An ATSB investigation has found that nobody was assigned to guide the leading end of a shunting movement of a Pacific National freight train which collided with the side of the Sydney to Melbourne XPT on the evening of 19 January 2005 at South Dynon. The ATSB investigation found that factors including the lack of procedures, poor communications, erroneous assumptions and a depleted team of terminal operators all contributed to the collision. The investigation also found that the catchpoints were ineffective in deflecting the wagons away from the main line.
The final investigation report by the Australian Transport Safety Bureau states that three employees were directly involved in the shunting operation, a qualified terminal operator, a trainee and a locomotive driver. The terminal operator stayed with the locomotive to disconnect it from the wagons and allow the front portion of the train to connect. He incorrectly thought that the trainee understood that he was to guide the leading wagon and stop the train short of a signal guarding the main line.
However, the trainee however thought he had to go to a position only halfway down the yard, remove a derailing device (a 'scotch-block') from the rail and wait there until the locomotive reached him, when he would disconnect the locomotive from the wagons. He had done this job on previous shunting movements and he was not qualified to guide the leading wagon.
The locomotive driver was not aware of the exact position of the leading wagon and was receiving 'distance-to-go' information over the radio from the trainee. He continued pushing the wagons until he saw the trainee and then realised that nobody was at the leading end of the shunt and that the distances given by the trainee related to the distance that the locomotive had to go to his position. The driver immediately brought the shunt to a stop. In the meantime the leading two wagons had derailed on catchpoints guarding the main line and continued at a speed of about 9 km/h into the side of the XPT train passing at the time at a speed of about 13 km/h.
Nobody was hurt and relatively light damage was sustained by the XPT.
The ATSB issued two safety recommendations in the course of the investigation and is releasing a further seven recommendations today with the final report.