[Peetwo]

Popinjay to the rescue on 2020 Wallan train derailment?? - 

Remember this when HVH once again rushed to the rescue?? - 

Well after three and a half years, of making sure all of the asses within the DIPs of Commonwealth bureaucracies are totally covered, the PJ led ATSB have released their final report...  

Via the other Aunty (PJ quotes in bold):

Final report into Wallan train derailment finds there was no way to confirm driver understood route changes

By Courtney Withers and staff

Posted Yesterday at 10:31am, updated Yesterday at 3:39pm

• In short: A final report into the Wallan train derailment has found no protocol was in place to ensure the driver understood changes to his route
  
• What's next? The ATSB recommended emerging technologies be adopted to mitigate risks
  

The Australian Transport Safety Bureau (ATSB) says the absence of a protocol to ensure train drivers understood changes to their route contributed to the 2020 derailment of a passenger train north of Melbourne which killed two people.

The ATSB has released its final report into the incident, in which an XPT train travelling from Sydney to Melbourne left the tracks, killing the train's driver, Canberra man John Kennedy, 54, and train pilot, 49-year-old Sam Meintanis of Castlemaine.

The ATSB report said the driver was given information on the routing of the train through the Wallan loop, but no protocol was in place to ensure the driver understood it.

A fire in a signalling hut two weeks earlier meant drivers were being given instructions on paper documents.


The XPT train from Sydney to Melbourne derailed near Wallan on February 19, 2020.(Supplied: James Ashburner)

"In the 12 days prior to the accident, the driver had operated the XPT service through Wallan eight times, and on all occasions the crossing loop was locked out of service," ATSB Chief Commissioner Angus Mitchell said in the final report. - P2 comment: I think they mean in the final report word weasel confection attributed to Popinjay?? (see HERE)

"This has led us to believe they probably expected to remain on the straight track, where the speed limit was 130Km/h through Wallan.

"However, there was no protocol in place to confirm the driver's understanding of the revised instruction, with no requirement for the driver to read back or confirm the instructions to the network control officer."

The train entered the crossing loop at a speed of 114-127km/h when the maximum speed permitted to enter the crossing loop was 15 km/h.

The report made 37 findings, including identifying 15 safety issues which contributed to the derailment.

The Investigator said the administrative systems used deviated from established network rules in Victoria, with weaknesses in delivering critical safety information.

Report recommends adoption of new technology

Chief Commissioner Mitchell said the Wallan loop had been out of action but was brought back into service on the day of the accident.

That information was included in the written advice given to the train driver, but he was not required to confirm verbally that he had understood it.

"In other industries there is a read back or acknowledgement of the change so it's fully understood. That didn't occur in this instance," he said.


The cab and first passenger carriage of the train completely derailed during an incident on February 20, 2020.(AAP: David Crosling)

"When systems change and risks are changed and modified there needs to be an understanding of what the new risks are, how they're going to be mitigated and, particularly, how all of the users understand it and are part of that mitigation."

Chief Commissioner Mitchell said there was an "over reliance on administrative controls" and missed opportunities to embrace "existing and emerging technologies" to mitigate risk associated with human error.

Train driver's cabin safety highlighted

The ATSB's final report found that the design of the XPT train's cab contributed to the "adverse outcome for the driver and accompanying qualified worker", who both died in the crash.

The report found the power car's left-side door detached when it overturned, allowing earth and other material to enter the driver's cabin as it slid on its side.

That resulted in both people in the cabin becoming trapped.

Chief Commissioner Mitchell said cabin safety was an issue that should be addressed.

"When we understand dynamic forces that occur in an accident and ergonomic design of cabins and how they may have contributed to adverse outcomes then we can make recommendations to address that and that's what we've done in this particular case," he said.

The ATSB also recommended audio and video recording equipment be installed in driver cabins to give a better understanding of events.

Rail track operator commits to all recommendations

The Australian Rail Track Corporation (ARTC), which owns and maintains the section of track where the derailment occurred, said it had already begun to address the six recommendations addressed to it.

"Since the incident, ARTC has implemented additional controls into our operations to ensure that we provide a safe rail network," a spokesperson said.

"Over the months ahead, ARTC will continue to work with the ATSB, rail regulators and industry so that all the recommendations are fully implemented."

The national Rail, Tram and Bus Union said the report highlighted the need to review and reform Australia's rail safety regime.

"This was a failure of communication, a failure of process, and a failure of risk management," assistant national secretary Shayne Kummerfeld said.

"We can only hope that this tragic incident spurs genuine change to rail safety processes so that something like this never happens again."

While on the subject of Popinjay again sacrificing his tax-payer funded expertise in transport safety investigation, I note that PJ is donating more of his (our) valuable time and wisdom to appear in not one but two presentations at the (International tin-kickers association) ISASI in Nashville Tennessee, in two weeks time:  
 

Wednesday, August 23, 2023, Main Session (11 Presentations/Speakers)
Wednesday Morning Events, Broadway 2 and 3
(Seated at 8:00 a.m.)

Morning Moderator – Stacey Jackson

8:00 – 8:05 Morning Announcements
8:05 – 8:30 Keynote Speaker – Angus Mitchell, Chief Commissioner and Chief Executive
Officer, Australian Transport Safety Bureau (ATSB)

---

Thursday, August 24, 2023, Main Session (10 Presentations/Speakers)
Thursday Morning Events, Broadway 2 and 3
(Seated at 8:00 a.m.)

9:25 - 9:55 Announcements and Break
9:55 – 10:25 Wet-Runway Overruns: Still a Slippery Problem – J. O'Callaghan, NTSB
10:25 – 10:55 Human Factors Failure Modes and Effects Analysis (HF - FMEA) - Tools for
Pre-Mishap and Post-Mishap Investigation – D. Hollaway and C. Pohlen, National
Air and Space Administration (NASA)
10:55 – 11:25 Accident Investigation - Sydney Seaplanes DHC-2 Collision with Water Accident
– Angus Mitchell, Chief Commissioner and Chief Executive Officer, Australian
Transport Safety Bureau (ATSB)

 

Hmm...Sydney Seaplanes Beaver accident - curious choice for PJ?? Wonder if he will explain how it took 3 years to complete and how it took till the DIP draft final report review for the ATSB to consider doing a toxicological testing of the pilot and pax blood samples to examine for possible CO poisoning?

Update: 3 July 2020

During the draft investigation report review process, the aviation medical specialist engaged by the ATSB recommended that carbon monoxide (CO) toxicology testing be undertaken on blood samples of the aircraft occupants that had been taken and suitably stored by the New South Wales State Coroner. This required testing at a specialised laboratory. With results pending, the ATSB draft report was submitted to Directly Involved Parties (DIPs) in December 2019 for comment.

The results of the testing were provided to the ATSB in March 2020, indicating that the pilot and two of the passengers had elevated levels of CO. The ATSB notes that post-mortem examinations established that the pilot and passengers received fatal injuries sustained as a result of the impact sequence.

MTF...P2