Level Crossing Collision between Ghan Passenger Train (1AD8) and Road … · 2007-02-15 · 1...
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ATSB TRANSPORT SAFETY INVESTIGATION REPORT Rail Occurrence Investigation 2006/015
Preliminary
Level Crossing Collision between
Ghan Passenger Train (1AD8) and Road-Train Truck
Ban Ban Springs, NT
12 December 2006
ATSB TRANSPORT SAFETY INVESTIGATION REPORT
Rail Occurrence Investigation 2006/015
Preliminary
Level Crossing Collision
between
Ghan Passenger Train (1AD8)
and Road-Train Truck Ban Ban Springs, NT
12 December 2006
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Published by: Australian Transport Safety Bureau
Postal address: PO Box 967, Civic Square ACT 2608
Office location: 15 Mort Street, Canberra City, Australian Capital Territory
Telephone: 1800 621 372; from overseas + 61 2 6274 6130
Accident and incident notification: 1800 011 034 (24 hours)
Facsimile: 02 6274 6474; from overseas + 61 2 6274 6474
E-mail: [email protected]
Internet: www.atsb.gov.au
© Commonwealth of Australia 2007.
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ISBN and formal report title: see ‘Document retrieval information’ on page iv.
– ii –
CONTENTS
THE AUSTRALIAN TRANSPORT SAFETY BUREAU ....................................v
1 Factual Information ............................................................................................1
1.1 Introduction ...............................................................................................1
1.2 Location .....................................................................................................1
1.3 Ghan Passenger Train (1AD8) .................................................................3
1.4 Road-Train Truck......................................................................................3
1.5 Sequence of events....................................................................................4
1.5.1 Events leading up to the collision..........................................4
1.5.2 The collision ...........................................................................5
1.5.3 Emergency Response .............................................................8
1.5.4 Site Investigation/Recovery...................................................8
1.6 The ATSB Investigation...........................................................................8
– iii –
DOCUMENT RETRIEVAL INFORMATION
Report No. Publication date No. of pages
2006/015 9 February 2007 14
Publication title
Level Crossing Collision between Ghan Passenger Train (1AD8) and Road-Train Truck
Ban Ban Springs, NT, 12 December 2006
Prepared by
Australian Transport Safety Bureau
PO Box 967, Civic Square ACT 2608 Australia
www.atsb.gov.au
Acknowledgements
The map section identified in this publication is reproduced by permission of Geoscience
Australia, Canberra. Crown Copyright ©. All rights reserved. www.ga.gov.au
The satellite image in this publication is reproduced by permission of Google Earth. Copyright ©.
The aerial image in this publication is reproduced by permission of Northern Territory News.
Copyright ©.
Other than for the purposes of copying this publication for public use, the map information
section and photos may not be extracted, translated, or reduced to any electronic medium or
machine readable form for incorporation into a derived product, in whole or part, without prior
written consent of the appropriate organisation listed above.
Abstract
At about 1400 on 12 December 2006, an empty double trailer road-train truck drove into the path
of the north bound Ghan passenger train (1AD8) at the Ban Ban Springs level crossing
approximately 130 km south-east of Darwin (NT). Both locomotives and ten of the train’s sixteen
wagons were derailed as a result of the collision. The truck was severely damaged and both of its
trailers were destroyed.
There were no fatalities, however, the truck driver and a female passenger were hospitalised and
several other passengers and crew sustained minor injuries.
– iv –
THE AUSTRALIAN TRANSPORT SAFETY BUREAU
The Australian Transport Safety Bureau (ATSB) is an operationally independent
multi-modal Bureau within the Australian Government Department of Transport
and Regional Services. ATSB investigations are independent of regulatory, operator
or other external bodies.
The ATSB is responsible for investigating accidents and other transport safety
matters involving civil aviation, marine and rail operations in Australia that fall
within Commonwealth jurisdiction, as well as participating in overseas
investigations involving Australian registered aircraft and ships. A primary concern
is the safety of commercial transport, with particular regard to fare-paying
passenger operations.
The ATSB performs its functions in accordance with the provisions of the
Transport Safety Investigation Act 2003 and Regulations and, where applicable,
relevant international agreements.
Purpose of safety investigations
The object of a safety investigation is to enhance safety. To reduce safety-related
risk, ATSB investigations determine and communicate the safety factors related to
the transport safety matter being investigated.
It is not the object of an investigation to determine blame or liability. However, an
investigation report must include factual material of sufficient weight to support the
analysis and findings. At all times the ATSB endeavours to balance the use of
material that could imply adverse comment with the need to properly explain what
happened, and why, in a fair and unbiased manner.
Developing safety action
Central to the ATSB’s investigation of transport safety matters is the early
identification of safety issues in the transport environment. The ATSB prefers to
encourage the relevant organisation(s) to proactively initiate safety action rather
than release formal recommendations. However, depending on the level of risk
associated with a safety issue and the extent of corrective action undertaken by the
relevant organisation, a recommendation may be issued either during or at the end
of an investigation.
The ATSB has decided that when safety recommendations are issued, they will
focus on clearly describing the safety issue of concern, rather than providing
instructions or opinions on the method of corrective action. As with equivalent
overseas organisations, the ATSB has no power to implement its recommendations.
It is a matter for the body to which an ATSB recommendation is directed (for
example the relevant regulator in consultation with industry) to assess the costs and
benefits of any particular means of addressing a safety issue.
About ATSB investigation reports:
How investigation reports are organised and definitions of terms used in ATSB
reports, such as safety factor, contributing safety factor and safety issue, are
provided on the ATSB web site www.atsb.gov.au.
– v –
1 FACTUAL INFORMATION
1.1 Introduction
At about 14001 on 12 December 2006, an empty double trailer road-train drove into
the path of the Ghan passenger train (1AD8) at the Ban Ban Springs level crossing
approximately 130 km south-east of Darwin (NT). The collision caused both
locomotives and ten of the train’s sixteen wagons2 to derail.
There were no fatalities but the truck driver and one of the passengers were
seriously injured. Other passengers and train staff also sustained minor injuries as a
result of the collision and subsequent derailment.
The Australian Transport Safety Bureau (ATSB) initiated an investigation of the
accident under the provisions of the Transport Safety Investigation Act 2003 (TSI
Act). The purpose of the investigation is to identify the factors which led to the
accident and any other associated safety issues with the intention of encouraging
safety actions in order to prevent future accidents of this type.
The ATSB has released this preliminary report to convey factual information.
Additional factual material and analysis will be included in the final report which
may include revisions to the material in this report and safety recommendations.
When completed, the final report will be released in accordance with the provisions
of the TSI Act. The investigation is continuing.
1.2 Location
Ban Ban Springs pastoral station is a 1800 square kilometre property used for cattle
breeding and grazing, located approximately 130 km south-east of Darwin (Figure
1). Access to the station is via Fountain Head road (sealed) which intersects the
Stuart Highway approximately 45 km south-east of Adelaide River. From the Stuart
Highway, Fountain Head road continues north-east for about 11 km where it
crosses the Defined Interstate Rail Network (DIRN) at the Ban Ban Springs level
crossing (Figure 2).
At the time of the incident the level crossing at Ban Ban Springs consisted of a
single track crossed at right-angles by the roadway and was passively protected
using road-side ‘stop’ signage for both road approaches. Freight Link Pty Ltd,
manage and maintain the rail infrastructure in this section of the DIRN including
level crossings. The Northern Territory Department of Planning and Infrastructure
(DPI) are responsible for the installation and maintenance of road markings and
approach warning signage at the crossing.
1 The 24-hour clock is used in this report to describe the local time of day, Central Standard Time
(CST), as particular events occurred.
2 One motorail wagon and nine passenger wagons.
– 1 –
Figure 1: Location of Ban Ban Springs, NT
Ban Ban Springs
Geoscience Australia. Crown Copyright ©.
Figure 2: Ban Ban Springs level crossing
Direction of
train travel
Direction of
road-train travel
To Ban Ban Springs Station
and Fountain Head mine
Mount Wells Road
Brocks Creek Road
Fountain Head Road
Ban Ban Springs
level crossing
Google Earth. Copyright ©.
– 2 –
1.3 Ghan Passenger Train (1AD8)
The Ghan passenger train is operated by Great Southern Railway3 (GSR) and
travels the 2754 km between Adelaide and Darwin four times a week. The Ghan
departs from the Keswick passenger terminal at Adelaide late afternoon on Sundays
and Fridays and arrives at the Berrimah terminal at Darwin late afternoon on
Tuesdays and Sundays. The return service departs from the Darwin Berrimah
terminal mid-morning on Wednesdays and Mondays and arrives at the Adelaide
Keswick passenger terminal mid-morning on Fridays and Sundays.
International tourists are a significant portion of patronage on the Ghan. In the peak
season the Ghan can consist of up to 24 passenger and motorail wagons4 and
upwards of 200 passengers.
On this occasion though, the Ghan consisted of 15 passenger wagons, one motorail
wagon and two locomotives (AN5 leading and NR109). There were 62 passengers,
13 Great Southern Railways staff and four train drivers on the train. The total train
weight was 1022 tonnes, including the two locomotives, and it was 425 m long.
The driver operating the Ghan at the time of the accident was a 60 year old male
who had in excess of 30 years experience in the rail industry, including over 20
years driving trains. He was based in Alice Springs and had worked on the Alice
Springs to Darwin rail corridor for almost two years. The co-driver was a driver
trainer5 from Adelaide who was in the process of learning the route between Alice
Springs and Darwin. This was his third trip over the line. He had more than 28
years experience driving trains.
Following the accident, the two train drivers were breath tested for blood alcohol
concentration. The tests, administered by an officer of the Northern Territory
Police, returned a negative result for each driver.
1.4 Road-Train Truck
The road-train6 involved in the collision at Ban Ban Springs level crossing
consisted of a 1994 Mack prime mover towing two empty side tip trailers. This
combination was approximately 27 m long from the ‘bull-bar’ to the rear of the
second trailer and had a combined weight of approximately 26 tonnes. However,
the prime mover was permitted to haul a combination up to 53.5 m in length and
140 tonnes gross combined mass.
Downes Graderways Pty Ltd was the owner and operator of the road-train. The
company is based in Katherine (NT) and is involved in road construction.
3 Great Southern Railway is an accredited rail organisation providing interstate passenger rail
transport linking Sydney, Melbourne, Adelaide, Perth and Darwin. GSR contracts the
responsibility for train operations to Pacific National, who provides locomotives and crew under a
‘hook and pull’ arrangement.
4 Motorail wagon – a wagon in which the motor vehicles of passengers is conveyed.
5 Driver trainer – Is a higher classification than that of a driver. Conducts on route and classroom
assessments of drivers, various training courses and projects as required.
6 Road Train – A combination road vehicle consisting of a prime mover towing two or more
trailers, where the second and subsequent trailers a drawn by drawbar connected dollies.
– 3 –
At the time of the incident, Downes Graderways was working for GBS Gold
Australia Pty Ltd, on some road works for their gold mining operations in the area.
For the month prior to the accident, Downes Graderways trucks had been carrying
gravel from GBS Gold’s Fountain Head mine for use on road works to the south of
the Ban Ban Springs level crossing.
The driver of the truck was a 57 year old male from Tennant Creek. He had been
employed by Downes Graderways on a casual basis of varying tenure for about five
years. He was paid an hourly rate of pay (in lieu of distance scales). The driver was
appropriately licensed and had extensive experience on various road maintenance,
construction machinery and road-train combination trucks over a period of about 40
years.
A sample of the truck driver’s blood was tested for blood alcohol concentration
following the accident and returned a negative result.
Figure 3: Prime mover involved in collision
1.5 Sequence of events
The following sequence of events is based on recorded train data and other verified
sources of information. The final report will contain a full description of the events
which led up to the collision and the subsequent emergency response.
1.5.1 Events leading up to the collision
Based on various verified sources of information including the train’s data loggers:
• At about 1209 on 12 December 2006, the Ghan departed from Katherine (NT)
for the final leg of its northbound journey to Darwin.
– 4 –
• At 1356:167 when the train was 488 m from the Ban Ban Springs level crossing
the train driver sounded the horn for a period of about four seconds. The train’s
speed at the time was 104 km/h.
• At 1356:27 when the train was 172 m from the level crossing the driver sounded
the horn again for a period of about one second.
• At 1356:30, when the train was 85 m from the level crossing, the train driver
saw the road-train approaching the crossing on the road to his left, realised that
it was not going to stop and then simultaneously sounded the horn and made an
emergency brake application.
• At 1356:33 the collision occurs. The train’s speed was 101 km/h8.
Figure 4: Aerial view of accident site
Prime mover
Direction of
train travel
Direction of
road-train travel
Second locomotive (NR109)
Note: Lead locomotive (AN5)
located a further 200 m along track
Trailers
Gate into Ban Ban Springs
cattle station
Northern Territory News. Copyright ©.
1.5.2 The collision
The initial impact with the road-train truck was distributed across the front of the
lead locomotive (AN5) and primarily absorbed by the locomotive’s steel
cowcatcher (Figure five below). Markings on cowcatcher indicated that AN5 made
hard contact with the road-train between the two rear axles of the prime mover.
This scenario was supported by the following observations:
• A steel bar found imbedded in the locomotive’s ditch light was consistent with a
wheel guard and mudflap support spar that was missing from the rear of the
double road-train’s prime mover.
• A hole punched immediately above the coupler on AN5 was consistent with the
side-tip trailer’s hinge support located above the pivot point of the trailer.
7 Time reference as recorded on the locomotive data logs.
8 The maximum permitted speed of the Ghan at the accident site was 110 km/h.
– 5 –
Figure 5: Point of Impact
X
Circular impressions
from the rear wheels of
the prime mover
Support spar from the
prime mover’s rear wheel
guard & mudflap.
Puncture caused by the
hinge support on the
front side tipper trailer
Following the initial impact, the road-train was pushed sideways and begun to bend
in a ‘V’ shape at the pivot point above the prime mover’s rear axles. Moments after
impact, the forces acting on the road-train caused the prime mover to separate from
its trailers, spin away from the train and come to rest approximately 18 m to the
right of the track (Figure six below).
Figure 6: Damaged prime mover (right) and trailers (left)
The momentum and bending of the road-train caused its trailers rotate and move in
a whipping motion towards the left hand side of the train. The first trailer struck the
side of the lead locomotive (AN5) while the second trailer struck the side of the
second locomotive (NR109) (Figure seven below). The force of the trailers hitting
the side of the locomotives was sufficient to punch holes in each locomotive. The
two trailers then rebounded away from the train and came to rest on top of each
other about 16 m to the left of the track (Figure six above).
– 6 –
Figure 7: Left Side of Locomotives AN5 (top) and NR109 (Bottom)
Impact point from first trailer of
road-train on lead locomotive AN5
Impact point from second trailer of
road-train on second locomotive NR109
The two locomotives, the motorail wagon and nine passenger wagons then derailed
as a consequence of the collision. The fuel tanks on both locomotives ruptured
during the accident and a minor grass fire started adjacent the track. Both
locomotives were shut down and isolated while train staff extinguished the fire
using handheld fire extinguishers.
– 7 –
1.5.3 Emergency Response
At the time of the collision, a helicopter was mustering cattle in a Ban Ban Springs
station paddock adjacent to the level crossing. The station manager on board saw a
large cloud of dust and instructed the pilot to land the helicopter alongside the train
to see if they could assist they then flew several kilometres to the GBS Gold Brocks
Creek mine site where they landed and raised the alarm.
By about 1420, GBS Gold employees, including a paramedic and nurse, had arrived
at the accident site. Radio communications were established between the Brocks
Creek mine and the accident site and messages received from the site were relayed
by telephone to emergency services agencies in Darwin, Adelaide River and Pine
Creek.
GBS Gold personnel, GSR on train staff and medically qualified passengers
rendered initial assistance to passengers in need. The Adelaide River clinic and Pine
Creek clinic staff arrived at the accident site at about 1450. Other emergency
services personnel were all on site by about 1625.
Between 1515 and 1610, 65 passengers and train staff were progressively
transported to GBS Gold’s Cosmo9 camp where they were accommodated until
they were transported by bus to Darwin.
At 1702 the truck driver was transferred in an ambulance to Darwin. A passenger
who had sustained a serious head injury was stabilised by the medical personnel at
the site and was then transferred by helicopter to Darwin at 1825.
1.5.4 Site Investigation/Recovery
ATSB investigators were mobilised from Canberra, Brisbane and Adelaide and
arrived on site at approximately 0125 on Wednesday 13 December 2006. By 1640
on Wednesday 13 December 2006, examination of the accident site was largely
completed, allowing rail organisations to begin recovery works.
Undamaged rollingstock was hauled from the site by rail while heavy lift cranes
relocated the remaining rollingstock clear of the track. Approximately 300 m of
track infrastructure (rail and sleepers) was subsequently repaired/replaced allowing
the track to be reopened for rail traffic (under a speed restriction) by about 0400 on
Saturday 16 December 2006.
1.6 The ATSB Investigation
The ATSB investigation is ongoing and will include further examination of the
following:
� the Ban Ban Springs level crossing,
� issues relating to similar passively protected level crossings,
� issues relating to motorist behaviour at level crossings in general,
9 The Cosmo Camp is a GBS Gold employee/contractor accommodation base. It has facilities such
as air conditioned rest areas and a fully stocked kitchen. It is about 17 km from the accident site.
– 8 –
� human factors issues in relation to the road train driver, and,
� emergency response issues including train crash-worthiness.
– 9 –