Executive summary
At about 0400 on 17 August 2007, the 48th wagon of Australian Railroad Group iron ore train 6413 derailed on a right-hand curve in a cutting 595.9 km from Perth in the Stewart to Bonnie Vale section of the Defined Interstate Rail Network in Western Australia. Thirty one wagons in total were derailed and 25 of those wagons were seriously damaged. There were no injuries. The track sustained significant damage and was closed for 4 days.
Train 6413 consisted of three locomotives and 126 wagons loaded with iron ore. It was travelling from Koolyanobbing to the port of Esperance, via Kalgoorlie. Rail traffic in this area includes fast passenger trains, general interstate freight and iron ore trains.
Train 6413 had been authorised by train control to pass a signal that had failed to clear following the passage of the previous train. Both the train controller and the train crew were aware that one possible cause of the signal failure was a broken rail.
The Australian Transport Safety Bureau (ATSB) investigation determined that the derailment occurred when a piece of rail containing a large, previously undetected vertical split head defect, disintegrated under train 6413. A rail insert that had recently been used to replace a section of defective rail found during a routine track inspection probably contained the defect. Alternatively, it was possible, but less likely, that the parent rail on either side of the insert may have contained an undetected vertical split head.
As a result of the investigation, the Australian Transport Safety Bureau identified a number of safety issues concerning train operations, record keeping and rail replacement practices.
Rail safety recommendations
The Australian Transport Safety Bureau advises that pilots operating into non-towered aerodromes should consider the safety implications of this safety issue and take action where considered appropriate.
Some pilots operating at non-towered aerodromes do not fully understand the significance of hearing (or not hearing) the various ARFU transmissions.
There was no record to indicate that a worn section of rail, inserted into the track on 25 July 2007, was tested as being suitable for reuse as prescribed in the WestNet Rail Standard Gauge Mainline Code of Practrice. The lack of construction and maintenance documentation compromises the ability to maintain railway infrastructure safely and places greater importance on adhering to mandated test procedures.
Action taken by WestNet Rail
WestNet Rail has advised:
A complete review of WestNet Rail's ultrasonic testing regime is being conducted by Monash University's Institute of Railway Technology to ensure best practice is being followed.
WestNet Rail has also advised that it is establishing an electronic track asset management system.
ATSB assessment of action
The Australian Transport Safety Bureau notes that WestNet Rail has taken action in response to this safety issue. These actions are still in the formative stage. WestNet Rail does not yet have systems in place that address the specific safety issue.
Safety Recommendation
The Australian Transport Safety Bureau recommends that WestNet Rail takes action to address this safety issue.
There was no clear guidance within the WestNet Rail rules for train crews that defined an allowable speed associated with proceeding 'cautiously'. Had the train been travelling at a slower speed it is probable that the extent of damage caused by the derailment would have been less.
Action taken by WestNet Rail RO-2007-006-NSA-007
WestNet Rail has advised:
Immediately after the derailment WestNet Rail implemented, on the 47 kg/m track equipped with CTC, between Koolyanobbing and West Kalgoorlie, the following instruction - Upon any unexplained illumination of a track or block section in the above section the Train controller must not permit any train to enter the section concerned until the Infrastructure person and the Safeworking Technician on call have both been advised and attended to ascertain the cause and corrective action implemented.
The above instruction applies 24 hours a day until further notice.
ATSB assessment of action
The Australian Transport Safety Bureau notes that WestNet Rail has taken action in response to this safety issue. However, WestNet Rail has not addressed the lack of guidance within their rules for train crews who are requested to proceed 'cautiously'. WestNet Rail's rules in this regard are not best practice when compared to rules in other rail systems.
Safety Recommendation
The Australian Transport Safety Bureau recommends that WestNet Rail undertake further work to address this safety issue.