IN 2023 a Pacific National train driver took the wrong track at Port Botany, colliding with a Qube Logistics train causing severe damage and derailment of both trains.
The cause of the crash has been identified in a NSW Office of Transport Safety Investigation (OTSI) released on Thursday.
The investigation identified inconsistent work practices and risk assessment issues prior to the collision.
The report says that on 13 January 2023, a Pacific National train passed a stop signal before colliding with the side of a Qube Logistics train, resulting in the derailment of wagons from both trains.
“The accident resulted in significant damage to rollingstock and rail infrastructure. Fortunately, no injuries were reported,” the report said.
OTSI’s investigation found the accident occurred after the qualified driver directing the propelling movement of the Pacific National train mistook the track the train was on. Propelling involves reversing a train into the port.
As a result of the misunderstanding, when the signal changed and the Qube Logistics train began its authorised move, the Pacific National train was incorrectly authorised to move as well, and subsequently collided with the side of the Qube logistics train.
Rail infrastructure manager Australian Rail Track Corporation (ARTC) has taken steps to address the issues of the investigation which concluded ARTC did not proactively follow risk assessment principles specific to propelling movements, to ensure rail operations within shunting yards under its control were safe.
OTSI chief investigator Jim Modrouvanos said the accident demonstrated the importance of risk controls in protecting safety systems against human error.
“The investigation identified ARTC’s local shunting procedure was unique to the Port Botany yard, ambiguous, and described by crews as difficult and time consuming,” Mr Modrouvanos said.
“Subsequently, operators routinely deviated from the procedure, opting for what they perceived was a simpler method of working.”
ARTC has subsequently updated the Port Botany yard shunting instructions, is developing new procedures, and undertaking a structured review of risks associated with line-of-sight shunting at Port Botany.
“For ARTC and other rail infrastructure managers, this accident demonstrates the importance of following accredited risk management procedures to ensure risk controls remain relevant and effective,” Mr Modrouvanos said.
“Additionally, it shows how an effective risk assessment requires effective and meaningful engagement with subject matter experts and end users, and that those end users must be given the opportunity to provide feedback on procedures.”
While it was not found to have contributed to the accident, it was also identified that the person driving the Pacific National train, under direction of the authorised driver, was not authorised to do so.
“Rail operators are reminded to ensure that rail safety workers hold a verified competency for the task they are conducting,” Mr Modrouvanos said.