Rail safety investigations & reports

Derailment of freight train 9101 near Ouyen, Victoria on 10 August 2013

Investigation number:
RO-2013-021
Status: Completed
Investigation completed

Summary

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[Download  PDF: 2.38MB]
 

What happened

At about 0834 on 10 August 2013, freight train 9101 derailed at a failed mechanical rail joint between Tempy and Bronzewing in Victoria. Nine wagons located mid-consist derailed and separated from the consist with three wagons ending on their side. The two locomotives and the leading 21 wagons and the last 10 wagons remained on the track. Approximately 300 m of track was destroyed as a result of the derailment. There were no injuries to train crew in the incident.

What the ATSB found

The ATSB found that the mechanical rail joint failed due to the development of fatigue cracks in both fishplates resulting in their subsequent overload fracture. The fatigue cracks had originated in the top surface of each fishplate and it is possible that differential sleeper support may have contributed to higher than normal cyclic tensile stress in the fishplates. Lower than required fishbolt torque was also identified and it is possible that movement within the joint may also have contributed to the development of the fatigue cracks, and the subsequent joint failure.

The fatigue cracks had developed over a period of time and the overload fractures had occurred prior to train 9101. Movement of the separated rail ends during the passage of train 9101 resulted in a lateral discontinuity in the running rail at the joint and the train’s derailment.

The ATSB found that the degraded and deteriorating condition of the rail joint was not detected by track inspections. In the 27 months preceding the derailment, visual inspections of this section of track had been conducted solely from rail vehicles and track walking inspections had not been conducted at intervals specified by maintenance procedures.

What's been done as a result

V/Line has updated its maintenance system to generate automated work orders for track walking inspections.  In order to improve the detection of track defects, maintenance staff have been provided with specific inspection criteria for track infrastructure including joints and fastenings in their work orders.

Safety message

The implementation of effective inspection and maintenance regimes for the early detection and management of track defects is critical to the safety of rail operations.

 

Download Final Report
[Download  PDF: 2.38MB]
 
 
 

Safety Issues

Go to RO-2013-021-SI-01 - Go to RO-2013-021-SI-02 -

Degraded rail joint was not detected

V/Line's track inspection regime did not identify the degraded condition of the mechanical rail joints.

Safety issue details
Issue number: RO-2013-021-SI-01
Who it affects: All operators of freight trains and infrastructure managers.
Status: Adequately addressed

Track inspections frequency

Track walking inspections were not conducted at intervals specified by V/Line’s maintenance program

Safety issue details
Issue number: RO-2013-021-SI-02
Who it affects: All operators of freight trains and infrastructure managers.
Status: Adequately addressed
General details
Date: 10 August 2013   Investigation status: Completed  
Time: 0834 EDT   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): near Ouyen    
State: Victoria    
Release date: 01 August 2014    
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Train details

Train details
Train operator Pacific National  
Train registration 9101  
Type of operation Freight  
Damage to train Substantial  
Departure point Appleton Dock, Vic  
Destination Merbein, Vic  
Last update 14 November 2018