On Sunday 16 March 2003, at about 1508:45 Eastern Summer Time, a Pacific National freight train 1SP2N travelling from Sydney to Perth via Melbourne derailed at the 265.115 kilometre point, a location 7.112 kilometres south of Chiltern railway station on the standard gauge railway line. The train was carrying steel products and various other goods.
At about 1512 a V/Line locomotive hauled passenger train 8318, travelling from Albury to Melbourne on the broad gauge railway line, collided with wreckage from derailed train 1SP2N. The collision derailed the locomotive and two carriages of train 8318.
No serious injuries were reported by either train crew or passengers.
Chiltern is located on the main railway corridor between Sydney and Melbourne, approximately 272.227 kilometres from Spencer Street Station. The rail corridor contains two tracks, one broad gauge and one standard gauge. The standard gauge track is controlled and managed by the Australian Rail Track Corporation (ARTC) located in Adelaide. The broad gauge track is controlled and managed by Freight Australia located in Melbourne.
The derailment of train 1SP2N was caused by a 'screwed journal' on a wagon located in the 15th position of the train consist. The wagon had reportedly been in storage for several years and had been reintroduced into service. The screwed journal was the result of a failed wheel bearing due to a loss of interference fit on the axle journal. Heat (from friction) built up to a point at which the bearing seized and the journal detached from the axle. The wheelset then became unstable causing the derailment.
Maintenance schedules for the bearing were based on distance travelled, rather than a combination of distance and time. The maintenance history for the wagon was significantly degraded as a result of time and changes of ownership. The lack of bearing history allowed an ineffective analysis of the history and points to a deficiency in the system that may indicate poor practice at that time.
There was an about two minute window from the time train 1SP2N came to a stand, up to the time the driver of train 8318 applied the emergency brake, to try and stop train 8318 before the derailed train. In that time the drivers from train 1SP2N had repeatedly tried to warn train 8318, but were unsuccessful. The drivers also followed procedure by notifying ARTC train control but the message was delayed by four minutes before being relayed to the broad gauge train control(Centrol), not in time to prevent the collision.
A number of reports from previous incidents at Hexham, Elders Block Point and Wodonga were reviewed by the investigation team for any similar factors. In both the past incidents and the derailment at Chiltern, deficiencies were evident in the emergency communications between train control centres.
The investigation identified a number of contributing factors including wagon maintenance; inadequate industry standards or 'best practice'; and communication systems, condition, procedure and use.
Pacific National has already initiated changes to the maintenance procedures for wagons.
The report makes a number of safety recommendations in Section 6.1 relating to:
- Bearing maintenance based on distance and time;
- Reviewing procedures for rolling stock entering service after extended periods ofstorage;
- A review of communications procedures between train control centres;
- A review of emergency train radio procedure training;
- Consideration of communication system update and/or upgrade; and,
- Consideration of the implementation of minimum standards for roller bearings.
|Date:||16 March 2003||Investigation status:||Completed|
|Release date:||21 October 2004||Occurrence category:||Accident|
|Report status:||Final||Highest injury level:||None|