Rail safety investigations & reports

Derailment of train 5DD2 at Ceduna, SA on 23 October 2014

Investigation number:
RO-2014-018
Status: Completed
Investigation completed

Final Report

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What happened

On 23 October 2014, Genesee & Wyoming Australia (GWA) train 5DD2 departed from Kevin, a gypsum mine near Penong, South Australia. The train was loaded with gypsum destined for the port at Thevenard. Shortly after entering the Penong Junction to Thevenard section, the driver felt two severe jerks and noticed a loss of brake pipe pressure and an unusual amount of dust from the rear of the train. After the train was brought to a stop, the second driver walked back along the consist and found several derailed wagons and a section of damaged track.

What the ATSB found

The ATSB found that the track infrastructure was generally in poor condition, with the rail exhibiting substantial head wear. The poor track condition had also allowed a wide gauge condition to develop, allowing rolling stock wheels to track away from the rail web. As a result of the head wear, gauge widening and the wheel tracking position, the capacity of the rail to support the wheel loads had been progressively reduced. This condition ultimately resulted in the failure of the rail head during the passage of train 5DD2, with the consequent derailment and infrastructure damage.

It was evident from the ATSB’s investigation that defect monitoring and reporting was not being conducted as specified in the relevant Code of Practice. As such, awareness of the rail condition and deterioration was reduced and remedial maintenance actions were not being planned or implemented.

The ATSB also found that Genesee & Wyoming Australia’s maintenance oversight had been limited, allowing the track to deteriorate to a point where trains could not be run safely.

What's been done as a result

Following the derailment, the track maintainer (Transfield Services) has undertaken to increase track inspection detail, with a view to identifying areas of concern for assessment and remedial works. GWA advised that they undertook their own inspection of identified sections of track with an emphasis on gauge and cant, and identified other locations that presented potential for a derailment to occur under similar circumstances. This resulted in the application of temporary speed restrictions over the affected areas and the insertion of timber sleepers to maintain gauge.

GWA also advised that they will undertake a review of the processes and procedures applied to rail infrastructure maintenance and have requested more regular track inspection reports from the contracted infrastructure maintainer. The ATSB has been advised that upgrade works are scheduled to improve the track condition and reduce the associated derailment risk, with the majority of works to be completed in 2015.

Safety message

This incident illustrates the importance of rail maintainers effectively documenting and accurately reporting the condition of the track to the responsible owner/operator. Similarly, owners and operators must maintain diligent oversight of infrastructure maintenance activity, particularly in areas where the track condition is known to be poor or deteriorating.

Download Final report
[Download  PDF: 2.35MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issues

Go to RO-2014-018-SI-01 - Go to RO-2014-018-SI-02 -

Maintenance, defect monitoring and reporting as per CoP

Track defect monitoring and reporting was not being conducted as specified in the Westrail Narrow Gauge Mainline Code of Practice, limiting the awareness of the deteriorating track condition and the need for reassessment of track operating limits.

Safety issue details
Issue number: RO-2014-018-SI-01
Who it affects: Rail infrastructure maintainers
Status: Adequately addressed

Oversight of Infrastructure Maintenance

The rail transport operator (GWA) had not maintained sufficient oversight of the activities of the rail infrastructure manager (Transfield Services), allowing the track to deteriorate to a level where trains could not be reliably run in a safe manner.

Safety issue details
Issue number: RO-2014-018-SI-02
Who it affects: Rail network managers and owners
Status: Adequately addressed
General details
Date: 23 October 2014   Investigation status: Completed  
Time: 0905 CDT   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Ceduna    
State: South Australia    
Release date: 15 October 2015   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Genesee & Wyoming Australia  
Train operator Genesee & Wyoming Australia  
Train registration 5DD2  
Type of operation Mineral Ore  
Sector Freight  
Damage to train Serious  
Departure point Kevin, SA  
Destination Thevenard, SA  
Last update 14 November 2018