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What happened

On 29 December 2015, Pacific National grain train 9156 was travelling on the V/Line regional network from Carwarp in north-western Victoria to Geelong. The train consisted of two locomotives and 40 wagons.

At about 1713, the train was passing over the William Street level crossing in Ouyen travelling at about 40 km/h and was braking to stop at Ouyen Railway Station. As it crossed William Street, 12 loaded grain wagons located mid-consist derailed. The train came to a stand straddling the crossing. There were no injuries to train crew or members of the public.

There was extensive damage to the derailed wagons, trackside infrastructure and about 200 m of track. Community power, water and gas services were also disrupted. The level crossing was closed for three days and the rail line closed for five days.

What the ATSB found

The ATSB found that the derailment was probably the result of a track lateral misalignment that developed during the passage of train 9156. Over time the track had bunched at the William Street level crossing increasing the potential for a lateral misalignment in the hot conditions of that day.

Several safety factors were identified in this investigation that were similar to factors found in the investigation of a derailment at Nunga (8 km south of Ouyen) that had occurred seven weeks earlier. The asset management systems used to identify problematic levels of rail creep (the longitudinal movement of rail over time) did not incorporate algorithms to flag rail creep that had accumulated over an extended period. In addition, the management systems did not adjust creep measurements for fixed points. The network relied on this asset management system to identify problematic creep and there was no other supplementary system of identifying rail creep in jointed track.

V/Line had also identified deficiencies in the training and development of track maintenance personnel across its network and had commenced restructuring its training to address these deficiencies.

What's been done as a result

Given that this event occurred shortly after a similar derailment at Nunga (RO-2015-022), several safety actions are common to both occurrences. Following both events, V/Line made changes to its asset management system to better address cumulative creep and to correct for fixed points.

V/Line has also updated its network standard for the inspection and assessment of lateral stability, developed training materials for rail adjustment and the management of stress in rail, and undertaken additional training of track maintenance personnel.

Safety message

Asset management systems, track standards and training should provide a complementary suite of systems for the effective management of rail creep of jointed track and track stability in extreme weather conditions.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

 
 

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Safety issues

RO-2015-029-SI-01 - RO-2015-029-SI-02 - RO-2015-029-SI-03 - RO-2015-029-SI-04 -  

Rail creep

Asset management systems that were used to identify problematic levels of rail creep did not evaluate nor assess cumulative creep.

Safety issue details
Issue number:RO-2015-029-SI-01
Who it affects:Managers of rail networks
Status:Adequately addressed


 

Correcting rail creep for fixed points

Asset management systems used to identify problematic levels of rail creep did not correct for fixed points between creep monuments.

Safety issue details
Issue number:RO-2015-029-SI-02
Who it affects:Managers of rail networks
Status:Adequately addressed


 

Other track inspections

There was no supplementary system of inspection that was effective in identifying rail creep in jointed track. The network placed a high reliance on the asset management system to initiate closer inspection of track potentially affected by creep.

Safety issue details
Issue number:RO-2015-029-SI-03
Who it affects:Managers of rail networks
Status:Partially addressed


 

Track maintenance personnel training and development

There was an identified gap in the knowledge of track maintenance personnel that was probably the result of deficiencies in training and development. In addition, network standards for the assessment of track lateral stability, including creep management, provided limited information and tools for maintenance personnel.

Safety issue details
Issue number:RO-2015-029-SI-04
Who it affects:Managers of rail networks
Status:Adequately addressed

 
General details
Date: 29 December 2015 Investigation status: Completed 
Time: 1713 EDT Investigation type: Occurrence Investigation 
Location   (show map):Ouyen  
State: Victoria  
Release date: 12 July 2017  
Report status: Final Highest injury level: None 
Expected completion: July 2017  
 
Train details
Line operator: V/Line 
Train operator: Pacific National 
Train registration: 9156 
Type of operation: Freight 
Sector: Freight 
Damage to train: 406 
Departure point:Carwarp, Vic.
Destination:Geelong, Vic.
 
 
 
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Last update 12 July 2017