ATSB Rushall Derailment Report

 
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
The ATSB has issued its report on the derailment of a suburban train at Rushall in February 2016 (over 2 years ago).

The Report is basically critical of Metro's track maintenance practices, its communications systems and the resultant lack of protection for the down line which was fouled by the derailed train.

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  Pressman Spirit of the Vine

Location: Wherever the Tin Chook or Qantas takes me
The ATSB has issued its report on the derailment of a suburban train at Rushall in February 2016 (over 2 years ago).
YM-Mundrabilla
Link to the report https://www.atsb.gov.au/publications/investigation_reports/2016/rair/ro-2016-002/
  Lockspike Chief Train Controller

The ATSB has issued its report on the derailment of a suburban train at Rushall in February 2016 (over 2 years ago).

The Report is basically critical of Metro's track maintenance practices, its communications systems and the resultant lack of protection for the down line which was fouled by the derailed train.
YM-Mundrabilla
Thanks YM and Pressman, interesting reading.

It's a shame that the ATSB's investigations don't just stop at finding what happened but looked into the reasons why they happened; that would be illuminating.
  historian Assistant Commissioner

The immediate cause of the accident was the transfer of maintenance activities from Sunstone Resources back to MTM at the end of 2015. Sunstone was a five day political wonder in late 2015 when it was revealed that MTM had outsourced maintenance to this company which was jointly owned by MTR (Hong Kong), John Holland, and UGL Ltd. After the political heat was applied, MTM decided that this did not look good and brought maintenance back in house.

One of the maintenance activities undertaken by Sunstone was lubricator maintenance. Sunstone ceased maintaining the lubricators in December 2015. One of the team transferred to MTM, and with an existing employee, was responsible for teaching the normal track maintenance staff how to maintain the lubricators. It appears that lubricator maintenance ceased for two months over the entire network. One reason for this seems to have been that the MTM maintenance plan called for the lubricators to be serviced every three months. However, Sunstone actually found it necessary to perform the servicing every month. This mismatch between what MTM thought was necessary and what was actually required may explain the delay to servicing.

The consequence of the lack of servicing was a deterioration in wheel condition during Dec/Jan/Feb over the fleet due to wear on sharp curves.

The lack of rail lubrication meant high flange/rail friction, and a train eventually derailed on the sharpest running curve on the network. This particular train had just come out of having it's wheels turned, which meant that the wheel that derailed was rough (from the turning) and had a shallow flange angle.

There were a number of features that exacerbated the situation.

1. There was a kink in the rail at a rail joint in the curve. This would have assisted the wheel to climb the rail. The MTM standards did not control these types of kinks.

2. The rail lubricator was placed in an ineffective location. To be effective, the lubricator should be placed at the start of the transition curve leading into the sharp curve. In this case, the lubricator was placed in a straight well before the sharp curve. A significant proportion of lubricators were similarly misplaced. To be fair to MTM, they were probably mislocated well before MTM took over.

3. The track standard of the curve was within tolerances - just - but the report questioned whether the tolerances should be tighter on such a sharp curve.

4. No defences were in place to reduce the risk of derailment (e.g. check rails). Again, to be fair to MTM, this was a long standing practice. Check rails, for example, had been removed from Victorian curves in the '60s.

When the train derailed, the Driver attempted to call Metrol by the new digital train radio. The Driver initially attempted to make a normal call. These, however, have no priority and are simply placed in a queue for the Train Controller to answer in turn. The driver then attempted to make a Train Emergency Call (TEC). However, it turns out that the system is (mis)designed such that the TEC doesn't override the ordinary calls in the queue. The ordinary calls have to be answered or cancelled (by the driver) before the TEC is let through.  The Driver should have used a Rail Emergency Call (REC) which would have forced the call through. MTM is, of course, responsible for the training of the Driver. However, it inherited the digital train radio.
  potatoinmymouth Junior Train Controller

The Driver should have used a Rail Emergency Call (REC) which would have forced the call through.
historian


Thanks historian, just wanted to clarify two things from that:

1. What does a TEC provide if not call priority (because why is it called "emergency" at all?); and

2. Under what circumstances should a TEC be used as opposed to an REC?
  skitz Chief Commissioner

The immediate cause of the accident was the transfer of maintenance activities from Sunstone Resources back to MTM at the end of 2015. Sunstone was a five day political wonder in late 2015 when it was revealed that MTM had outsourced maintenance to this company which was jointly owned by MTR (Hong Kong), John Holland, and UGL Ltd. After the political heat was applied, MTM decided that this did not look good and brought maintenance back in house.

One of the maintenance activities undertaken by Sunstone was lubricator maintenance. Sunstone ceased maintaining the lubricators in December 2015. One of the team transferred to MTM, and with an existing employee, was responsible for teaching the normal track maintenance staff how to maintain the lubricators. It appears that lubricator maintenance ceased for two months over the entire network. One reason for this seems to have been that the MTM maintenance plan called for the lubricators to be serviced every three months. However, Sunstone actually found it necessary to perform the servicing every month. This mismatch between what MTM thought was necessary and what was actually required may explain the delay to servicing.

The consequence of the lack of servicing was a deterioration in wheel condition during Dec/Jan/Feb over the fleet due to wear on sharp curves.

The lack of rail lubrication meant high flange/rail friction, and a train eventually derailed on the sharpest running curve on the network. This particular train had just come out of having it's wheels turned, which meant that the wheel that derailed was rough (from the turning) and had a shallow flange angle.

There were a number of features that exacerbated the situation.

1. There was a kink in the rail at a rail joint in the curve. This would have assisted the wheel to climb the rail. The MTM standards did not control these types of kinks.

2. The rail lubricator was placed in an ineffective location. To be effective, the lubricator should be placed at the start of the transition curve leading into the sharp curve. In this case, the lubricator was placed in a straight well before the sharp curve. A significant proportion of lubricators were similarly misplaced. To be fair to MTM, they were probably mislocated well before MTM took over.

3. The track standard of the curve was within tolerances - just - but the report questioned whether the tolerances should be tighter on such a sharp curve.

4. No defences were in place to reduce the risk of derailment (e.g. check rails). Again, to be fair to MTM, this was a long standing practice. Check rails, for example, had been removed from Victorian curves in the '60s.

When the train derailed, the Driver attempted to call Metrol by the new digital train radio. The Driver initially attempted to make a normal call. These, however, have no priority and are simply placed in a queue for the Train Controller to answer in turn. The driver then attempted to make a Train Emergency Call (TEC). However, it turns out that the system is (mis)designed such that the TEC doesn't override the ordinary calls in the queue. The ordinary calls have to be answered or cancelled (by the driver) before the TEC is let through.  The Driver should have used a Rail Emergency Call (REC) which would have forced the call through. MTM is, of course, responsible for the training of the Driver. However, it inherited the digital train radio.
historian
A good post, I would argue that item 2 is not correct though.   There are not a lot of options for this lubricator, while not as effective as it could be, it was working.   The cause of it not working was it was not serviced!  The only real down side of its ineffectiveness is the mess on pick up.  Note, there was noting in the report about the defective lubricator directly opposite the one in question.

The issue is systemic to the organisation of Metro.  Lubrication, despite its unattractiveness, is a critical activity.  they dropped the ball.  I would also highlight that the actions of this time that dried the whole network, not just Rushall, and this coincides with the V/line wheel wear fiasco/disaster.   While not the only contributing factor to the V/line wheel wear (the commissioning of RRL happening at the same time), the Metro system drying out took away the ONLY dominant source of rail lubrication for both the Metro and V/Line system.   How about the parliamentary enquiry be reopened to examine the facts around the evidence supplied at the last enquiry.

The root cause of this, in my opinion, was that the criticality of the lubrication function was not understood and the organisation is dysfunctional to put robust systems around items of criticality.    

There is a lot of focus on the change of equipment being a solution.  I can tell you, with some confidence, it does not matter what equipment you have, if you neglect it the result will be the same whether it be by mechanical pots, hand lubrication (whaaaaat?), hirail lubrication, train based lubrication or electronically controlled units.   The method is a cost/risk equation and all can be made to work (if you want to).  This did not come out clearly in the report.  Wiz bang lubricators with gizmos and stuff wont fix the dysfunction that allowed the problem to happen in the first place.   It should be noted that this kind of lesson is not exclusive to Metro, VR/PTC have a few to their name too.

I would also add, that the attitudes of the departments within Metro is such that the new equipment is not even installed as designed.  So nothing really has been learned to have a robust system installed and have the systems in place to ensure it is doing what it designed to do.

One final point, why does it take so long for such a report to be issued?
  LancedDendrite Chief Commissioner

Location: Trapped in a meeting with Rhonda and Karsten
The Driver should have used a Rail Emergency Call (REC) which would have forced the call through.


Thanks historian, just wanted to clarify two things from that:

1. What does a TEC provide if not call priority (because why is it called "emergency" at all?); and

2. Under what circumstances should a TEC be used as opposed to an REC?
potatoinmymouth


From the report:

The Digital Train Radio System (DTRS) has several levels of call with escalating priority and treatment by Metrol. The DTRS log showed that in this instance the driver initially made three lower-priority Train Controller Calls (TCC). A TCC is placed in a queue for the train controller for that track group to respond when able. The driver’s recollection was that he pushed the Train Emergency Call (TEC ) button, the level 2 priority call that should be used in an emergency but where there is no immediate danger, however, the system did not recognise or register this call. Post-incident testing of the DTRS by MTM found that once a TCC call was queued, the system would not override it with a TEC call. The system required that the lower-priority call first be cancelled by the driver prior to initiating a higher-priority call.

There is also a Rail Emergency Call (REC) feature on the DTRS that is the highest-priority call. REC calls go to Metrol and to other trains on the same line, to enable those train drivers to take immediate action. It should be used when an emergency could physically affect other trains , such as in the event of a derailment where an adjacent running line is or may be fouled. As this derailed train was lying foul of the other track, an REC call would have been appropriate.
ATSB
  bevans Site Admin

Location: Melbourne, Australia
I am aware of that location as is nearby for me.  The tracks have been concrete sleeper-ed since the incident and lubrication points removed to make way for the larger monthly serviced lubrication systems which have replaced the pot which were in the area.  The pots were checked weekly for top-ups.

MTM were paid money to upgrade the lubrication systems approved by the government to reduce headcount around maintenance.
  skitz Chief Commissioner

I am aware of that location as is nearby for me.  The tracks have been concrete sleeper-ed since the incident and lubrication points removed to make way for the larger monthly serviced lubrication systems which have replaced the pot which were in the area.  The pots were checked weekly for top-ups.

MTM were paid money to upgrade the lubrication systems approved by the government to reduce headcount around maintenance.
bevans
The lubricator servicing that curve is near Reservoir.  The one serving the other track is at (should be) at Vic Park.

The installations show on NearMap ok.
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
The inability to urgently and adequately protect the down line for whatever reason(s) is equally as important if not more so than the  investigation into the actual cause of the derailment.

Had a down train collided with the derailed train or been side swiped by the derailing vehicle(s) the results could have been far more serious. It seems to me that the communications issue has not been adequately pursued.

Has the communications system been changed/upgraded in the two years plus since this incident? To have designed a system where it is impossible to upgrade the priority of a call without 'hanging up and starting again' is naive. Even in the days of the party line Train Control phones one could always break into a conversation in an emergency.

As to the two years delay in compiling the report one can only assume that everyone at the ATSB was out looking for MH370.
  kitchgp Chief Train Controller

From the ATSB report:

Safety issue description:
The functionality of the Digital Train Radio System (DTRS) did not allow an emergency call to
override an initial lower-priority call.
Proactive safety action taken by MTM:
MTM has enhanced its driver training to highlight the operation of the DTRS for normal and
emergency use, including the need to cancel a lower-priority call prior to initiating an emergency call. MTM is also reviewing the functionality of similar digital radio systems used by other rail operators, and options for changing the functionality of the DTRS.
Action number: RO-2016-002-NSA-009
Current status of the safety issue:
Issue status: Partially addressed
Justification: The safety action taken by MTM should reduce risk associated with the safety
issue. Improved DTRS functionality that provides automatic override of a lower-priority call would further reduce risk.
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
From the ATSB report:

Safety issue description:
The functionality of the Digital Train Radio System (DTRS) did not allow an emergency call to
override an initial lower-priority call.
Proactive safety action taken by MTM:
MTM has enhanced its driver training to highlight the operation of the DTRS for normal and
emergency use, including the need to cancel a lower-priority call prior to initiating an emergency call. MTM is also reviewing the functionality of similar digital radio systems used by other rail operators, and options for changing the functionality of the DTRS.
Action number: RO-2016-002-NSA-009
Current status of the safety issue:
Issue status: Partially addressed
Justification: The safety action taken by MTM should reduce risk associated with the safety
issue. Improved DTRS functionality that provides automatic override of a lower-priority call would further reduce risk.
kitchgp
Over two years down the track and ...................?
  Jack Le Lievre Junior Train Controller

Location: Moolap Station, Vic
The inability to urgently and adequately protect the down line for whatever reason(s) is equally as important if not more so than the  investigation into the actual cause of the derailment.

Had a down train collided with the derailed train or been side swiped by the derailing vehicle(s) the results could have been far more serious. It seems to me that the communications issue has not been adequately pursued.

Has the communications system been changed/upgraded in the two years plus since this incident? To have designed a system where it is impossible to upgrade the priority of a call without 'hanging up and starting again' is naive. Even in the days of the party line Train Control phones one could always break into a conversation in an emergency.

As to the two years delay in compiling the report one can only assume that everyone at the ATSB was out looking for MH370.
YM-Mundrabilla
ATSB did make a comment at one point during the search for MH370 that other "Lower Priority" areas were to be affected by the search, including Rail and Marine, as well as Air.
  kitchgp Chief Train Controller

The accident happened in Feb 2016; the report was released in May 2018.

From the ATSB web page ‘The Investigation Process’:

........
The report is then released publicly on the ATSB website and communicated on social media channels. The progress of safety action to address ATSB recommendations is tracked and communicated, on an ongoing basis, via the ATSB website.
...........
ATSB


From the ATSB particular report web page (using the link above, click on the ‘Safety Issues’ tab):

Safety issue description
The functionality of the Digital Train Radio System (DTRS) did not allow an emergency call to override an initial lower-priority call.
Proactive Action
Action organisation: Metro Trains Melbourne
Action number: RO-2016-002-NSA-009
Date: 16 May 2018
Action status: Monitor

Metro Trains Melbourne (MTM) has enhanced its driver training to highlight the operation of the DTRS for normal and emergency use, including the need to cancel a lower-priority call prior to initiating an emergency call. MTM is also reviewing the functionality of similar digital radio systems used by other rail operators, and options for changing the functionality of the DTRS.

Current issue status: Partially addressed
Status justification:  The safety action taken by MTM should reduce risk associated with the safety issue. Improved DTRS functionality that provides automatic override of a lower-priority call would further reduce risk.
ATSB


The ATSB is an investigator; not a regulator.
  DalyWaters Chief Commissioner

The most damning part of all:

Under the Safety issues and actions heading:



"Management of wide gauge defect
[b]Safety number: RO-2016-002-SI-05[/b]
Safety issue description:
Track geometry through the Rushall curve was not managed in accordance with MTM network standards. A wide-gauge ‘A’ fault was not rectified in the field despite being closed-out on the asset management system."


MTM deliberately declared a fault as rectified on their safety management system without attending to the fault at all.

This should trigger an immediate audit under the terms of their accreditation as a public transport operator.  A bus company was recently closed down and the owners arrested for the same sort of actions.  Of course, MTM will be declared too big for such action.  The closeness of the relationship between MTM and the highest echelons of PTV would also prevent TSV from doing anything about this abhorrent disregard for safety.
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
Where is the Rail Safety Regulator in all this or is he/she as effective as ASIC in relation to the banks has been and the Nursing Home Regulator, the Petrol Price, Electricity and Gas Regulators (whatever each is called these days) have been.

It's scary what a few more Royal Commissions might reveal these days.
  duttonbay Minister for Railways

Where is the Rail Safety Regulator in all this or is he/she as effective as ASIC in relation to the banks has been and the Nursing Home Regulator, the Petrol Price, Electricity and Gas Regulators (whatever each is called these days) have been.

It's scary what a few more Royal Commissions might reveal these days.
YM-Mundrabilla
I have no idea, but perhaps the regulator may be waiting until the ATSB report has been released?
  Valvegear The Ghost of George Stephenson

Location: Norda Fittazroy
Where is the Rail Safety Regulator in all this
YM-Mundrabilla"
In a meeting; where else?
  kitchgp Chief Train Controller

............
One final point, why does it take so long for such a report to be issued?
skitz

There’s a page on the ATSB website about the investigation process that is worth reading. For example, the draft report is submitted to external parties that are directly involved, referred to as Directly Involved Parties or, by the rather appropriate acronym in this case, DIPs. The DIPs have a certain time frame to respond which contributes to the delay in releasing the final report.

At the end of the page is this note:
It is important to note that the ATSB does not wait until its investigations are complete or the final report is published to address critical safety issues. If a critical safety issue is identified during the course of an investigation, it is brought to the attention of the relevant parties immediately so that safety action can be taken.
As the DTRS safety issue and others are listed as proactive, one would assume that such action was taken by the ATSB.
  Madjikthise Assistant Commissioner

From the ATSB report:

Proactive safety action taken by MTM:
MTM has enhanced its driver training to highlight the operation of the DTRS for normal and
emergency use, including the need to cancel a lower-priority call prior to initiating an emergency call.
kitchgp
This has not happened.
  kitchgp Chief Train Controller

Suggest you pass this on to the ATSB.
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
Suggest you pass this on to the ATSB.
kitchgp
Look into it in 2023 but only after they have found MH370.
  Valvegear The Ghost of George Stephenson

Location: Norda Fittazroy
Look into it in 2023 but only after they have found MH370.
"YM-Mundrabilla"
They'll probably find the Philosopher's Stone, or the Fountain of Youth, or the lost city of Atlantis first.
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
A bit off thread but why bother any further with MH370?
What worthwhile point is to be achieved by continuing the search?
Sadly, the aircraft and its crew, passengers (guests, customers, clients - whatever) are gone as a result of what is, almost certainly, a deliberate act.

I see nothing to be gained other than yet another opportunity for Julie Bishop to get her face on TV.
  kitchgp Chief Train Controller

Look into it in 2023 but only after they have found MH370.
YM-Mundrabilla


Posting on Railpage is not going to see anything done about it. It’s important that it is passed on to the ATSB, directly or indirectly.

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