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What happened

On 30 December 2013 at 1547, train 2DA2 (travelling from Darwin to Adelaide) derailed while traversing the points into the loop line at Union Reef. Shortly beforehand, the train crew had commanded the points to reverse for entry into the loop line, however the automated points system was unable to complete the reversal movement – leaving the points in an unsafe open position.

There were no injuries sustained during the derailment, but about 100 m of track infrastructure was damaged, and the main line between Darwin and Tarcoola was blocked for about 5 days.

What the ATSB found

The ATSB found that the northern points at Union Reef had most likely failed to fully transition for the crossing loop because of ore product build up and inadequate lubrication. It had been previously recognised that this location was prone to ore product build up in the four foot and points, but the inspection and maintenance regime had not been adjusted to address this localised issue and the potential increase in risk to rail operations that it presented.

The ATSB also found that the train crew were distracted by several conflicting responsibilities at a time when they were also expected to be preparing for entrance to the crossing loop. While the driver was operating the train at a speed he considered appropriate for traversing the points, he did not expect the point enhancer to remain at red (or the points to be unsafe), and as such, he was unable to stop the train before the open points. Reduced sighting of the point indicator/enhancer due to track curvature and track side vegetation had limited the opportunity for early identification and response to the red indication, even though a repeater indicator had provided prior warning as to its unsafe status.

What's been done as a result

Following this occurrence, Genesee Wyoming Australia (GWA) reviewed the reliability, inspection and maintenance frequency of motorised self-restoring points machines. Similarly, with a view to identifying and addressing any increased risk in these locations, GWA specifically undertook to monitor the functionality and performance of track/points exposed to the accumulation of mining products.

Responding to the human element, GWA advised that a Critical Safety Zones program will be introduced to provide clarification to train crews on acceptable speeds and necessary caution required when approaching points with reduced sighting distances.

Safety message

Rail operators and train crews are reminded that distraction can have a profound impact on safety during critical phases of train operation. To combat situations where signals (often the final defence against an incident) are affected by reduced sighting distances, strengthened guidance should be given to train crews on ensuring that appropriate approach speeds are established and maintained throughout the critical areas.

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Safety issues

RO-2013-028-SI-01 - RO-2013-028-SI-02 - RO-2013-028-SI-03 -  

Special locations

Union Reef was not treated as a special location as defined in the ARA Code of Practice for the Australian Rail Network.

Safety issue details
Issue number:RO-2013-028-SI-01
Who it affects:All owners and operators of track infrastructure
Status:Adequately addressed


 

Guidelines

The GWA guidance does not provide clear and unambiguous information for train crews on acceptable points approach speeds where sighting distance is reduced

Safety issue details
Issue number:RO-2013-028-SI-02
Who it affects:All owners and operators of freight trains
Status:Safety action pending


 

Train crew distraction and priorities

The train crew had conflicting responsibilities distracting them from the safety critical task of driving. GWA did not have specific policies and procedures to define responsibilities of train crews approaching safety critical phases of operation.

Safety issue details
Issue number:RO-2013-028-SI-03
Who it affects:All owners and operators of freight trains
Status:Safety action pending

 
General details
Date: 30 December 2013 Investigation status: Completed 
Time: 1547 CST Investigation type: Occurrence Investigation 
Location   (show map):Union Reefs approx. 200 km south of Darwin  
State: Northern Territory  
Release date: 17 February 2015 Occurrence category: Accident 
Report status: Final Highest injury level: None 
 
Train details
Line operator: Genesee & Wyoming Australia 
Train operator: Genesee & Wyoming Australia 
Train registration: 2DA2 
Type of operation: Freight 
Sector: Freight 
Damage to train: Minor 
Departure point:Darwin, NT
Destination:Adelaide, SA
 
 
 
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Last update 25 February 2015