Final report

Summary

What happened

At about 1453 CDT on Thursday 17 January 2013, train 3PS6 derailed on the main line at the north eastern end of the Yunta passing loop, after a track buckle formed under the train. No injuries resulted from the incident; however, a number of wagons were derailed and approximately one and a half kilometres of track was damaged. Two months prior to the derailment new rail had been placed on both legs of the track.

What the ATSB found

The ATSB’s investigation found that the buckle that caused the derailment was the result of excessive compressive stresses in the newly installed rail and a lack of lateral track stability through the derailment site. No records were available to demonstrate that the new rail had been destressed at the derailment location, and a Track Stability Management Plan did not exist for the section of track through the derailment site.

It was evident that the works provider’s quality assurance process and documentation was inadequate in relation to the re-railing works through Yunta, especially in the area where train 3PS6 subsequently derailed. In addition, project oversight was inadequate, given that both the infrastructure owner and works contractor had signed off on practical completion of the track work, even though the quality documentation was incomplete and, in some cases, suggested that work had not be undertaken.

What's been done as a result

Transfield Services have revised their quality system for re-railing projects to include a Rail Adjustment Plan which will list all required stressing required for the project. They have also introduced or updated the De-stress Pull Form, In Process Checklist, and Inspection and Test Plan/Checklist to improve the robustness of their quality system.

ARTC has developed a Track Stability Plan for the section of track where the derailment occurred and revised the plans for the rest of its network. These plans will be reviewed annually and include inputs from regular rail stress tests. The Track Stability of Concrete Sleepered Track procedure will also be reviewed annually and changes are being considered for the rail stressing standards and procedures. ARTC have updated their project management procedures and are undertaking a review of procedures relating to scopes of work.

Safety message

To ensure the safety of rail operations during and after capital upgrade projects, project quality assurance processes and documentation should be fully developed and utilised. Oversight by clients should be robust and the completion of critical activities verified. Documents addressing the ongoing management of track infrastructure should be developed, used, and maintained in accordance with mandated standards.

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions