The removal of a brake from road-rail front guidance equipment was found to be one of the primary causes of an accident that led to the death of a rail worker at Haig on the Goldfields of Western Australia in May of 2012.
Poorly maintained rear brakes and non-compliance with operational procedures were also found to have contributed to the accident according to a report released by the Australian Transport Safety Bureau yesterday.
Traces of cannabis were found in the system of the deceased worker, however other workers involved in the incident were not tested for drug and alcohol impairment at the time.
The Report states;
“On 24 May 2012, three Transfield Services Australia (Transfield) road-rail vehicles were travelling in convoy in a westerly direction between Forrest and Haig in Western Australia, where they were to be taken off the track.”
“Shortly before 1700, on arrival at the Haig level crossing, the lead vehicle was off-tracked, but a problem with the second vehicle prevented its removal from the track. At about 1711, while work was continuing to remove the second vehicle from the track, the third vehicle in the convoy, a flatbed truck, collided with the rear of the second vehicle. The force of the impact shunted the stationary vehicle forwards with both vehicles running over one worker, fatally injuring him, while the other jumped clear. The driver of flatbed truck was not injured.”
What the ATSB found
The ATSB determined that the flatbed truck could not be stopped in time to avoid the collision because the brakes that were originally fitted to its front rail guidance equipment had been removed, and the vehicle’s rear wheel brakes were in a poor state of repair. The investigation also identified that the rail workers had developed localised practices that were not compliant with Transfield’s operational procedures.
A sample of the deceased worker’s blood tested positive to both the active and inactive metabolite of cannabis. The other workers were not tested for the presence of drugs and alcohol following the accident.
The ATSB identified a number of systemic issues associated with Transfield’s road-rail vehicle maintenance regime, rail safety worker training, management oversight and drug and alcohol policy and procedures.
In addition, the ATSB highlighted the absence of a national standard for road-rail vehicles which addresses the fitment, modification and maintenance of road-rail equipment and the consequent risk that unsuitable modifications may adversely affect the safe operation of a road-rail vehicle.
What’s been done as a result
Transfield Services Australia has reviewed and updated its road-rail vehicle maintenance regime. The company has also taken action to improve its management oversight of rail safety workers, its training processes for maintenance and operational staff and its drug and alcohol policies and procedures.
The Rail Industry Safety Standards Board (RISSB) is facilitating the development of Australian Standard, AS 7502, Road Rail Vehicles. The standard will cover the basic requirements for road-rail vehicles across their life cycle, including design, construction, testing and certification, operation, maintenance, modification and disposal.
Safety message
Rail operators should ensure that safety critical road-rail vehicle equipment is appropriately maintained. Maintenance regimes and activities should consider the increased loading and wear and tear on the vehicle and its various components as a result of fitting of rail guidance equipment and of the operation of the vehicle on rail.
Rail Operators should also conduct regular reviews of staff members’ and contractors’ ability and competency to ensure they are consistently performing their duties in accordance with the most up to date and endorsed working instructions.
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