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A breakdown of controls due to a combination of ambiguous radio communications and missteps by staff led to the dangerous runaway of two locomotives at a large Sydney rail yard, transport safety investigators have found.
Investigators have also found the co-ordination between Pacific National, the owner of the locomotives, and the federal government's Australian Rail Track Corporation was "ineffective in capturing an uncontrolled movement" at the freight terminal at Chullora in Sydney's west.
In a report released by the Australian Transport Safety Bureau on Tuesday, investigators have revealed how the two locomotives rolled away uncontrolled at Pacific National's freight terminal and onto major rail lines on September 23 last year.
As part of a 1.5-kilometre long train, the two locomotives had been hitched to three others to enable them to haul 76 wagons from Melbourne.
After arriving at Chullora and detaching wagons, the train's crew shifted the five locomotives towards the end of the yard where a shunt driver was waiting to take over from them.
When they stepped out of the cab, the crew left the locomotive's independent brake handle fully applied but did not use the park brake.
In preparing to detach the locomotives, one of the yard's operators stepped between them and disconnected the train hoses and lifted a pin to the two last locomotives. Immediately afterwards, the yard operator took a meal break.
However, neither the train's crew not the shunt driver knew the last two locomotives had been detached. A short time later, the front three locomotives were moved to another part of the yard while the last two remained where they were.
Just before 6pm, the two locomotives began to roll away uncontrolled through the yard, reaching a speed of up to 21 kilometres an hour, and onto the rail network. In doing so, they set off two alarms at a control centre at Junee near Wagga Wagga.
Fortunately, they came to rest at Chullora West Junction without injury or damage.
In the final report released on Tuesday, investigators found communication protocols and procedures for the shunt were ineffective "in ensuring that the shunt plan was clear and unambiguous and that adequate protections against the unintended movement" were in place.
They also found that if the train crew had applied the park brake it "would almost certainly have prevented the runaway from occurring."
While NSW has had instances in recent years of uncontrolled wagons, investigators said "none was directly comparable to the runaway incident" in September last year.
This article first appeared on www.watoday.com.au
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