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What happened

At about 0025 on 30 May 2016, freight train 9305 derailed at a fractured welded rail joint at Katunga in northern Victoria. The train consisted of two locomotives and 37 flatbed wagons carrying empty containers. Twelve wagons located mid-consist (wagon positions 6 to 17) derailed resulting in severe damage to about 350 m of track. There were no injuries.

What the ATSB found

The ATSB found that the fracture was at a flash butt weld joining early twentieth century rail. The weld contained microscopic defects within the crystalline material structure that indicated improper material processing during flash butt welding, and had probably existed for many years.

It was concluded that the fracture was probably the result of higher than normal loading due to inadequate support of the rail. The loss of effective support was probably the result of deteriorated sleeper condition. The deferral of the replacement of select sleepers through the location had increased the potential for rail fracture, although it was not possible to directly link this decision to this fracture.

The condition of the fracture surfaces indicated that the fracture was probably present for several days prior to the passage of train 9305. After the rail’s fracture, the loosening of the track fasteners allowed the lateral misalignment of the rail ends that led to the derailment of the train. The regime that may have detected the fractured rail before the track deteriorated to an extent that would result in derailment was ineffective for this track and its condition.

What's been done as a result

V/Line has revised their Technical Maintenance Plan schedule to clarify that front of train inspections cannot be used to replace hi-rail patrols on the Tocumwal line.

Further, V/Line intends undertaking a risk review of the appropriateness of its current condition based responses for sleeper condition, as set out the V/line standard for inspection and assessment. The ATSB has recommended that V/Line completes the risk review and implements safety actions to reduce the likelihood of derailment following a rail fracture.

Safety message

Systems of inspection should be designed to ensure detection of rail fractures before track deteriorates to a condition that results in train derailment. 

Download Final Report
[ Download PDF: 1.89MB]
 
 
 

The Occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

 

Safety issue

RO-2016-007-SI-01 -  

Rail fractures

The inspection regime to identify rail fractures was ineffective for the condition of this track.

Safety issue details
Issue number:RO-2016-007-SI-01
Who it affects:All operators of rail freight

 
General details
Date: 30 May 2016 Investigation status: Completed 
Time: 0028 EST Investigation type: Occurrence Investigation 
Location   (show map):Katunga  
State: Victoria  
Release date: 30 May 2017 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Train details
Line operator: V/Line 
Train operator: Pacific National 
Train registration: 9305 
Type of operation: Freight 
Sector: Freight 
Damage to train: Substantial 
Departure point:Appleton Dock, Vic.
Destination:Tocumwal, Vic.
 
 
 
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Last update 30 May 2017