700-1900* 0700-1900* 0900-2200* 0800-1800* 0700-1900* 0700-1900*
12
12
13
10
0700-1900* 0700-1900* 0900-2200* 0800-1800*
12
12
13
10
12
12
10
12
0700-1900
0700-1900*
0700-1700
0700-1900*
12
12
10
12
Resurfacing crew roster
*
No crib break (designated break) was taken during this shift.
#
No ten hour break
RDO – Rostered Day Off
Note: Roster is inclusive of all travel time.
Analysis of this rostering cycle appears at Section 2.3 of this report.
page 18
Queensland Transport, Rail Safety Investigation QT2140, 2008
Wed
Thu
Fri
Sat
Sun
Mon
Tue
Wed
Thu
Fri
28/11
29/11
30/11
01/12
02/12
03/12
04/12
05/12
06/12
07/12
0600-1700* 0700-1700* 0600-1600*
RDO
0800-1600* 0700-1800* 0700-2200* 0900-2200* 0700-1530# 0700–2100*
11
10
10
N/A
8
11
15
13
8.5
14
0700-1800*
0700-1600
RDO
RDO
RDO
RDO
RDO
0700-1800*
0700-1530
0700-2200*
11
9
N/A
N/A
N/A
N/A
N/A
11
8.5
15
0700-1800*
0700-1600
RDO
RDO
RDO
RDO
RDO
0700-1800*
0700-1530
0700-2300*
11
9
N/A
N/A
N/A
N/A
N/A
11
8.5
16
RDO
RDO
0800-1600
N/A
N/A
8
RDO
RDO
RDO
N/A
N/A
N/A
0600-1700* 0700-1700*
11
10
0600-1700* 0700-1700*
11
10
0700-1800* 0700-2200* 0900-2200* 0700-1530#
11
15
13
8.5
0700-1800* 0700-2200* 0900-2200* 0700-1530#
11
15
13
Queensland Transport, Rail Safety Investigation QT2140, 2008
8.5
0700-1700
10
0700-1700
10
page 19
1.6.3
Network controller
1.6.3.1
Relevant network controller competencies
Competencies
Network Controller
Medical Fitness to QR Standards
Fit for Duty
Date Commenced with QR
08/01/96
Basic Electrification Awareness
Current
Trackside Safety Induction
Current
STD 36 Safety General
Current
STD 36 Train Movements
Current
STD 37 Observance of Signals
Current
STD 38 Trackside Safety General
Current
STD 39 Isolation Protection
Current
STD 40 RCS Signals and Systems
Current
Safety Risk Management Awareness
Expired (16/10/07)
SPC 22 Operational Emergency Procedures Manual
Current
Transport Officer *
Current
* Includes relevant Transport Officer safeworking competencies.
Table 6:
Network controller competencies
1.7
QR safety communication
1.7.1
Documented communication
QR initiated numerous safety communications prior to and following the accident.
The Risk and Environmental Services Unit, ISG and Network Access each issued
safety documentation that was relevant to the circumstances and addressed some
contributory factors identified in the collision.
Key documents reviewed included:
Publication
Issued by
Date of Issue
Distribution
ISG Work Instruction
ISG
Unknown
Programmed Maintenance
Services
“ISG How to - Resurfacing and
Safety Facilitator
Resurfacing Staff
13
Maintaining Track Turnouts ”
and
Supervisor No. 21
ISG Safety Message No. 1
ISG
“SPAD Focus”
Manager Programmed
Maintenance Services
26 Feb 2003
All Programmed
Maintenance Services Teams
13 WI-MPM-0204-1.0.
page 20
Queensland Transport, Rail Safety Investigation QT2140, 2008
Publication
Issued by
Date of Issue
Distribution
Network Safety Bulletin
Network Access
Oct 2007
“Setting Back or Propelling”
General Manager
Network Operations
ISG Marketing and
Communications Officer and
Communications Advisor
ISG Safety Spotlight No. 99
Group General Manager
ISG
10 Dec 2007
All ISG personnel
Chief Risk Officer
23 Jan 2008
All ISG personnel
“Workplace Fatalities”
QR Safety and Environmental Alert
“Pre-use Inspections on Plant”
Table 7:
1.7.2
QR safety documentation and distribution
Voice communication
Standard STD/0037/SWK Observance of Signal Manual provided protocols for
the effective use of radio or satellite phone communication systems on the QR
network.
Analysis of voice recordings from Mackay Network Control revealed that
communication protocols and associated phraseologies, used during normal
operations, prior to the accident and through the post accident emergency
situation, were non compliant with this standard.
Senders and receivers did not identify themselves correctly on all occasions.
Critical safety communications rely upon a comprehensive understanding of all
operational messages and their subsequent intent. The perennial issue of verbal
communication strategies underpinned many former safety recommendations
to QR.
1.7.2.1
Mobile telephones
ISG issued QR mobile telephones to the Resurfacing Supervisor and also to the
Systems Maintainer. Each telephone utilised the Telstra network which provided
reliable communication between all parties at the Mindi site.
The investigation noted that ISG staff at all levels placed significant reliance on
mobile telephone usage for coordination as well as personal business. ISG does
not provide a policy on the use of private mobile telephones or guidance for their
use around the network other than that delivered through the Trackside Safety14
training process.
The QR Trackside Safety Induction Handbook states:
“When using mobile communication equipment always move to a position of
safety”.
14 Sometimes referred to as Pink Card training.
Queensland Transport, Rail Safety Investigation QT2140, 2008
page 21
1.7.2.2
Telex radios
MMA59 was fitted with a Telex BTR-300 duplex wireless communication system
that permitted simultaneous coordination between all occupants of the track
machine and the Groundperson.
The machine based crew communicated through a wired system whereas the
Groundperson benefited from the mobility of a wireless headset.
All headsets served to eliminate most internal ambient noise associated with the
operation of MMA59.
1.7.2.3
Train control radio
Both cabs of MMA59 (Switch Tamper and Broom Trailer) are fitted with a Trunk
Radio, Train Control Radio (TCR) and Maintenance Supervisory Radio (MSR –
telephone radio).
The primary means of communication with Network Control is the TCR
system. Road vehicles, primarily used in conjunction with track inspection and
maintenance activities, are fitted with TCR.
Machine noise and the use of the corded Telex headset meant that the TCR in
MMA59 was, by necessity, selected to a high volume setting for it to be heard
over the ambient noise levels.
1.8
Rolling stock
MMA59 consisted of a Self Propelled Switch and Crossing Tamper Liner (Switch
Tamper) and Track Sweeper Broom Trailer and Hopper (Broom Trailer). These
machines are permanently coupled for operational purposes.
The Switch Tamper can also be used to lift, line and level plain track as well as
turnouts.
The Broom Trailer was used for sweeping ballast from the top of track. Ballast
could be distributed to the side of the track or transferred to a five cubic metre
hopper for storage and later distribution. Although the Broom Trailer is not self
propelled it provides a driver cabin to control the Switch Tamper when travelling.
No Broom Trailer functions were utilised on 7 December 2007.
Rolling stock specifications for MMA59 appear in Appendix 5.1.
1.8.1
Mechanical examination of MMA59
Following the release of MMA59 from the Mindi site, it was taken to the QR
Coppabella Depot where it was impounded and secured to enable an independent
mechanical integrity examination to be performed by QT during 12 and 13
December 2007. Significant defects were identified during this examination.
page 22
Queensland Transport, Rail Safety Investigation QT2140, 2008
Following this examination, QT issued a formal Safety Direction to QR on 14
December 2007 to refrain from operating MMA59 until all advised defects had
been rectified. A completion date of 15 January 2008 was nominated.
In addition, QR was required to provide a risk assessment and action plan to
QT in relation to any planned movement of the rolling stock if it was unable to
undertake necessary restoration at the current location. Movement of the rolling
stock for this purpose was subject to written approval from QT’s Director (Rail
Safety).
Actions to comply with the full intent of the Safety Direction to the satisfaction of
QT were completed by 15 January 2008, and MMA59 was returned to service.
Figure 13: MMA59 – Broom Trailer
1.8.2
MMA59 reversing camera system testing
The interview process determined references to the reversing camera system fitted
to MMA59.
Five cameras were fitted to MMA59 and mounted in strategic locations to support
job functionality such as operators viewing the ballast hopper, broom assembly
and lateral extremities of MMA59.
Critical rearward vision was provided by a cab mounted camera, located above the
operating instrument panel in the Broom Trailer cab. Its purpose was reported to
provide assistance in viewing the track from an elevated central position.
The investigation measured the effectiveness of this system through a test
program constructed and assessed by QT and observed by local QR management.
An object with dimensions measuring one metre above track level and 450mm
wide was utilised as representative of a track worker in a semi-crouched position.
A previously worn QR orange safety shirt was attached to this apparatus to add
depth and realism to the assessment.
Queensland Transport, Rail Safety Investigation QT2140, 2008
page 23
Figure 14: Apparatus on-track (not viewed through camera)
Two persons were seated in the Switch Tamper cab of MMA59 and they assessed
rearward visibility through the fitted monitors at the ranges specified in the
following table. The test program was repeated on the similar camera system fitted
to Switch Tamper Track Machine MMA64. These results are analysed at section
2.4.9.3 of this report.
Range
100m
75m
50m
25m
10m
5m
3.5m
2m
MMA59
invisible
invisible
barely
visible
barely
visible
visible
visible
visible
invisible
MMA64
invisible
invisible
invisible
invisible
clearly
visible
clearly
visible
clearly
visible
clearly
visible
Table 8:
1.8.3
Camera test results
MMA59 communication system testing
Communication between operating crew was stated as vital to the resurfacing
operation. As such, the investigation tested the effectiveness of the Telex BTR-300
system in accordance with a QT constructed program (refer Appendix 5.2).
In all aspects the system proved effective, reliable and fit for purpose. Two
locations were determined that provided a slight reduction in readability but the
degradation was not considered significant.
These results are analysed at section 2.1.4 of this report.
page 24
Queensland Transport, Rail Safety Investigation QT2140, 2008
1.9
Safeworking procedures
QR Standard SAF/STD/0038/SWK Track and Trackside Safety Manual (Track and
Trackside Safety Manual) provided the minimum requirements for working within
the Right of Way and applied to all individuals and organisations involved with
activities on or near the track and safe operation of trains on the QR network.
This standard provided the requirements for protecting a worksite15 from network
traffic and for protection within a worksite that is protected from network traffic.
The Remote Controlled Signalling Standard provided the protection and speed
requirements for trains setting back.
1.9.1
Worksite protection
The track resurfacing activity on the day of the accident was conducted under
a Proceed Authority (working under signals). The Track and Trackside Safety
Manual provided for a Proceed Authority for trains and on-track vehicles to work
on a section provided the safeworking procedures for the authority are carried out.
In practice, the Network Controller sets the signals at either end of the worksite at
red to restrict entry to the worksite.
1.9.1.1
Protection within worksite
The Track and Trackside Safety Manual required a Worksite Safety Briefing to be
conducted before workgroups commenced work at any worksite, on or near the
track. The Trackside Safety Manual further stated:
A Track Protection Officer (TPO) was required to be nominated to:
Determine the method of worksite protection and complete a track worksite
protection planner (Forms SW01 or SW02);
Remind workers or visitors to:
Comply with safety instructions;
Use protective equipment provided;
Not to place themselves and others at risk of injury; and
That trains/on-track vehicles may approach from either direction on any
track at any time.
Provide information to all workers defining:
The worksite;
The escape route to clear the track when trains/on-track vehicles
approach; and
The method of worksite protection.
15 The Track and Trackside Safety Manual defines a worksite as “the area necessary to carry out work for a specific purpose for
a specified time. A worksite within three metres of the track centre line requires protection”.
Queensland Transport, Rail Safety Investigation QT2140, 2008
page 25
The Worksite Safety Briefing form partially completed for 7 December 2007
nominated both the Team Leader and Operator Maintainer 1 as the “Cat 3 Driver”.
The investigation was advised at interview that Category 3 driver training
provided a specific requirement for the Category 3 driver to be responsible for the
safeworking. This requirement was also stated in the content of Safety Message 1
(refer to section 2.4.4.1 of this report).
The SW02 Form used at Mindi differed from that displayed in the Track and
Trackside Safety Manual. A recent internal QR Safeworking Compliance Audit16
initiated on behalf of the General Manager Network Operations, and conducted
during October and November 2007, also identified non compliance with Worksite
Safety Briefings and safeworking forms.
These facts were recorded in the ‘Network Safety Safeworking Compliance Audit –
Document 2.6.4 20-07’ as:
Executive Summary
“Documentation was inconsistent and varied from district to district with
safety officers/staff determining/interpreting their requirements even though
Infrastructure Services internal quality management system documents the ISG
Form (Worksite Briefing Form) as a controlled document.
Worksite Safety Briefings were quite often conducted at the depot prior to
leaving for the worksite, negating the actual or changed worksite conditions
for risk assessment. Changed conditions at the worksite were not reassessed to
address the risks.”
Inherent with worksite protection at this site was that the Remote Controlled
Signal Manual limited any reversal movement conducted within RCS territory to
a maximum speed of 10 km/h. At interview, no member of the MMA59 crew was
aware of this requirement.
1.9.1.2
Additional workgroups
The Track and Trackside Safety Manual also required that when additional
workers or workgroups joined a worksite, the additional Track Protection Officer
(TPO)17 was to liaise with the onsite TPO to determine the appropriateness of
independent working. The additional TPO was also to complete a Worksite Safety
Briefing or obtain a worksite briefing from the onsite TPO and work under
existing protection.
16 Document 2.6.4 20-07.
17 TPO - The worker in charge of the Track Worksite Protection and has the responsibility for liaising with Network Control
(except when a Track Protection Coordinator has been appointed) to obtain the appropriate authority for the work being
performed and arranging for the necessary track protection in relation to that authority. A Track Protection Coordinator
is the worker who has the overall responsibility for liaising with Train Control to obtain the appropriate authority for the
work being performed and arranging for the necessary track protection in relation to that authority, defining the limits of all
worksites in the possession and the safeworking requirements for the closed section.
page 26
Queensland Transport, Rail Safety Investigation QT2140, 2008
Whilst a Worksite Safety Briefing form was partially completed for the
Resurfacing crew, the Systems Maintenance crew was not included on the form
nor did they complete a form in their own right.
1.9.2
Vigilance
The Track and Trackside Safety Manual provides an obligation for vigilance and
warned against items such as reliance on:
Train times;
Schedules;
Train overviews;
Train announcements;
Boom gates;
Signal indications;
Points, or train monitoring systems for information as to the running of
trains; and
Trains and on-track vehicles may run without prior advice.
The manual provided further procedures for situations when working on or near
the track and continual vigilance can be maintained:
When it is was necessary to be on or near the track and workers could
maintain continual vigilance, the standard listed relevant responsibilities that
included:
Be aware that trains/on-track vehicles may approach from either direction
on any track at any time;
Face an approaching train/on-track vehicle where possible;
Do not rely on anybody else to give warnings of approaching trains/on-track
vehicles;
Watch and listen for trains/on-track vehicles approaching at all times;
Do not be distracted by persons or events in your vicinity;
Look frequently (approximately every five seconds) to make sure there is
sufficient warning of the approach of a train/on-track vehicle;
Note: This must be done even if a train/on-track vehicle is not expected to
approach;
Other than when performing shunting duties, move to a position of safety at
least 10 seconds before the train/on-track vehicle arrives;
Be aware of trains/on-track vehicles on adjacent tracks and noise which may
mask the sound of an approaching train/on-track vehicle; and
Keep clear of moving rail vehicles.
Queensland Transport, Rail Safety Investigation QT2140, 2008
page 27
1.9.3
Lookouts
The Track and Trackside Safety Manual provided for protection by lookouts:
Lookouts may be used when it was determined, through a risk assessment, that
the level of protection for the worksite required a qualified lookout, and:
The track remains safe (at normal or restricted speed) for the passage of
train/on-track vehicles;
Workers and equipment can quickly move to a position of safety if necessary;
and
Workers are able to move clear of the track 10 seconds before the arrival of a
train/on-track vehicle.
The following relevant requirements are to be considered before providing
lookout protection for a worksite:
Lookouts will be used whenever approaching movements may be seen from
the worksite:
When parallel or adjacent lines are not closed to trains; and
When track is restored for the passage of trains and workers remain in the
vicinity of the track when trains are likely to approach.
The TPO will appoint competent lookouts whose sole duty is to give warning
of approaching movements;
An effective method of communicating warnings such as whistles, sirens,
voice or touch will be provided and used; and
Track workers will be given the warning in sufficient time to:
react to the warning of approaching movements;
remove their tools, equipment and materials from and clear of the track;
and
move from the track and stand clear in a position of safety, at least 10
seconds before a train arrives, and remain clear until the train has passed.
When it is necessary to protect a worksite, the TPO must tell the workers that
protection will be provided by lookouts; provide sufficient lookout/s to give
ample warning of an approaching train/on-track vehicle and not allocate any
other duties to the lookout/s.
Lookouts must wear safety yellow clothing; make sure ample advance warning
of an approaching train/on-track vehicle can be given and when a train/ontrack vehicle approaches - do not carry out any other duty.
A lookout was not appointed at the Mindi worksite on 7 December 2007. Each
Systems Maintenance crewmember was clothed in a safety orange shirt18.
18 Trackside Safety Manual Note: The safety yellow clothing must be worn only when performing lookout duties, except when a
team of two workers are required to alternate lookout duties, then both workers may wear safety yellow clothing.
page 28
Queensland Transport, Rail Safety Investigation QT2140, 2008
1.9.4
Setting back within a signal section
The Remote Controlled Signalling Standard stated:
When it was necessary to set back, the Train Driver must drive from the
leading driving cab in the direction of travel of a train unit. The driver was
also to regulate the speed of the train to be able to stop within one-half of
the distance of line-of-sight or have a second train driver, or other qualified
worker (with radio communication), proceed ahead of the reversing train
to warn others travelling or working on the track. The second Train Driver/
Qualified Worker (when used) at rear of train should tell the train driver the
required speed and stop the train if required.
Trains may only set back at a maximum speed of 10 km/h, and regulate the
speed of the train to be able to stop within one-half the distance of the line-ofsight.
Section 2.1.3 of the Remote Controlled Signalling Standard established that the
QR SMS defines MMA59 as a “train”.
The reversing movement undertaken on the day of the accident was driven from
the Switch Tamper cab (trailing cab of MMA59), and did not have a second train
driver/qualified person at the rear of the train. It attained a maximum speed of
20 km/h.
Queensland Transport, Rail Safety Investigation QT2140, 2008
page 29