Canberra, ACT: ATSB publishes report into school bus collision

The Australian Transport Safety Bureau (ATSB) has published its report into the collision between a school bus and a train on the Nulla Nulla South Road open active level crossing near Moorine Rock in Western Australia. The accident occurred at about 15.40 after the school bus drove onto, and became stuck on, an excavated section of railway track. There were no injuries as a result of the collision but there was significant damage to the school bus.

The ATSB investigation determined that the collision occurred as a result of the school bus being driven around road closure signs and onto a level crossing worksite where the rails through the intersection were being replaced.
ATSB’s investigation identified the following contributory factors pertinent to the management of risk at level crossings:

• The rail replacement contractor did not follow a previously established interface process outlined in the Main Roads Western Australia - Traffic Management for Works on Roads Code of Practice. As a result, JHR did not effectively communicate information about the intended work at the level crossing with the affected parties. In addition, JHR did not receive written approval from the Shire of Yilgarn for the closure of the Nulla Nulla South Road level crossing before commencing work
• Detour signs were not placed in advance of and at the road closure points on Nulla Nulla South Road to redirect and guide road users around the closed level crossing in accordance with Australian Standard AS 1742.3-2009
• It is likely that the Coordinating Principal did not fully understand the level of authority she had to plan an alternative temporary bus route in accordance with the Transport Assistance for Students Operational Policy Manual and then discuss other route options with the relief bus driver before the driver commenced the afternoon bus service

• The relief school bus driver was reluctant to deviate from the designated school bus route as she was unfamiliar with the route and branch roads off Nulla Nulla South Road
• The combination of being unfamiliar with the roads in the area, the absence of detour signs in advance of and at road junctions to redirect traffic flow, and being uncertain of what she may encounter near the level crossing ahead, resulted in the bus driver choosing to drive around the traffic control devices that had been placed primarily to stop the passage of road traffic.
• The school bus driver failed to observe that the road structure had been completely removed before driving the school bus into the excavation area close to the railway track.

• Induction & training of the relief school bus driver had not been carried out in accordance with the Public Transport Authority school bus contractor’s safety management plan
• The locomotive horn was not activated near the whistle sign located about 370 m before the Nulla Nulla South Road level crossing, contrary to WestNet Rail Network Rule 27

(June 30th, 2010)

The independent Rail Accident Investigation Branch (RAIB) has released a bulletin into the fatal collision on a level crossing in Penrhyndeudraeth, Gwynedd, Wales, which says that line-side vegetation obstructed the view of the line at the time of the accident in September 2010 (LXinfo October 2009, LXinfo May 2010). The vegetation obstructing the view of and from the crossing has since been cut back.

The RAIB suggestion that installation of miniature warning lights to this user worked crossing could have prevented a collision has drawn a response from Network Rail, contained within the bulletin, that miniature warning lights increase the risk to users of the crossing.

The rationale for RAIB proposing miniature warning lights is that the use of the telephone to establish it is safe to cross can mean waiting for up to 20 minutes for a train as the signalling section on which the crossing sits is very long. Using miniature warning lights with local train detection would significantly reduce waiting time.

The RAIB bulletin records that the level crossing telephone was last used three before the fatal incident. This suggests that regular users like the 83-year-old victim routinely crossed without first establishing from the signaller that it was safe for them to cross the railway. This and knowledge of the train timetable perhaps explains why the accident occurred as the train involved in the collision was an additional working over and above the Cambrian Line’s regular passenger service.

 

The RAIB bulletin can be found at: http://www.raib.gov.uk/cms_resources.cfm?file=/Bulletin
%20(Penrhydeudraeth)%2007-2010.pdf

(June 16th, 2010)

 

Penrhyndeudraeth UWC, restricted view, source RAIB

• The tram driver not perceiving the risk in sufficient time
• The speed of the tram and its relationship to the driver’s training
• The tram not stopping at the tram-stop
• The pedestrians’ assumptions about the tram’s position
• The tram driver’s attention towards the tram-stop
• The tram driver’s assumptions about the people in the tram shelter
• The feasibility that the tram driver’s inexperience played a part.

• Blackpool Transport Services Ltd (BTS) management should develop and document a company-wide policy for the determination and application of speed limits throughout the network. This should include a maximum speed for non-stopping trams through tram-stops. They should also develop, document, train and brief a speed limit signage policy
• BTS should develop and document an effective and consistent system to monitor compliance with speed limits among tram drivers, and adjust BTS recruitment, training and compliance procedures as necessary to increase levels of compliance.

June 3rd, 2010