Rail safety investigations & reports

Derailment of MTM train TD1064 near Rushall Station in Fitzroy North, Melbourne, Victoria, on 6 February 2016

Investigation number:
RO-2016-002
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 4.45MB]
 

What happened

At about 1650 on 6 February 2016, metropolitan passenger train TD1064 was travelling towards Melbourne between Merri and Rushall Railway Stations when it derailed one bogie on a small-radius curve. There was one minor injury reported.

The derailed car was foul of the adjacent track and there was the potential for more serious consequences had a train from the opposite direction been passing at the time.

What the ATSB found

The ATSB found that the leading right-hand wheel of the second car climbed the outside rail of the small-radius curve. The main factors contributing to the derailment were the high coefficient of friction between wheel and rail and the geometry of a rail joint. The train was being operated within the speed limit for this curve and the manner of its operation did not contribute to the derailment.

It was found that the train’s wheel flanges and the rail’s gauge-face had low levels of lubrication. The performance of rail lubricators on the metropolitan network had diminished prior to the derailment, leading to a deficiency in lubrication on the network. This was probably the result of a decline in lubricator maintenance. Rail lubricator maintenance was being transferred from contractors to Metro Trains Melbourne (MTM) staff and this transition was not adequately managed.

The derailment at this point on the curve was triggered by a lateral angular discontinuity at a mechanical rail joint, resulting in a localised increase in the wheel-to-rail lateral force. The network’s track geometry standard did not preclude the presence of such a discontinuity.

While not mandated by MTM, a check rail on this small-radius curve (installed adjacent to the inner rail) would have provided an additional defence against flange-climb and derailment. A network standard to potentially address derailment risk at higher-risk locations was under consideration at the time of this derailment.

A number of other safety factors were identified that were not directly causal to this incident. They included the ineffective locating of some rail lubricators within the network, a high tolerance on allowable track geometry deviations at this and similar low-speed mainline locations, and a failure to address a wide-gauge defect on this curve.

What's been done as a result

MTM have undertaken a range of actions including the wide-spread installation of new electronic lubricators and significant changes to the management of track condition and faults. These actions, when taken in concert, are expected to reduce the risk of derailment on small-radius curves.

Safety message

The potential for flange-climb derailment on small-radius curves is sensitive to track condition and lubrication between wheel and rail gauge-face. It is therefore important to maintain lubrication across the network and address reductions in performance flagged by unusual wheel wear or evidence of metal loss at the wheel-rail interface.

Download final report
[Download  PDF: 4.45MB]
 
 
 

Occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issues

Go to RO-2016-002-SI-01 - Go to RO-2016-002-SI-02 - Go to RO-2016-002-SI-03 - Go to RO-2016-002-SI-04 - Go to RO-2016-002-SI-05 - Go to RO-2016-002-SI-06 - Go to RO-2016-002-SI-07 -

Rail lubricator maintenance

The maintenance of rail lubricators had become less effective in the months leading up to the derailment. This work was being transferred from contractors to internal Metro Trains Melbourne (MTM) staff and the transition was not adequately managed.

Safety issue details
Issue number: RO-2016-002-SI-01
Who it affects: Owners and operators of passenger rail services in Victoria
Status: Adequately addressed

Standard for angular discontinuity at mechanical joints

The network’s track geometry standard did not include any specific requirement to limit a localised lateral angular discontinuity in rail line at a mechanical joint.

Safety issue details
Issue number: RO-2016-002-SI-02
Who it affects: Owners and operators of passenger rail services in Victoria
Status: Partially addressed

Location of rail lubricators

The positioning of the rail lubricators at this and several other locations on the network was not consistent with Metro Trains Melbourne (MTM) guidelines and probably reduced their effectiveness.

Safety issue details
Issue number: RO-2016-002-SI-03
Who it affects: Rail: Passenger – metropolitan and regional
Status: Adequately addressed

Track geometry standards

The network’s track geometry standards were probably unsuitable for small-radius Broad-Gauge curves. A combination of track geometry irregularities had increased the probability of flange-climb at several locations on the small-radius Rushall curve.

Safety issue details
Issue number: RO-2016-002-SI-04
Who it affects: Owners and operators of passenger rail services in Victoria
Status: Safety action pending

Management of wide gauge defect

Track geometry through the Rushall curve was not managed in accordance with Metro Trains Melbourne (MTM) network standards. A wide-gauge ‘A’ fault was not rectified in the field despite being closed-out on the asset management system.

Safety issue details
Issue number: RO-2016-002-SI-05
Who it affects: Owners and operators of passenger rail services in Victoria
Status: Adequately addressed

Standard for derailment risk on small-radius curves

There was no network standard that directly dealt with increased derailment risk on small-radius curves.

Safety issue details
Issue number: RO-2016-002-SI-06
Who it affects: Owners and operators of passenger rail services in Victoria
Status: Partially addressed

Train radio functionality

The functionality of the Digital Train Radio System (DTRS) did not allow an emergency call to override an initial lower-priority call.

Safety issue details
Issue number: RO-2016-002-SI-07
Who it affects: Owners and operators of passenger rail services in Victoria
Status: Safety action pending
General details
Date: 06 February 2016   Investigation status: Completed  
Time: 1650 EDT   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Near Rushall Railway Station, Fitzroy North   Investigation phase: Final report: Dissemination  
State: Victoria    
Release date: 16 May 2018    
Report status: Final   Occurrence category: Incident  
  Highest injury level: Minor  

Train details

Train details
Line operator Metro Trains Melbourne  
Train operator Metro Trains Melbourne  
Train registration TD1064  
Type of operation Passenger  
Sector Passenger - metropolitan  
Damage to train Minor  
Departure point South Morang, Vic.  
Destination Melbourne (Flinders St), Vic.  
Last update 14 November 2018