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    Level Crossing Safety & Accident Investigation: Mark Stallbaum Team Leader, Rail Safety Investigation, ATSB

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    Neha Khan
    The Australian Transport Safety Bureau investigates transport accidents involving rail, marine, and aviation. They summarized a level crossing collision in Ban Ban Springs, Northern Territory between a road train truck and a passenger train called The Ghan. Key factors included that the road train driver did not stop at the passive level crossing and had limited sight lines due to vegetation, while the train was traveling at the speed limit and sounded its horn. The emergency response was effective with no serious injuries, and the crashworthiness of the train helped prevent injuries despite the derailment.

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    Level Crossing Safety & Accident Investigation: Mark Stallbaum Team Leader, Rail Safety Investigation, ATSB

    Uploaded by

    Neha Khan
    39 views28 pages
    The Australian Transport Safety Bureau investigates transport accidents involving rail, marine, and aviation. They summarized a level crossing collision in Ban Ban Springs, Northern Territory between a road train truck and a passenger train called The Ghan. Key factors included that the road train driver did not stop at the passive level crossing and had limited sight lines due to vegetation, while the train was traveling at the speed limit and sounded its horn. The emergency response was effective with no serious injuries, and the crashworthiness of the train helped prevent injuries despite the derailment.

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    The Australian Transport Safety Bureau investigates transport accidents involving rail, marine, and aviation. They summarized a level crossing collision in Ban Ban Springs, Northern Territory between a road train truck and a passenger train called The Ghan. Key factors included that the road train driver did not stop at the passive level crossing and had limited sight lines due to vegetation, while the train was traveling at the speed limit and sounded its horn. The emergency response was effective with no serious injuries, and the crashworthiness of the train helped prevent injuries despite the derailment.

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    © All Rights Reserved
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    Download as ppt, pdf, or txt
    39 views28 pages

    Level Crossing Safety & Accident Investigation: Mark Stallbaum Team Leader, Rail Safety Investigation, ATSB

    Uploaded by

    Neha Khan
    The Australian Transport Safety Bureau investigates transport accidents involving rail, marine, and aviation. They summarized a level crossing collision in Ban Ban Springs, Northern Territory between a road train truck and a passenger train called The Ghan. Key factors included that the road train driver did not stop at the passive level crossing and had limited sight lines due to vegetation, while the train was traveling at the speed limit and sounded its horn. The emergency response was effective with no serious injuries, and the crashworthiness of the train helped prevent injuries despite the derailment.

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    Level Crossing Safety &

    Accident Investigation

    Mark Stallbaum
    Team Leader, Rail Safety Investigation, ATSB

    The Australian Transport Safety Bureau (ATSB)

    Accident Investigations
    Aviation
    Marine
    Rail
    Research Investigations
    Aviation / Marine / Rail

    Australian Transport Safety Bureau


    Australian Federal Government agency
    investigates transport accidents rail, marine, aviation
    focus on system safety
    ATSB reports not admissible in criminal or civil courts
    ATSB recommendations are not binding (similar to NTSB
    USA & TSB of Canada
    Headquarters in Canberra + Field Offices in Adelaide,
    Brisbane & Perth
    about 100 staff majority focussed on aviation
    rail safety investigators signalling, track, rolling stock,
    recorded data, operations, human performance
    www.atsb.gov.au

    Ban Ban Springs


    (Northern Territory)
    12 December 2006

    Ban Ban Springs, NT

    FountainHeadRdLX
    atBanBanSprings

    Major level crossing collision at


    Ban Ban Springs, NT
    Both locomotives, motorail wagon and 9 passengers coaches
    derailed as a result of the collision
    No fatalities
    Injuries incurred mainly superficial, but female passenger
    collapsed and lapsed into unconsciousness about 15 mins after
    the collision. The unconscious passenger and the truck driver
    were the only persons admitted to hospital
    The road-train truck was damaged beyond repair
    The lead locomotive incurred extensive structural damage,
    2 passenger coaches were damaged beyond repair
    About 280 metres of rail infrastructure was extensively
    damaged.

    The road-train truck & task


    The road-train truck combination was a 1994 Mack prime mover
    hauling 2 side-tip trailers
    The combination was 36 metres long. The two trailers were empty,
    the gross combined mass was 26 tonnes
    The company that owned the combination had been contracted by a
    local mining company to build a private access road from the Stuart
    Highway to its Brocks Creek mine
    This task involved conveying multiple loads of road-base from a
    disused mine to the road under construction (about 12 km)
    Three road-train truck combinations were employed on this task. All
    were similar to the combination involved in the accident
    Each combination travelled about 15 round trips per day, each round
    trip crossed the Fountain Head Road level crossing twice.

    The road-train truck & task (cont)


    This equals about 30 movements across the level crossing per
    driver, about 90 for the 3 trucks every day
    This task had been performed continuously for about a month
    before the accident
    Including travel time to the site, the road-train drivers worked from
    0600 until about 1700 seven days a week
    Therefore, each road-train driver would have traversed the Fountain
    Head Road level crossing about 800 times over the month
    The road-train driver involved in the accident said he had only seen
    4 freight trains during this period
    He did not have to alter his driving pattern for any of these trains.

    The Ghan
    Powered by an AN and NR class locomotive
    One motorail wagon, 13 passenger carriages and a luggage van
    Length 425 metres, weight 1022 tonnes, maximum speed 110 km/h
    64 passengers, 13 on-train staff and four train drivers
    Very experienced train driver 30 years on locomotives, 20 as a
    driver, mainly in NSW. Had driven the Alice Springs to Darwin
    corridor almost since the opening in 2004
    Second driver was an Adelaide based Driver Trainer, was learning
    the route from Alice Springs to Darwin
    Had a valid train order authority to be on the section of track where
    the Fountain Head Road level crossing is located.

    The Fountain Head Road level crossing


    at Ban Ban Springs
    Public level crossing
    Passive level crossing, controlled by Stop signs.
    Fountain Head Road is oriented North - South, it intersects the rail
    line at 90 degrees
    Sighting distance from the Stop Line is about 1200 metres to the
    East and about 1000 metres to the West
    However, a mound of dirt and trees prevents a driver of a
    northbound road vehicle from seeing along the track to the east
    until about 17 metres from the level crossing Stop sign. This is the
    direction that the road-train and The Ghan were travelling
    Although not as restricted, there is also a limited view from the
    opposite side of the level crossing along the line to the West.

    Fountain Head Road Level Crossing.


    To Ban Ban Springs Station and Fountain Head Mine

    Direction of train travel

    Direction of road-train travel

    Fountain Head Road level crossing

    Mount Wells Road

    Brocks Creek Road

    Fountain Head Road

    Leading to the accident - the road-train


    Had unloaded road base at the head of the road construction and
    was returning empty to Fountain Head Mine
    Weather very hot, cab windows up, air conditioning on
    Road-train driver stopped several hundred metres from the level
    crossing to close a gate on the leading trailer
    Started off again, was just changing to the high-box as entered the
    level crossing
    Estimated his speed to be 20 30 km/h. Did not stop at the Stop
    sign
    First sighting of train was when he heard the train horn and turned
    his head 90 degrees to the right
    Applied power to try and get the prime-mover clear.

    Before the collision - The Ghan


    Train was travelling at about 110 km/h under partial power, slight
    undulating upgrade
    Driver said headlight was illuminated
    Said he sounded horn twice, once at the whistle board and again
    closer the level crossing
    Saw a road-train approaching the level crossing at an estimated 50
    km/h, could see the top of the vehicle over the mound of grass and
    shrubs
    Knew a collision was imminent, made an emergency application of the
    train brake with his left hand, blew the horn with his right hand
    Yelled a warning for the second driver to hit the floor.

    Accident site

    Analysis - Key questions


    Did the train have authority to occupy the section of track and
    was it being driven in accordance with the rules and
    procedures?
    Were the emergency response measures adequate?
    Was the crashworthiness of the locomotive and carriages
    adequate?
    Were the level crossing warning signs and sighting distances
    in accordance with the standards?
    Why did the road-train driver not stop?
    Medical standards, how do road and rail compare?
    Road-train clearance times, level crossings.

    Operation of The Ghan


    The Ghan had a valid train order
    The train crew said the horn was operated and that the headlight was
    on
    The driver said that at first sighting he simultaneously placed the train
    brake in the emergency position and again operated the horn
    Logger of locomotive AN 5 did not record several parameters correctly
    or at all (throttle position, brake-pipe pressure and headlight and time)
    Correlation necessary with NR 109 however, still no recording of
    headlight on AN 5
    Later testing of the horn revealed that it met the minimum requirements
    of the Draft Code of Practice for the DIRN (Rollingstock).

    Speed of the road-train


    Train driver estimated he first saw the road-train when it was
    100 metres from the level crossing, over a mound of dirt and
    scrub on the southern side of the level crossing.
    The train driver estimated the speed to be about 50 km/h
    The road-train driver said he had stopped 200 to 300 metres
    from the level crossing to close a door on the leading trailer.
    Then accelerated to the extent that he had just changed to the
    top box gear range. He estimated his speed at the level
    crossing to be 20 to 30 km/h
    The road-train speedometer needle was stuck at about 50
    km/h

    Emergency response
    First on scene was the Ban Ban Springs station manager and his
    son who were mustering cattle in a Robinson R22 helicopter
    They flew to the GBS Gold Mine Site several kilometres away
    Meanwhile, GSR staff and the resting train drivers extinguished
    line-side fires. GSR staff also accounted for the passengers
    GBS Gold responded with company ambulance, fire truck
    paramedics and other medically qualified personnel and were on
    site in about 20 minutes
    No serious injuries but, about 15 minutes after the accident, a
    woman lapsed into unconsciousness
    GBS Gold transferred passengers to their employee/contractor
    Cosmo Camp (about 15 km away) commencing at about 1515.

    Crashworthiness
    7 of the 10 vehicles that derailed were passenger carriages
    No fixtures such as seating, tables, chairs fixed panels, windows etc
    dislodged
    Loss items such as crockery, kitchen utensils etc were thrown about
    Only 1 carriage exit door jammed, this was forcefully opened
    Apart from walkways between the carriages, occupant safety was
    not compromised by failed structural components
    The lead locomotive was damaged at the point of impact at the
    cowcatcher/skirt and at the side by the whipping motion of the roadtrain trailers
    The crew cab was not breached or compromised
    A key factor in this was that despite continuing 440 metres with only
    one wheel-set railed, the locomotive remained upright.

    Point of impact

    X
    Puncture caused by the hinge
    support on the front side
    tipper trailer

    Circular impressions from the


    rear wheels of the primemover

    Support spar from the primemovers rear wheel guard &


    mudflap

    Level crossings, NT
    The Fountain Head Road level crossing is a public level crossing. There
    were some minor non-conformances in signage and road markings, but
    these were not considered causal to the accident
    There are 171 level crossings between Alice Springs and Darwin. 145
    are passively controlled. Of this 145 only 21 are public level crossings
    (124 are occupation crossings)
    It was decided that Stop sign control would be the default level of
    passive control to all level crossings in the NT, this was due primarily to
    the cost of clearing sight triangles
    It was also decided that all level crossing would have a sight distance
    from the Stop line of at least 1000 metres
    This was in excess of the requirements contained in the various sight
    distance warrants at the time.

    Road-train driver did not stopwhy?


    As said earlier, the task was repetitious, 7 days a week, in the order
    of 30 crossings per day per driver
    Factors that can lead to an error in this instance could relate to
    fatigue, environmental conditions, distraction, toxicology and medical
    issues (causing attention or memory problems)
    Factors that can lead to a violation in this instance are expectation,
    equipment constraints and the manner in which the task is usually
    performed
    Fatigue, environmental conditions, distraction and toxicology were all
    ruled out during the course of the investigation
    Medical issues, expectation, equipment constraints and usual
    practice were all ruled in.

    An error or a violation?
    The road-train driver said during the month of work at this site
    (some 800 crossings) he had only seen 4 trains. All were freight
    trains and he did not have to alter his driving habits for any of them
    It was practice for drivers to warn others on the radio when a train
    was seen (further reducing the expectation of seeing a train
    unannounced)
    It is good driving practice not to bring a road-train to a complete
    stop where a stop is not mandated (commonly referred to as
    rolling stops)
    The evidence is that it was usual practice for the 3 road-train
    drivers engaged in this task to not stop at the level crossing
    All this points to a routine violation

    An error or a violation? (cont)


    However, there was a serious medical issue. The road-train
    driver had severe bilateral hearing loss
    This loss was to the extent that he would not have been eligible
    to retain his MC class vehicle license
    The question is, would the loss have prevented him from hearing
    the approaching train? This cannot be concluded with certainty.
    However, compared to a person with normal hearing, would his
    ability to hear the approaching train be compromised? The
    answer is most certainly yes.
    Despite the severe bilateral hearing loss, the evidence is that in
    this instance the act was a routine violation, characterised by the
    unsafe act being the normal way of performing the task

    Key findings
    The Ghan was being operated in accordance with the
    relevant rules and procedures
    The agreed level crossing sighting distances for Stop sign
    control adopted by the NT DPI, FreightLink were in excess of
    the requirements of the relevant standards
    The stop sign control at the Fountain Head Road level
    crossing was largely being ignored by road vehicle drivers
    before the accident
    The road-train driver had severe bilateral hearing loss which
    compromised his ability to hear The Ghan before the
    accident
    This hearing loss would have made him ineligible to hold an
    unrestricted MC class licence

    Key findings
    The crashworthiness of the locomotives and carriages was
    such that, with the exception of the vestibules between the
    carriages that concertinaed, no area of occupation was
    breached or compromised
    The first response measures enacted by GBS Gold were of
    a very high standard, in terms of timeliness and the level of
    assistance provided
    The remoteness of much of the rail corridor in the NT could
    make a timely response to a rail accident challenging
    Tests conducted by the ATSB in August 2007 found that the
    time taken for 53.5 metre road-trains to clear a level
    crossing from a stop calls the calculation of sighting
    distances into question.

    Recommendations
    Members of the Standing Committee On Transport (SCOT)
    note the ineligibility of the road-train driver to hold an MC
    class licence due to hearing loss and that he had never been
    medically examined in conjunction with this licence
    State and Territory rail regulators consider the implications of
    the clearance times of the 53.5 metre road-trains
    Continued action by the NT Department of Planning &
    Infrastructure (DPI) regarding enforcement and education of
    motorists at railway level crossings

    Thank you questions?


    Mark Stallbaum
    Team Leader Rail Safety Investigation
    mark.stallbaum@atsb.gov.au
    October 2008

    For more information:


    www.atsb.gov.au

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