The collision caused major damage to a wagon and locomotive. Photo: ATSB
THE AUSTRALIAN Transport Safety Bureau is urging rail-transport operators and registered training organisations to review and validate their rail safety worker competency assessments following an investigation into a grain train collision near Tamworth on 6 January 2022.
The investigation was launched after Southern Shorthaul Railroad locomotives detached from the train, which led to a collision when the train stopped.
This resulted in significant damage to the rear wagon and one locomotive.
Three locomotives, which detached during the journey, were an addition to the rear of a loaded grain train at Werris Creek, to assist it up a steep uphill gradient later in its journey.
A transport safety investigation was conducted by the Office of Transport Safety Investigations (OTSI), which investigates rail accidents in New South Wales on behalf of the ATSB.
The investigation found the train separation was highly likely due a knuckle on one of the locomotives not being locked.
OTSI’s acting chief investigator Jim Modrouvanos said it was found the train crew had not performed a “stretch test” after attaching the banking locomotives.
“A stretch test would have identified that the knuckle on the bottom-operated coupler of the lead banking locomotive had remained unlocked after coupling,” Mr Modrouvanos said.
“It was also found that while the train crew had been assessed as competent in shunting during both vocational education and training (VET) 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 as a result of these findings, a Safety Advisory Notice has been issued 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.
“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.”
Additionally, OTSI’s investigation found after the separation event, the response taken by the banking locomotive’s driver in relation to the sudden loss of brake pipe pressure was consistent with their training and SSR’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.
“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.
“Particular attention should be given to procedures utilised in past operational environments to ensure their ongoing appropriateness in these unique operational circumstances.”
SSR 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.
Source: ATSB