Miscellaneous

The NSW Government created Special Commissions of Inquiry for the Waterfall and Glenbrook rail accidents.  Other special commissions have been created from time to time and reports from such investigations are made available in this section. 

Changes in government department organisation have sometimes resulted in reports becoming very difficult to find.  Some such reports are available here.

Documents

Order by : Name | Date | Hits [ Ascendant ]

Derailment of Coal Train EG37 Connors Range - 1 July 2001 Derailment of Coal Train EG37 Connors Range - 1 July 2001

Australian Transport Safety Bureau (ATSB), Queensland Transport and Queensland Rail (QR).

On 1 July 2001 at approximately 0538 hours, EG37, a Locotrol II-equipped coal train operated by QR, was hauling 120 fully loaded wagons from Coppabella to Hay Point, Mackay, and commenced to negotiate the steep descent of the Connors Range.

Shortly after, the Driver reported to the Train Control Centre in Mackay that he had a ‘runaway’ train and that he had been in Emergency Brake for some minutes. As EG37 reached a speed of 93 km/h, it entered a left curve in the track approximately 38 km from Hay Point. The front portion of the train, including the first 28 wagons, separated from the remainder of the train but stayed on the track. Seventy-four of the following wagons, the two remote locomotives and the Electric Locomotive Control Unit (ELRC) derailed at that time. The last 18 wagons on the rear of the train remained on the track.

Within seconds of separating from the rest of the train, the front portion of the EG37 commenced to rapidly decelerate. It stopped some two minutes later and approximately two kilometres beyond the point of separation. Neither of the Drivers was injured as a result of the accident.

It was later determined that the sequence of events had been triggered by an extended loss of the Locotrol radio signal at the top of the range and that the back-up safety mechanism in the Train Brake system of EG37’s ELRC had failed due to a supernumerary errant O-ring lodged in the seat of the cut off portion of the Brake Pipe Control Valve.

As a result of that failure, the Remote Feed Valve at the ELRC remained open and fed air into the Train Brake Pipe throughout the accident sequence, opposing Train Brake applications made by the Driver. Consequently, the braking capacity of EG37 was reduced to something less than half its normal braking capacity and was insufficient to allow the Driver to control the speed of the train as it travelled down the range. Despite extensive testing, the investigation has not been able to determine the reason for the extended loss of Locotrol radio signal.

Hexham Derailment & Collision - 12 July 2002 - Final Report Hexham Derailment & Collision - 12 July 2002 - Final Report

On 12 July 2002, at approximately 0614 hours1, an empty coal train MO151 derailed 24 wagons on the Down2 coal line at 104 points at Hexham. As the driver of MO151 attempted, unsuccessfully, to contact the signal box at Maitland, the second person3] placed protection on the Up main line and the Up coal road. Contact was made with Train Control advising them of the derailment at Hexham and procedures to close the coal lines were then initiated.

However, approximately 8 minutes after coming to rest, one of the derailed wagons which were fouling the Up coal and Down main lines, was then struck by a two-carriage passenger train 715 travelling on the Down main. The collision occurred in clear but semi-dark conditions, adjacent to the Hunter Valley Co-operative Dairy complex, just west of Hexham Railway Station.

The coal train was operated by Pacific National Pty Ltd, whereas the passenger train was a State Rail Authority (SRA) service. As a result of the train crew of MO151 placing track-circuit shorting clips on the Up main, the Newcastle bound SRA passenger train 714 was stopped at Tarro station, 1.75kms west of the derailment site. The driver and guard and ten passengers of passenger train 715 suffered minor injuries with one passenger being transported to hospital with suspected spinal injuries.

The 30th to the 53rd wagons (inclusive) of MO151 were derailed, as were both carriages of 715. All the derailed vehicles remained upright but resulted in both coal roads and adjacent main lines being blocked. Passenger and freight operations were disrupted as a result of the accident. After the collision, the response to the emergency by local services, and rail organisations, was carried out with speed and efficiency, substantially in accordance with established procedures.

Restoration of services was largely accomplished by 14 July, without further injury. The investigation found the circumstances of the derailment of MO151 were consistent with the track owner failing to have appropriate infrastructure maintenance and inspection procedures in place to ensure safe and consistent rail operations. After the initial derailment, there was inadequate performance of interfaces between relevant personnel (accentuated by ineffective communication processes and by systems intolerant of human error). There were inadequate defences against such interface breakdowns, so that there was no adequate recognition of the danger to train 715 nor were any effective steps taken to prevent the subsequent collision. These matters are dealt with in the body of the report.

Special Commission of Inquiry into the Glenbrook Rail Accident - Final Report Special Commission of Inquiry into the Glenbrook Rail Accident - Final Report

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The Honourable Peter Aloysius McInerney - April 2001

The accident occurred at 8:22 am on 2 December 1999 when inter urban train W534 operated by the SRA of New South Wales collided with the rear wagon of the Indian Pacific. The locomotive and wagons of the latter train were owned by National Rail Corporation and Great Southern Railway respectively. At the time the leading engine of the Indian Pacific was commencing to draw away from signal 40.8, while the rear of the train was 426 metres further west located in a cutting approximately 700 metres east of Glenbrook railway station on the up main line to Sydney. The accident occurred in daylight hours on a fine, clear morning where the grade of track was 1 in 60. In the section of track where the accident occurred the movement of trains was controlled by automatic signals. This signalling was designed using overlap track circuits so that a stop signal would be displayed until such time as a train had cleared an additional track circuit beyond the next signal in the direction of travel.

Special Commission of Inquiry into the Glenbrook Rail Accident - Second Interim Report Special Commission of Inquiry into the Glenbrook Rail Accident - Second Interim Report

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The Honourable Peter Aloysius McInerney

 

This is the second interim report and was followed by the final report, available in this category of the Aitken & Partners web site.

Special Commission of Inquiry into the Glenbrook Rail Accident - First Interim Report Special Commission of Inquiry into the Glenbrook Rail Accident - First Interim Report

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The Honourable Peter Aloysius McInerney

 

This is the first interim report and was followed by a second interim report and the final report, available in this category of the Aitken & Partners web site.

"Things that have never happened before happen all the time."

 

Scott D Sagan, The Limits of Safety

"The enemy of safety is complexity."

 

Behind Human Error, Woods et al, Ashgate 2010 p 23

"Knowledge and error flow from the same mental sources, only success can tell one from another."

 

 

Ernst Mach, 1905

 

 

 

"Enhancing error tolerance, error detection, and error recovery together produce safety."

 

Behind Human Error, Woods et al, Ashgate 2010 p 26