Monday, May 20, 2024

Bindarrah - 31/12/2023 - A Case Study

Bindarrah case study

At a Glance

WHAT HAPPENED?

On New Year’s Eve 2023 a fully laden freight train travelling from Sydney to Perth collided with a B-Double truck at a level crossing on the Barrier Highway near Bindarrah, South Australia approximately 80 kilometres west of Broken Hill. The driver of the truck was unhurt in the collision but the two train drivers were fatally injured.

WHY?

  • The failure of the truck driver to observe or react to an active level crossing.

ONRSR DRIVEN SAFETY IMPROVEMENTS:

  • Development of the ONRSR Code of Practice – Level Crossings and Train Visibility (ongoing)
  • Review of safety interface agreements
  • National education program
  • Collation of data to identify opportunities for sharing across road and rail.

The Investigation

After arriving at the scene, ONRSR investigators worked with emergency services before conducting a thorough site inspection and collecting evidence. This work included the launch of a drone to assist in the scene examination and to establish the full extent of the incident footprint and assist in assessments of the damage to infrastructure. Having completed these tasks, and liaised with SA Police, ONRSR investigators lifted the non-disturbance notice later that evening.

The post incident investigation by ONRSR identified the direct and sole cause of the derailment was the truck driver’s failure to observe or react to an active level crossing and the approaching train.

Additional observations included that the design and operation of the level crossing and the condition of the road could be discounted as having contributed to the incident and that there were no obstructions to the truck driver’s view of the railway line, the crossing (including the series of warning signs) or the approaching train.

The Incident

The collision between a B-Double truck and a Pacific National freight train on the morning of 31 December 2023 was the most serious incident on Australia’s vast rail network since the double fatality at Wallan, Victoria in February 2020. Like that occurrence, this one was felt nationally, particularly given its timing in the heart of the festive season. The incident killed two respected rail safety workers while a truck driver was lucky to escape with his life when a Perth bound train collided with a truck at an active level crossing.

The level crossing had both active and passive controls including warning signage, flashing lights and warning bells, and while there were no boom gates installed at the location, all crossing controls were visible and in working order. At this particular location, the single gauge railway track was generally straight and level, while the road was a dual carriageway that swept right to cross the railway line but was otherwise flat.

ONRSR deployed a team of rail safety officers and a senior investigator to the scene on the afternoon of 31 December and immediately issued a non-disturbance notice to the Rail Infrastructure Manager, the Australian Rail Track Corporation and the rail operator, Pacific National.

"The incident occurred on a section of road with very little vegetation or obstructions to the view of the rail crew or truck driver as they approached the level crossing. The weather at the time was fine and dry and occurred during daylight hours. Observations of the position of the sun on the day after the incident, at approximately the same time that the collision occurred, indicated that it would not have affected the visibility of neither truck driver nor the rail crew."

ONRSR Investigation Report

Sequence of events

The sequence began when the truck driver approached the sweeping bend in the road that led to the level crossing at which point the truck was travelling at 97 km/h. At the same time the freight train was more than 730 metres from the crossing travelling at 89 km/h.

The truck driver apparently did not notice the train until his vehicle was around 150 metres from the crossing at which point he first noticed the flashing red lights, heard the train’s horn and saw the flashing headlights of the locomotive. Believing he did not have the time or required distance to stop the vehicle, the truck driver made the fatal mistake to accelerate his vehicle, crossing the solid white lines on the highway in a bid to minimise the distance to the crossing.

With the truck unable to clear the level crossing before the train arrived, the lead locomotive collided with the left side of the B-trailer before lifting off the rails, rotating upon landing and becoming detached from the remainder of the train which subsequently derailed.

"The risks of road and rail traffic coming into conflict with one another at the level crossing was considered by ARTC and a recent reassessment of the risk, based on the volume of road and rail traffic, existing controls and existing design, identified that there was no requirement for any additional controls... "

ONRSR Investigation Report

Safety Improvement

Reducing safety risks at level crossings is a collective responsibility. Members of the public, rail transport operators, road transport industries, governments, emergency services and regulators all have a vital role to play.

Level crossing safety has been a key focus for ONRSR for several years and remains a priority.

Most recently ONRSR has facilitated important research into train visibility as part of a continuing focus on safety at regional level crossings. On the back of this research, in June 2023, Infrastructure and Transport Ministers tasked ONRSR with the development of a Level Crossings and Train Visibility Code of Practice. ONRSR is now finalising the Code of Practice following a detailed period of stakeholder engagement with the document designed to set out train visibility expectations and provide industry with guidance on how to tailor assessment and treatment of the risks. The Code will have legal standing, with evidence of compliance levels for rail operators being admissible in a proceeding as evidence of whether or not a rail operator has complied with the law. Its eventual introduction will be complemented by in-field compliance activities.

A final draft of the Code will be submitted to Infrastructure and Transport Ministers in mid-2024 for consideration and approval.

In the immediate aftermath of the Bindarrah incident, Pacific National Chief Executive, Paul Scurrah called for a national roundtable to discuss safety at Australian level crossings. ONRSR was a key participant in the event that was held in Brisbane on March 6, 2024, with Chief Executive, Dr. Natalie Pelham invited to lead sections of the discussion, in particular relating to the sharing of data among all stakeholders and how it could be improved.

Among several agreed outcomes of the roundtable were a series of safety improvement measures that ONRSR is leading, all designed to contribute to improved safety at more than 23,000 level crossings around Australia.

The investigation concluded that no defects were identified with the rollingstock, truck or rail infrastructure that could have contributed to the cause of the collision.

The truck driver has since been charged with several serious criminal, road-related offences by SA Police that are now before the relevant court.

  • Review of safety interface agreements.

ONRSR has led a review of the specific requirements of, and overall effectiveness of, safety interface agreements between road and rail managers and provided that information to the National Transport Commission for input to the Review of the Rail Safety National Law. Road managers, (councils or governments) and rail operators must have an interface agreement in place for any shared rail or road crossing. This means they must identify the risks to safety and determine measures to minimise the risks SFAIRP.

  • National education program.

ONRSR and the National Heavy Vehicle Regulator will lead the establishment of a sustainable, national education program for safe driving around level crossings.

  • Collation of data to identify opportunities for sharing across road and rail.

ONRSR, the National Heavy Vehicle Regulator, Austroads, National Transport Research Organisation and the Australian Transport Safety Bureau will lead the collation of meta data, including the identification of data owners and gaps and opportunities to improve data sharing across organisations and industries. This work will also provide greater visibility of risk assessments for Heavy Vehicle General and Restricted Access Routes and how to capitalise on opportunities to improve ALCAM data quality and outputs to provide detailed level crossing mapping.

Final note

Reducing safety risks at level crossings is a collective community responsibility. Members of the public, rail transport operators, road transport industries, governments, emergency services and regulators all have a vital role to play. There is no silver bullet solution to what is a truly wicked problem. Rather, safety at level crossings relies on the rolling stock operator, the road manager, the rail infrastructure manager and the level crossing user each fulfilling their safety obligations. A lapse by one or more will lead to an unsafe situation.

For further information on the Bindarrah incident and the work ONRSR has done to drive safety improvements, please contact your local ONRSR office.

Last updated: May 20, 2024, 2:20:51 PM