Rail safety investigations & reports

Derailment of freight train 9501 at South Dynon Junction, West Melbourne, Vic on 2 March 2013

Investigation number:
RO-2013-009
Status: Completed
Investigation completed

Summary

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What happened

At about 0623 on 2 March 2013, Pacific National freight train 9501V, travelling from Appleton Dock to Tottenham Yard, derailed at South Dynon Junction near Melbourne, Victoria. Due to a track closure, the Network Control Officer (NCO) had been routeing all train movements via an alternative route through the South Dynon junction area via the North Dock line, signal DYN114, and 113 points. All of these train movements were standard-gauge trains. The NCO set the same route through South Dynon for train 9501V, a broad-gauge train. However, the route selected was for a standard-gauge train only as it did not contain a broad-gauge rail beyond signal DYN114, other than the 40-metre length leading to its truncation.

Having detected the train as broad-gauge and therefore incompatible with the remainder of the established route, the signal interlocking system prevented signal DYN114 from clearing. Train 9501V stopped at signal DYN114 and, through discussion, both the NCO and the locomotive crew assumed a signal failure. The NCO subsequently issued a verbal authority to the driver to pass signal DYN114. The locomotive crew then proceeded past signal DYN114 for a distance of about 40 m where the broad-gauge rail ended, resulting in train 9501V derailing at low speed.

What the ATSB found

The ATSB found that when the NCO established the route, the train control system provided no indication that sections of it were dual-gauge and sections were single-gauge. When train 9501V approached signal DYN114, there was minimal indication to the NCO that the train gauge and the selected route were incompatible. As the train proceeded past signal DYN114 and 113 points, it derailed because the configuration of the dual-gauge points assembly led to a truncated broad-gauge rail in the selected turnout direction.

The ATSB also found that there were deficiencies and ambiguity in the procedures for authorising movement past signals that display a Stop indication. There were also deficiencies in the route knowledge information provided to drivers and no additional indications to a train driver that the broad-gauge track terminated.

What's been done as a result

ARTC has modified the train control system to alert network control officers when a route is set that is not compatible with the gauge of the train, and has amended processes regarding authorising train movements past signals that are displaying a Stop indication.

Safety message

This report emphasises the need for rail transport operators to provide adequately designed system displays that are not provocative of decision-making error by operators. It also highlights the need for train crew and NCOs to ensure they have considered the possibility that an unexpected Stop indication is not always due to signal failure.

Download Final Report
[Download  PDF: 1.72MB]
 
 
 

Safety Issues

Go to RO-2013-009-SI-01 - Go to RO-2013-009-SI-02 - Go to RO-2013-009-SI-03 - Go to RO-2013-009-SI-04 - Go to RO-2013-009-SI-05 - Go to RO-2013-009-SI-06 - Go to RO-2013-009-SI-07 -

Train control system screen display – route information

The train control system screen display provided no direct indication to the network control officer that one section of the established route was dual-gauge and another section single-gauge.

Safety issue details
Issue number: RO-2013-009-SI-01
Who it affects: Infrastructure managers
Status: Adequately addressed

Train control system screen display – incompatible gauge warning

When train 9501 approached signal DYN114, which was displaying a Stop indication, there was minimal indication to the network control officer that the train gauge and the selected route were incompatible.

Safety issue details
Issue number: RO-2013-009-SI-02
Who it affects: Infrastructure managers
Status: Adequately addressed

Configuration of dual-gauge points assembly

The configuration of the dual-gauge points assembly led to a truncated broad-gauge rail in one of the turnout directions.

Safety issue details
Issue number: RO-2013-009-SI-03
Who it affects: Infrastructure managers
Status: Adequately addressed

Route knowledge information to train drivers

The train operator’s Route Knowledge Package did not include track layout diagrams, or specific information warning of the existence of dual-gauge turnouts where track terminated in one direction.

Safety issue details
Issue number: RO-2013-009-SI-04
Who it affects: Rail operators
Status: Adequately addressed

Indicating the termination of broad-gauge track

There was no warning indication at signal DYN114 to warn train crews that the broad-gauge rail terminated in the straight-ahead direction.

Safety issue details
Issue number: RO-2013-009-SI-05
Who it affects: Infrastructure managers
Status: Adequately addressed

Authorising movement past a signal at stop

The procedures and guidance documentation for authorising movement past signals displaying a Stop indication was ambiguous.

Safety issue details
Issue number: RO-2013-009-SI-06
Who it affects: Infrastructure managers
Status: Adequately addressed

Caution Orders - validating train and route compatibility

The process undertaken by the network control officer for issuing a Caution Order does not require validation of compatibility between the train gauge and the established route.

Safety issue details
Issue number: RO-2013-009-SI-07
Who it affects: Infrastructure managers
Status: Adequately addressed
General details
Date: 02 March 2013   Investigation status: Completed  
Time: 0623 EDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): South Dynon Junction, West Melbourne    
State: Victoria    
Release date: 04 September 2014   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Australian Rail Track Corporation  
Train operator Pacific National  
Train registration 9501  
Type of operation Freight  
Sector Freight  
Damage to train Minor  
Departure point Appleton Dock, Vic  
Destination Tottenham, Vic  
Last update 14 November 2018