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What happened

At about 1615 on 30 October 2013, Pacific National standard-gauge freight train 3XW4 derailed at Newport, in Melbourne. The train derailed one bogie on a curve between two turnouts resulting in track damage to the mainline and an adjacent siding. There were no injuries.

What the ATSB found

The ATSB found that the track had a significant wide-gauge defect at the point of derailment. The defect had been present for more than 12 months and was at a level that exceeded the network standard. During the passage of the train, the track gauge widened further and a wheel on the inside of the curve dropped inside the rail.

The section of track was being managed by the Australian Rail Track Corporation (ARTC). The wide-gauge defect had been detected by the track geometry recording vehicle several times, although the location designated to the defect was about 58 m from its actual location. ARTC had subsequently and incorrectly attributed the wide gauge readings as being associated with the transition area in a nearby dual-gauge turnout.

The track was also subject to weekly patrols by ARTC, many conducted on foot. However, these inspections did not recognise the critical level of the wide-gauge at the derailment location and the defect remained in the track.

The ATSB also found that Pacific National freight train 3XW4 had derailed at the same location about seven weeks prior. Following that incident, ARTC did not identify the need for priority remedial works at the location and the defect remained.

What's been done as a result

Since the derailment, ARTC has introduced several measures that address identified safety issues, including:

  • The development of an enhanced GPS-based defect locating system on its track geometry recording vehicle (AK Car), due for full implementation by mid-2016
  • Supplementary training and audit of maintenance staff
  • The introduction of a more structured Asset Management Policy and Asset Management Plan.

The ATSB has issued a recommendation to ARTC to take safety action to enhance the effectiveness of its response to a derailment event to prevent a similar incident.

Safety message

Network managers should ensure that track geometry recording machinery accurately identifies the location of track defects. Track patrols should also be vigilant in their monitoring of track conditions against network criteria.

Following a rail incident, involved parties should prioritise the identification and rectification of safety factors, including local conditions such as track defects.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

 

Safety issues

RO-2013-026-SI-01 - RO-2013-026-SI-02 - RO-2013-026-SI-03 - RO-2013-026-SI-04 -  

Identification of defect location

When the AK Car was operating in Manual mode, the methods used to identify the location of a defect, and assist track staff to locate the defect could be ineffective in certain scenarios. At the derailment location, there was a consistent offset of about 58 m between the recorded location of the wide-gauge defect and its actual location due to the presence of a ‘long kilometre’.

Safety issue details
Issue number:RO-2013-026-SI-01
Who it affects:Track managers
Status:Safety action pending


 

Track patrols

Track patrol processes were ineffective at detecting and remedying the wide gauge defect at the derailment location. Track patrols were overly reliant on the AK Car geometry recording vehicle to trigger maintenance action on this track geometry defect.  

Safety issue details
Issue number:RO-2013-026-SI-02
Who it affects:Track managers
Status:Adequately addressed


 

Actions following derailment on 11 September 2013

The ARTC response to the derailment on 11 September 2013 was ineffective and did not prevent a similar derailment at the same location on 30 October.

 

Safety issue details
Issue number:RO-2013-026-SI-03
Who it affects:Track managers
Status:Safety action pending


 

Rail head wear

ARTC processes for managing the condition of the rail were ineffective despite repeated recording of rail head wear by the AK Car, and local knowledge of the worn rail. The rail was worn beyond the rail condemning limits specified within the network code of practice.

Safety issue details
Issue number:RO-2013-026-SI-04
Who it affects:Track managers
Status:Adequately addressed

 
General details
Date: 30 Oct 2013 Investigation status: Completed 
Time: 1615 EDT Investigation type: Occurrence Investigation 
Location   (show map):Newport  
State: Victoria  
Release date: 13 Jan 2016 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Train details
Line operator: Australian Rail Track Corporation 
Train operator: Pacific National 
Train registration: 3XW4 
Type of operation: Structural steel transportation 
Sector: Freight 
Damage to train: Minor 
Departure point:Port Augusta, SA
Destination:Port Kembla, NSW
 
 
 
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Last update 13 January 2016