Operational procedure and training discouraged use of emergency brakes
Date issue released
Safety Issue Description

Qube’s operational procedure for train management between Moss Vale and Inner Harbour did not account for locomotive configurations that maintained locomotive dynamic braking during emergency applications. This increased the risk of the train driver avoiding the use of the emergency brake during a runaway event.

 

Response by Qube Logistics

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.

Qube gave a verbal undertaking to commence assessing what they would need to do to rectify the safety issue.

Following release of the first draft report, Qube provided the following feedback;

Qube believes that the driver not selecting the Emergency Brake was not a Contributing Factor to the incident. Qube’s analysis and independent report indicated that selecting Emergency in this situation would not have affected the braking performance of the train as the ATSB report suggests. Qube’s analysis indicates this more likely would have increased risk and wheel slide on the rail.
Qube acknowledged that there was an industry lack of knowledge for how this particular Emergency Brake system operated but maintains it did not contribute to the incident or its outcomes.
Qube’s understanding is that application of emergency braking in this instance would have likely resulted in a worse outcome.
Since receiving the ATSB draft report, Qube has undertaken initial tests on brake cylinder pressures for a train in full emergency.

Qube stated the initial results indicated that no further increase in brake cylinder pressure or brake force would have been experienced in emergency application.

ATSB comment

When ATSB requested these tests be run again in the presence of ATSB, Qube stated they would not be spending any more time on this testing.

Qube has since ceased any further testing.

Qube has updated their procedures to address the safety issue.

Issue number
RO-2020-022-SI-04
Issue Status
Closed – Adequately addressed
Transport Function
Rail: Freight
Issue Owner
Qube Logistics
Mode of Transport
Rail
Issue Status Justification

The safety issue was raised with Qube, with initial response to assess what they would need to do to address the safety issue. Qube acknowledged there was an industry lack of knowledge of how particular emergency brake systems operated.