View the Rail Safety Investigation Report
OTSI conducted this investigation in collaboration with the ATSB.
What happened
On 6 January 2022, freight train 5446, operated by Southern Shorthaul Railroad (SSR), departed from Narrabri West for Bullock Island at Newcastle. Due to a steep uphill gradient en route, three additional (banking) locomotives were attached to the rear of 5446 at Werris Creek.
Shortly after departure from Werris Creek, the banking locomotives separated from and then collided with the rear of the train.
A crew member suffered a minor head injury in the collision and there was significant damage to rolling stock.
What we found
The cause of the train separation was highly likely due to the knuckle on the lead banking locomotive’s bottom operated coupler – the component which connects the locomotive to the rear of the train – remaining unlocked after coupling.
The crew did not perform a ‘stretch test’ which would have identified that the knuckle was unlocked and the crew member who performed the shunt did not have a full understanding of automatic coupler operation.
The investigation could not determine whether the banking locomotive crew had previously demonstrated a sufficient level of competence in a stretch test procedure, either with their current employer or previous operators.
The investigation found that:
- The train crew had limited coupler functionality knowledge, and test procedures associated with shunting operations were not clearly defined.
- There was insufficient evidence to determine whether the banking locomotive crew had previously demonstrated a sufficient level of competence in a stretch test procedure, either with their current employer or previous operators.
- Procedures in the event of an emergency during banking operations were absent.
- There was limited effective and meaningful stakeholder engagement during the risk assessment process.
Actions taken by directly involved parties during the investigation
Southern Shorthaul Railroad has:
- Provided its train crew with reference materials on coupler functionality.
- Defined the process for a ‘stretch test’.
- Contextualised emergency procedures for banking operations.
- Further defined the need for adequate consultation during material change.
Safety message
- The competence of rail safety workers is critical to safe railway operations.
- Where competency assessments for rail safety workers are aligned to the Australian Qualifications Framework (AQF), certain standards must be met, including collecting sufficient assessment evidence to ensure a reliable competency decision can be made. Rail transport operators should follow these same principles when delivering enterprise-based assessments.
- When assessing risk, effective and meaningful engagement with stakeholders is key to ensuring risks are identified and appropriate controls are implemented. Appropriate engagement is especially important for unique operations and identifying novel risks which may not be immediately apparent.
- Rail transport operators should pay particular attention to procedures used in past operational environments to ensure they continue to be appropriate in unique operational circumstances.
Read Automatic coupler operation and design features Safety Advisory Notice
Read Assessment of rail safety worker competence Safety Advisory Notice