The assumptions regarding locomotive configurations that cut-out locomotive dynamic braking during emergency applications was found embedded in other rollingstock operator’s procedures with similarly configured locomotives in NSW.
The safety issue was raised with Qube after static testing on 4 May 2022. It was apparent the dynamic brake was not cutting out when emergency brakes were applied. Qube conducted further dynamic tests on 13 May 2022 and found the dynamic brake was not cutting out when emergency application was made.
Further questioning was raised with the other RSOs (s32's on 6 May 2022) to determine if the safety issue spread wider than Qube.
Responses received on 10 May 2022 and 24 May 2022.
ATSB comment
Qube updated their procedures to address the safety issue.
Responses from the other operators indicated there was a misunderstanding of locomotive capability/specification and this presents in the procedural and training information of these above rail operators.
The safety issue was raised verbally with these RSOs on 26 May 2022.
As an issue that potentially spread across a number of Operators, a Safety Advisory Notice was developed and released to the industry.
The safety issue has been found and addressed with Qube.
The safety issue was also found with two other major RSOs in NSW.
The ATSB advises that all Rollingstock Operators (RSO) should review the specifications and test the locomotives under their control to understand how the braking systems are configured. RSO’s must communicate this knowledge through the organisation’s procedures and training material to ensure train crew knowledge and competence in operating locomotive braking systems.
