View the Rail Safety Investigation Report
What happened
On 29 July 2020 at 0508, a loaded Pacific National (PN) coal train MB526 collided with the rear of a One Rail Australia (ORA) coal train AH378.
What we found
While AH378 was unloading at Kooragang Island Coal Terminal, several penalty brake applications, associated with a fault in its electronic pneumatic brake system, disabled the train bringing it to a standstill.
The crew investigated the faults using a series of technical exercises, which then caused the End of Train (EOT) light on AH378 to be extinguished.
The disablement of AH378 constituted a Condition Affecting the Network (CAN) but the crew did not report it to the Kooragang Network Controller as they were required to do.
As the Kooragang Network Controller was unaware that AH378 was disabled on number 3 arrival road, they set a signal for MB526 which allowed it to proceed, with caution along number 3 arrival road.
When the crew of MB526 saw the shunt proceed signal combined with information they had received earlier, they were expecting any train ahead to be operating farther along the track and illuminated with an EOT light.
The terminal area where the accident occurred was poorly lit by artificial trackside lighting and the absence of the EOT light on AH378 reduced its conspicuity. Light produced by an overhead gantry, above the accident site, may also have caused disabling glare for the drivers of train MB526.
In combination, these factors reduced the likelihood that the drivers of MB526 would have seen train AH378 in time to prevent a collision.
The crew’s expectations combined with glare from a nearby overhead signal gantry concealed the presence of AH378 until it was too late to avoid a collision.
What has been done as a result
On 1 August 2020, PN issued notices that informed drivers that on receiving a shunt proceed signal within Kooragang Coal Terminal, they must not exceed 8 km/h and should also proceed as if the line ahead is already occupied.
ORA added programmed monitoring of EOT lights into its asset management plan. ORA also circulated safety information (Notice to Drivers -HV-0046) to their drivers which reminded them of the requirement to communicate all conditions affecting the network to network control.
The Australian Rail Track Corporation (ARTC) provided advice to rail operators to clarify, the operation of trains with defective EOT lights. ARTC also updated information contained in the Rail Access Standard general information.
Safety messages
This accident highlights the importance of train crews communicating conditions affecting the network to network control.
It also emphasises the need for train crews operating in areas of restricted visibility to be prepared to stop short of any obstruction on the track.
Document download
- Rail Safety Investigation - Collision between coal trains MB526 & AH 378 - Kooragang - 29 July 2020 Download (PDF 1.56MB)
Rail Safety Investigation - Collision between coal trains MB526 & AH 378 - Kooragang - 29 July 2020