Rail safety investigations & reports

Track obstruction due to loss of freight from train 7WB3 and subsequent impact of passenger train NT32 with track obstruction near Telegraph Point, NSW, on 17 June 2018

Investigation number:
RO-2018-010
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
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What happened

On 17 June 2018, at about 1309, passenger train NT32 collided with a track obstruction as it crossed the Wilson River Bridge, near Telegraph Point, New South Wales and sustained minor damage. The track obstruction was identified as an awning from a container being carried by freight train 7WB3, operated by Pacific National (PN), which had separated when it came open and struck the bridge structure as the train passed over.

What the ATSB found

The ATSB found that the container involved had been modified to include a large side opening awning. The awning was only held closed by spring-loaded bolts accessed from the inside of the container. This was not compliant with PN’s Freight Loading Manual (FLM), which required a system that could be locked and was externally visible to assure that openings remained secure and enable examination by inspection staff.

Inspections conducted by PN terminal operators at the departure location did not identify the modified container or the absence of locks. The customer did not notify PN that the container was modified as they were not aware of a requirement to do so. Consequently, PN were unaware of the need to assess the modifications against the FLM requirements.

While PN made the FLM available to customers, they did not actively advise them when they had a responsibility identified by the manual and did not have a process for ensuring customers complied with the manuals requirements.

Additionally, the training and checking processes for terminal operators who carried out inspections did not include the FLM requirements for modified containers. This removed an opportunity for the requirements to be reinforced and practiced during training and regular checking of inspection staff.

What's been done as a result

PN have advised that they have implemented a range of processes to ensure customers are aware of, and are compliant with their FLM requirements. These have included the development of an online course for the FLM, and an auditing program to monitor FLM compliance and performance. PN has further introduced a number of measures relating to the training and checking of inspection staff. These include trialling a change to their transport management system, which triggers mandatory checks by PN inspectors at any terminal where a non-standard or modified container enters, and updating training and checking packages to include the FLM requirements.

Safety message

Any item on a container that can open into the rail corridor represents a potential risk as, should they come open, they may strike infrastructure, opposing trains or bystanders. This highlights the significance of ensuring that such items are adequately secured prior to transit.

Further, this occurrence emphasised the importance of training and checking to reinforce operational procedures, in this case, for identifying and securing openings on modified containers. It also identified the need to have processes in place to advise customers of the requirements for the safe transport of modified containers and to ensure compliance.

Download final report
[Download  PDF: 895KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issues

Go to RO-2018-010-SI-01 - Go to RO-2018-010-SI-02 -

Advise relevant external parties of container loading requirements and check for compliance

While the Freight Loading Manual was available to customers, Pacific National did not actively advise them when they had a responsibility identified by the manual. Further, they did not have a process for ensuring that customers complied with the manual’s requirements.

Safety issue details
Issue number: RO-2018-010-SI-01
Who it affects: Pacific National and relevant external parties (customers)
Status: Adequately addressed

Education on loading and inspection of modified containers

Pacific National's training course for the loading and securing of freight, and their verification of competency checks for inspection staff, did not include the Freight Loading Manual requirements for non-standard and modified containers.

Safety issue details
Issue number: RO-2018-010-SI-02
Who it affects: Pacific National inspection staff
Status: Adequately addressed
General details
Date: 17 June 2018   Investigation status: Completed  
Time: 1309 AEST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Wilson River Bridge between Telegraph Point and Wauchope   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 31 March 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train 1 details

Train 1 details
Line operator Australian Rail Track Corporation  
Train operator Pacific National  
Train registration 7WB3  
Type of operation Freight service  
Sector Freight  
Damage to train Nil  
Departure point Port Kembla, New South Wales  
Destination Brisbane, Queensland  

Train 2 details

Train 2 details
Line operator Australian Rail Track Corporation  
Train operator NSW Trains  
Train registration NT32  
Type of operation Passenger  
Sector Passenger - regional  
Damage to train Minor  
Departure point Brisbane, Queensland  
Destination Sydney, New South Wales  
Last update 31 March 2020