Section 21 (2) of the Transport Safety Investigation Act 2003 (the Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.
On 29 July 2017, the ATSB commenced an investigation into a collision with terrain involving a Zaklad Remontow I Produkeji Spreztu Lotnicz MDM-1P FOX-P glider, registered VH-GPT, at Lismore Airport, New South Wales.
The ATSB found that while conducting an aerobatic display, the glider impacted the ground heavily during the final manoeuvre. The pilot was seriously injured. Examination of the aircraft identified no mechanical issues or faults that may have contributed to the accident.
The ATSB has also reviewed the safety and administrative procedures necessary to conduct air shows and found that, in this case, preparations were consistent with regulatory requirements. The ATSB investigation AO-2017-013, Mallard aircraft, Perth, January 2017 is examining a range of issues associated with air shows, including the suitability of the regulations, approval and oversight of air shows, and compliance with regulatory approvals during air shows.
In this case, the ATSB did not identify any organisational or systemic issues that contributed to the development of the accident or that might adversely affect the future safety of aviation operations. The ATSB assessed that no safety issues would be identified through further investigation. On that basis, the ATSB will discontinue this investigation.
At about 0617 on 28 July 2017, a Bowmans Intermodal containerised ore train (1501S) travelling empty from Port Flat, South Australia (SA) stopped at Dry Creek South in SA. The driver felt the performance of the train ‘very sluggish’, as it was not rolling as it had prior to rounding a curve on the approach to Dry Creek South. The train crew notified the Australian Rail Track Corporation (ATRC) network control officer at Mile End, SA of their situation and that they intended to inspect their train. A short time later, the train crew confirmed to the network control officer that the last three wagons from 1501S had derailed. The train crew were uninjured. However, there was substantial damage to the wagons, track and signalling infrastructure.
What the ATSB found
The ATSB found a vertical split head defect had developed undetected from imperfections introduced during the manufacture of the rail 90 years ago. The defect propagated vertically and longitudinally, roughly through the centre line of the lower leg rail in the curve approaching Dry Creek South.
The passage of a previous train (1122) over this section of track caused an initial rail break, affecting the integrity of the rail and electrical continuity of the associated track circuit, which prevented a signal from clearing for the next train (1501S). The network control officer authorised the driver to pass the signal at stop, with the condition that the train travel at low speed.
However, the rail break was not visually obvious to the train crew as the locomotive rounded the curve. As the rear of that train passed over the break, a 2 m section of rail fragmented causing the last three wagons to derail.
Detailed (ultrasonic) inspection of the track about one month prior to the occurrence recorded a sustained loss of back wall echo at the derailment location, automatically marking the rail with a spray of paint. However, the ultrasonic inspection operator attributed the recorded event to the poor surface condition of the railhead, which is a common condition that can inhibit the testing. There was no retesting initiated or surface condition report lodged in response to the recorded event. The absence of any follow-up missed an opportunity to identify the presence of the vertical split head defect prior to the rail fracture and the subsequent derailment of 1501S.
What's been done as a result
Following the incident, Speno implemented a review of testing techniques used by operators where poor surface condition exists and the procedures for reporting and testing of rail affected by surface condition.
The Australian Rail Track Corporation reaffirmed the adequacy of the Track and Civil Code of Practice for ultrasonic inspections and the reporting requirements in accordance with contractual arrangements with the ultrasonic inspection operator. The rail in the Dry Creek area is programmed for replacement during 2018 as part of the Adelaide to Tarcoola Re-Railing Project.
Safety message
Defects can develop in rails (and welds) due to a wide range of reasons. Early detection and treatment of a defect that could cause a fracture of the rail is of major importance. While poor surface condition of the railhead is a known limit to the effectiveness of ultrasonic testing, its presence can mask internal track defects, particularly when the condition exists over an extended area. If an inspection cannot test or can only partly test rails, maintenance personnel must report the shortfall to highlight operational risk and the requirement for a timely supplementary examination.
Fractured rail section in lower rail of curve
Source: ATSB
The occurrence
At about 0145 on the 28 July 2017, a Bowmans Rail freight train (1501S) was prepared for departure from Port Flat near Adelaide, South Australia (Figure 1). Train 1501S was an empty containerised ore service comprised of two locomotives (GL108 leading, CM3308 trailing) and 56 wagons. The train was 802 m long, with a trailing mass of 1,283 t and crewed by two drivers. The train was to travel via Dry Creek in South Australia to the Bemax Siding located between Thackaringa and Kanandah in New South Wales.
At about 0548, the driver of 1501S contacted the Australian Rail Track Corporation (ARTC) network control officer (NCO) located at Mile End in South Australia to advise that they were ready to depart Port Flat. The NCO notified the driver that they would travel under signal indication up to Signal 1 at Dry Creek, where a Train Authority[1] would be required for train 1501S to proceed. The NCO was unable to clear signal 1 to a proceed indication,[2] as a track circuit[3] had remained occupied following the passage of the previous train (1122) about 30 minutes earlier.
Figure 1: Location of the derailment of Train 1501S in South Australia
Source: Geoscience Australia annotated by ATSB
At about 0608, the train crew stopped train 1501S at signal 1, and the NCO issued the train authority for the crew to pass the signal at stop. The NCO included instructions for the train crew to proceed at low speed and stop at the points[4] to ensure they were set correctly for the route to the next fixed signal[5] (signal 5). After confirming the content of the train authority with the NCO, the driver passed signal 1 and continued toward Dry Creek South, controlling train 1501S to maintain a speed below 25 km/h.
The driver recalled that when travelling about half way around the curve between signals 1 and 5 he felt the lead locomotive pass over a dip in the left (lower leg) rail. A short time later, train performance ‘felt very sluggish’ and it was not running as it was prior to the curve. At the time, the lead locomotive (GL108) was travelling at about 17 km/h. At about 0617, the driver contacted the NCO, and advised that train 1501S had stopped at Dry Creek South and that they would inspect the train.
At about 0626, an ARTC signal maintainer arrived onsite to investigate the cause of an earlier reported fault; that is, signal 1 not clearing. Shortly after, the signal maintainer contacted the NCO advising that the rear of train 1501S had derailed and there was substantial damage to the wagons, track, location case[6] and other signalling infrastructure (Figure 2).
Figure 2: Derailed rear three wagons of 1501S and damaged signal 5 location case
Source: ATSB
At about 0627, the driver of train 1501S contacted the NCO confirming that the last three wagons (CQYY 3264-G, CQYY 3261-C and CQYY 3265-P) had derailed. The wagons had travelled about 285 m in a derailed state before train 1501S stopped.
Site inspection
An inspection of the track identified a 2 m section of rail had fractured, on the lower leg of the left curve (Figure 3).
Figure 3: Fractured section of rail
Source: ATSB
The railhead had split vertically and longitudinally, roughly through the centre line of the rail in the affected section. The split propagated through to the head/web transition region and outward through the railhead toward the gauge side of the rail, separating the head from the web[7] (Figure 4).
The web had also fractured at several points through the affected section. These breaks were predominately vertical through the web, and transverse in the foot of the rail. The breaks through the web were due to overstress, which probably occurred during the passage of the previous train 1122, and the subsequent passage of 1501S that derailed.
Figure 4: Vertical split head section
Source: ATSB
Passing signal 1 at stop
The ARTC Code of Practice, Volume 3 (CoP) defines the operations and safe working rules for managing train movement[8] through the Dry Creek area. Before authorising the crew of a train to pass a signal at stop, the CoP required the NCO, and train crew, to assess the situation including:
why the signal is at stop
if the section is clear or occupied
if the track is safe or unsafe
the conditions to be included in the Train Authority to authorise the train to pass the signal at stop.
Track circuits in the Dry Creek area used the rails and other signalling equipment as conductors to form an electric circuit. The presence of a train or other rollingstock, or a break in the electrical continuity of the circuit, will cause the track circuit to signal an occupancy.
In this case, the signal was at stop due to an indication the track section remained occupied following the movement of the previous train (1122). A track section might indicate as occupied due to a number of reasons, such as an obstruction, faulty equipment, broken electrical connections, or as in this case, a broken rail.
When travelling on a track section indicated as occupied, there is an increased risk that the train may encounter an obstruction, points incorrectly set for the intended route, or other equipment not operating as expected (for example, level crossings). Consequently, when authorising a train to pass the signal at stop, an NCO should apply conditions to ensure appropriate management of these risks.
Prior to authorising the train crew to pass signal 1, the NCO communicated to the train crew that a track circuit in the route was indicating an occupancy, preventing the signal from clearing. There was no further discussion related to the safety of the track. However, the NCO issued conditions in the train authority for the driver to proceed past signal 1 at low speed and for the train to stop at points to ensure they were set correctly for the intended route. The CoP defined low speed as a speed which will enable a train movement to be stopped within half the distance that the track is seen to be clear ahead, but does not exceed 25 km/h.
Typically, a simple rail break would not result in a derailment, especially if a train is travelling at low speed. This is because, as in this case, the CoP also required a train crew to maintain vigilance by being alert, observing the track (including rails) in the direction of the movement, and being prepared to stop or reduce train speed if required.
Train 1501S passed signal 1 about an hour before sunrise. The driver continued at speeds below 25 km/h, travelling approximately 1,290 m toward Dry Creek South before stopping. Although the driver reported to the NCO that the locomotive dipped to the left when rounding the curve, the train crew did not report observing any significant anomaly with the track and were likely unaware that a rail had broken.
The locomotives and all wagons with the exception of the last three remained on the track. It is likely the rail disintegrated during the passage of one of the last two wagons (CQYY 3261-C or CQYY 3265-P) over the failed section of track. The derailment of the last two wagons likely pulled the rear bogie of the third to last wagon, CQYY 3264-G from the track. The rear of train 1501S travelled about 285 m from the point of derailment (break in the rail) before stopping.
Track inspection arrangements
The ARTC Track and Civil Code of Practice– Rail, defines the guidelines for the scheduled inspection the assessment of rail and rail wear. The scheduled inspections included:
A patrol inspection of the rail for visible defects and conditions (i.e. indications of a defect) that may affect the integrity of the track structure, including the following:
broken rails and rail welds
rail and rail weld deformations and discontinuities
wheel burns
damage to rail surface or section
unusual patterns of gauge face contact
unusual vehicle tracking patterns
rail corrugation
rail crippling
other obvious indications of defects (e.g. bleeding).[9]
The patrol inspections were typically carried out from an on-rail vehicle travelling at a speed consistent with the inspection or by walking. Where track circuits were installed, these could also be employed as an additional method to detect rail failures (such as a break). Patrols conducted two type of inspections:
A general inspection to visually inspect new welds or where the response following detection of a rail or weld defect is to ‘observe’.
A detailed inspection, carried out through continuous or manual ultrasonic rail flaw detection.
Continuous and manual ultrasonic rail flaw detection involved passing sound waves into the rail and monitoring the echo returned by the sound waves reflecting off internal and external surfaces (reflectors). Defects within the rail create reflectors that return echo patterns depending on their type, location and size. Examination of the reflectors enables a skilled operator to deduce the existence, type and size of a suspected rail defect.
The ARTC Civil Technical Maintenance Plan ETE-00-03 sets out the routine inspection tasks and minimum inspection frequency for the track and civil infrastructure (Table 1).
Table 1: Summary from Technical Maintenance Plan – Track System
Type of inspection
Infrastructure element
Description
Minimum Frequency
Conducted by
Track patrol inspection
(By road /rail vehicle or by walking)
Rails and Joints
Includes: Rail; New Welds; Mechanical and insulated Joints; Rail wear; Lubrication
1 Patrol / 7 days (1 day latitude)
Track inspector
Rail detailed inspection
Rail - internal
Continuous ultrasonic rail flaw inspection or manual hand-held inspection where continuous inspection is not effective
The ARTC standard for Track Patrol, Front of Train, General and Detailed Inspections specifies the scope and methodology for the performance of this inspection. The standard recognises the track patrol is principally:
A visual inspection intended to detect obvious, abnormal conditions. It is unlikely that hidden failures or conditions that don’t have a significant visual impact will be detected by Track Patrol which is typically performed from a hi-rail vehicle at moderate speed. Other scheduled (and ad-hoc) general and detailed inspections focus on specific components or conditions and are intended to detect these less obvious defects.
On 27 July 2017, the day preceding the derailment of 1501S, the ARTC track inspector completed a track patrol inspection for the section of rail between the Dry Creek Triangle[11] and Pelican Point. The track inspector did not record observing any anomaly in the rail condition through the area where the derailment occurred.
Continuous ultrasonic rail flaw inspections
ATRC’s technical maintenance plan specified the minimum frequency for a detailed inspection (ultrasonic rail flaw inspection) was at least every 15 MGT. Although the track section between the Dry Creek Triangle and Pelican Point carried around 7 – 10 MGT per annum, ARTC scheduled the detailed inspections yearly.
ARTC undertook the detailed inspections in the Dry Creek Triangle to Pelican Point section through a contractual arrangement with Speno Rail Maintenance Australia (Speno). The Speno Site Safety, Environmental & Quality Management Plan ARTC - Rail Flaw Detection, detailed the specific requirements for Speno accessing the rail network and the rail testing process undertaken.
The rail testing process typically involved the operation of two on-track vehicles. For this type of operation, a main test vehicle (Figure 5) would conduct continuous testing where the ultrasonic operator would interpret, mark and log ultrasonic events displayed on the test vehicles display monitors. Automatic paint guns sprayed a white paint mark on the gauge side, rail web and foot of each rail when the system detected the presence of a defined event.
Following the identification of an event, the operator in the main test vehicle relayed information to a following vehicle, where an operator in that vehicle was responsible for manual ultrasonic testing to localise, identify, size and assess the detected flaw in accordance with the relevant ARTC standards.
The ARTC Manual for Non-Destructive Testing of Rail, ETN-01-04 included specifications for the ultrasonic test equipment and the types and sizes of rail flaws for detection. The manual required the ultrasonic operators to use a range of probes when inspecting the rail and welds for cracks and similar discontinuities. The main test vehicle used in testing the rail in the Dry Creek area towed the roller search unit equipped with an array of 0°, 38° and 70° probes (Figure 5). The arrangement of the probes enabled continuous inspection of each rail leg for defects in various orientations.
Figure 5: FL-18 (RFAS-2100) rail analysis system (main test vehicle)
The 0° probe examined the full rail depth, including welds (Figure 6). Defects located by this probe include bolt hole cracks and longitudinal defects of a horizontal nature in the railhead, web and foot. However, vertical defects are more difficult to detect by continuous ultrasonic testing of rail, since the vertical surface of the defect is less likely to provide a clear reflection from any probe.
While the presence of a vertical split head defect may not display as a distinctive signature in the reflected signal on the operators screen, there are signature patterns that may indicate a potential issue. A vertical defect in the railhead may present as a loss of back wall echo (LBWE), where the signal from the 0o probe is deflected, thereby causing the reflected signal from the base of the rail (foot) to drop below a pre-defined level.
Figure 6: Area 0° probe coverage
Source: Australian Rail Track Corporation
A loss of signal from the bottom of the rail, over any length greater than 4 mm is displayed to the operator in the raw data. A loss of signal over 50 mm will activate an audible signal to the operator that has a unique tone dependent on the respective rail and display the LBWE as a length value to the operator. The pulse echo reliant transducers also activate the automatic paint guns spraying location marks on the rail web. Any ultrasonic shielding (LBWE) or anomalous indication should trigger a localised visual inspection and manual ultrasonic scanning from other faces of the rail to investigate.
The ARTC standard, Non-Destructive Testing of Rail ETE-01-03 detailed the response actions and timeframe to levels of shielding and testability of rail (Table 2).
Table 2: Summary from standard, non-destructive testing of rail
Shielding level
Purpose of assessment
Definition
Response time(s)
Action(s)
Minor
Require test car to re-test at low speed
Any of the following testing at normal speed
Vehicle had to reduce speed
LBWE greater than 50 mm
More than one LBWE per m
Line difficult to test
Immediately
7 days
Stop, examine rail to identify cause of loss of detection
Re-test at 5 km/h
Test car shall report shielding
Moderate
Report early stages for remediation or remediation planning
Any of the following testing at reduced speed
LBWE between 50 and 200 mm
If rail difficult to test
3 days
Test car shall report shielding
Rectification within timeframes specified in Corridor Management Plan
Major
Require hand testing if test car cannot test
Any of the following testing at reduced speed
LBWE greater than 200 mm
More than one LBWE per m
One or more probes giving inconsistent results
7 days
1 day
Test affected rail by hand or apply Track Speed Restriction as required
Test car shall report shielding
Source: ARTC modified by ATSB
The continuous ultrasonic inspection was undertaken on 26 June 2017, about one month prior to the derailment of train 1501S. There was no ultrasonic reflector indicating a vertical split head defect. However, there were occasions of intermittent LBWE and a prolonged period of LBWE over about 2 m that coincided with the derailment location (Figure 7). The inspection also indicated the presence of spurious reflectors from the 70° shear wave transducers. These reflectors likely emanated from the poor rail surface condition that often occurs when the roller search unit is having difficulty maintaining continuity with the rail.
Figure 7: Ultrasonic signatures at derailment location on 26 June 2017
Source: Speno Maintenance Australia, annotated by ATSB
Following the derailment, Speno reviewed replays and examined the ultrasonic signatures from other track structures (insulated joints and boltholes) taken in the area and confirmed the ultrasonic testing system in the main test vehicle was operating within normal parameters at that time.
Examination of the replays also suggested that the operator was having trouble (on occasion) in maintaining continuity of the roller search unit with the rail surface during the run. To compensate, the operator of the test vehicle was undertaking the testing at a reduced speed of 5 km/h, as specified in the response actions of the ARTC procedure.
The Speno rail analysis unit was equipped with audible alarms and paint spray guns that flagged the LBWE event as an exceedance and marked the rail during the ultrasonic inspection of the 26 June 2017 (Figure 8).
The prolonged LBWE event and continued difficulty experienced in testing should have triggered the next level of response action. If rail could not be tested or only partly tested, due to ultrasonic shielding, ARTC required the operator to test the affected area by hand or to forward a Rail Surface Condition Report detailing the circumstances that impeded the testing. Neither a response action nor a condition report was initiated in this case.
Figure 8: Failed section of railhead showing markings from ultrasonic car testing
Source: Speno Maintenance Australia, annotated by ATSB
The previous ultrasonic test of rail in the Dry Creek area occurred in May of 2016. This test also recorded an intermittent LBWE in the same vicinity. Prolonged periods of LBWE also occurred on the opposite rail (Figure 9) illustrated at the 0.226 km mark. Similarly, there was also no record of retesting or the lodgement of a surface condition report. It is likely that the operator on this occasion also assessed the spurious reflectors and LBWE were, in the absence of defined defect signatures, due to the poor surface condition of the railhead.
Figure 9: Ultrasonic signatures at 0.226 km point 4 May 2016
Source: Speno Maintenance Australia, annotated by ATSB
The rail installed in the lower leg of the curve at the Dry Creek North Fork displayed the manufacturer brand, AS BHP Co Ltd 1X27 100LBS OH. The branding indicates the manufacture date was in 1927, from an open-hearth (OH) furnace process. Older rails, produced by means of OH furnaces and cast into ingots, generally exhibited higher levels of impurities than rails produced through the current continuous casting process.[12]
The rail at the derailment site was installed in 1999. The running surface of the rail at the derailment location and in the curve exhibited rolling contact fatigue (RCF) defects that developed from shear stresses at the rail-wheel interface. The presence of RCF defects such as plastic flow, flaking and minor spalling, can mask the signal during ultrasonic inspection and hence prevent the detection of larger and deeper defects that may be present within the railhead.[13]
On-site examination of the section of rail showed evidence of an internal seam extending vertically within the centreline of the railhead. The seam surfaces were heavily corroded and punctuated by an elongated band of inclusions and oxidation located at a depth of around 10 mm from the running surface of the railhead (Figure 10). The general appearance and orientation of the inclusion banding indicated that it was pre-existing and very likely to have been produced when the rail was cast at the time of manufacture. Fatigue cracking had developed from the inclusion bands and had then propagated toward the railhead-running surface and the web transition region, creating a ‘vertical split head’. Typically, longitudinal crack propagation is influenced by a combination of increasing axle loads, wheel impacts or eccentric loading on a railhead exhibiting a flattened profile.
Figure 10: Railhead section detailing interior seam of inclusions/imperfections
Source: ATSB
The vertical split head in this instance propagated undetected into a critical defect of around 2 m in length. The defect exhibited the typical visual indicators of well-developed dark oxide streaking on the centreline of the running surface and oxide streaks (bleeding) on the fillet area of the rail web under the defect (Figure 11). The forces exerted by the passage of train 1501S across the area of rail containing the vertical split defect (and broken rail) resulted in the fragmentation of that section of rail. The disruption of the rail running surface then led to the derailment of the last three wagons of train 1501S.
Track inspection
As neither the scheduled track patrol nor ultrasonic inspection identified the presence of a defect, it cannot be determined when the vertical split defect first propagated towards a critical size. The yearly ultrasonic inspection is heavily reliant on the ability of the individual operator to detect and interpret anomalies in the rail infrastructure (or displayed ultrasonic signatures) that signal the presence of a potential defect.
Figure 11: Failed section of railhead
Source: ATSB
The continuous inspection of rail infrastructure by track patrol or ultrasonic test vehicles typically involves the operator undertaking repetitive tasks in scanning the track structures (or visual display screens) for anomalies while operating a vehicle or other on-board equipment over long sections of track. Track patrols undertaken from road-rail vehicles target the identification of abnormal conditions that may affect the integrity of the infrastructure or operation of rollingstock. Defects that do not have a significant visual impact may be overlooked, increasing the reliance on the detailed inspections to detect hidden conditions.
The Australian Rail Track Corporation (ARTC) also recognised that the non-destructive testing used in undertaking the detailed inspections did not assure detection of all defects due to limitations of existing ultrasonic techniques.
To minimise the risk of a missed defect, ARTC required the ultrasonic testing process, and in particular the conditions in the testing vehicle, be optimised to facilitate the concentration of the operator on the data being analysed. This included:
the judicious use of post analysis facilities of recorded data
in-car working conditions and temperature
computer screens that are adequately protected from sun glare
monitoring that the speed of the car is compatible with the ability to analyse data presented
safe working practices are adequately catered for outside the time allowed for test analysis
fatigue management of operators (consideration of rotation of operators with hand testers)
undue pressure on time allowed in section
peer development and regular training in compliance with this document
monitoring of operators’ performance in terms of percentage of defect identified.
On the 26 June 2017, Speno Rail Maintenance Australia (Speno) commenced the ultrasonic inspection of track at Pelican Point and then proceeded towards Dry Creek. Speno identified that the inspection run at Dry Creek through the area of the derailment would therefore have occurred at about 1645, toward the end of the operators shift. However, there was no further evidence to suggest that fatigue contributed to a failure to detect a rail defect.
The rail in the area of the derailment and a number of other areas along this section of track was in relatively poor condition and exhibited heavily flowed head[14] with severe flaking[15] on the rail surface. The condition of the railhead probably resulted in the failure of the roller search unit to maintain effective contact with the rail surface during the run, either producing spurious reflectors or inhibiting transmission of ultrasonic signals from a defect.
The operator did not follow-up the loss of back wall echo (LBWE) trace and alarm in the area of the derailment by triggering a localised ground inspection or forwarding a rail surface condition report to ARTC.
The generally poor condition of the track in the area of the derailment meant the operator received many spurious ultrasonic reflectors and alarms while traversing that track section. It is likely that the operator’s assessment of the importance of the indications decreased relative to the rail condition, track category and test frequency. Consequently, the operator attributed the LBWE indications to surface condition, rather than the presence of a defect.[16]
From the evidence available, the following findings are made with respect to the derailment of freight train 1501S near Dry Creek on the 28 July 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors
An undetected defect resulted in the formation of a longitudinal fracture within the railhead that propagated both longitudinally and vertically (parallel to the side of the head).
The forces exerted by the passage of train 1501S across the area of rail containing the vertical split defect (and broken rail) resulted in the fragmentation of a 2 m section of rail. The disruption of the rail running surface resulted in the derailment of the last three wagons of train 1501S.
Other factors that increased risk
The operator undertaking ultrasonic testing of rail at Dry Creek North Fork on 26 June 2017 assumed the reflectors recorded resulted from the poor surface condition of the railhead and did not follow-up the loss of back wall echo indication that occurred at the location of the rail break.
Other findings
The passage of a previous train (1122) across the section of rail containing the vertical split defect likely caused the rail to break, further reduced the integrity of the track to support the passage of rollingstock at this location.
Safety actions
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence
Proactive safety action taken by Speno Rail Maintenance Australia
Following the incident, Speno Rail Maintenance Australia investigated the broken rail occurrence and implemented a review of testing techniques used by operators in areas where poor surface condition exists and the implementation of procedures for reporting and testing of rail affected by surface condition.
Proactive safety action taken by Australian Rail Track Corporation
Following the incident, the Australian Rail Track Corporation (ARTC) addressed with Speno the reporting arrangements required in accordance with the contract between the two parties. Additionally ARTC reaffirmed the adequacy of the Track and Civil Code of Practice in relation to ultrasonic inspections.
The rail in the Dry Creek area is programmed for replacement during 2018 as part to the Adelaide to Tarcoola Re-Railing Project.
Sources and submissions
Sources of information
The sources of information during the investigation included the:
Australian Rail Track Corporation
Bowmans Rail
Speno Rail Maintenance Australia
References
Track and Civil Code of Practice, Rail, Section 1, Version 3.3, 22 July 2016, Australian Rail Track Corporation
Code of Practice for the Defined Interstate Rail Network, Volume 4, Operations and Safe working , Part 1: Rules, DOTARS Version 2: May 2002, ARTC Version 2.2: 04 October 2015, Department of Transport and Regional Services
Engineering (Track & Civil) Manual, Manual for Non-Destructive Testing of Rail, ETN-01-04, Version 1.3 07 July 2009, Australian Rail Track Corporation
Non-Destructive Testing of Rail (for Internal & Surface Defects), ETE-01-03, Version 1.6, 6 October 2016, Australian Rail Track Corporation
Rail Defects Handbook, Some Rail Defects, their Characteristics, Causes and Control, RC 2400 Issue A, Revision 0, March 2006, Australian Rail Track Corporation, pp. 48-54
Site Safety, Environmental & Quality Management Plan, ARTC – Rail Flaw Detection, Version 3 17/02/2015, Speno Rail Maintenance Australia
Site Safety, Environmental & Quality Management Plan ARTC - Rail Flaw Detection, Version 3 17.02.2015, Speno Rail Maintenance Australia
Track Patrol, Front of Train, General and Detailed Inspections, ETE-00-02, Version 1.7 28 Jun 16, Australian Rail Track Corporation
Vertical split head defects – some insights into their development and growth, Stephen Marich and Malcom Kerr, RTSA Conference on Railway Engineering, Darwin 20-30 June 2004, p 21.3
Submissions
Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the Australian Transport Safety Bureau (ATSB) may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.
A draft of this report was provided to the Australian Rail Track Corporation, Bowmans Intermodal, Speno Rail Maintenance Australia and the Office of the National Rail Safety Regulator.
Submissions were received from the Australian Rail Track Corporation, Speno Rail Maintenance Australia and the Office of the National Rail Safety Regulator. The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.
Purpose of safety investigations
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
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Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.
On 14 June 2017, the ATSB commenced an investigation into a level crossing collision between a car and XPT NT32, Kyogle, New South Wales, Australia.
At approximately 0810 (AEST) on 14 June 2017, the driver of a white Holden Commodore was driving across the Andrew Street level crossing at Kyogle. At the same time, XPT NT32 travelling from Brisbane to Sydney was approaching the level crossing. The train struck the motor vehicle and as a result of the collision, the driver of the car suffered fatal injuries.
ATSB’s preliminary evidence collection revealed:
The passive level crossing approach signage was to standard.
The sighting distances from both sides of the level crossing were unobstructed and provided ample time for safe crossing.
There was no evidence of the level crossing being poorly maintained.
There were no mechanical issues identified with the train.
There were no issues identified with the train driver.
The driver of the car was walking their pet dog beside the vehicle over the level crossing.
Based on this information, it is likely the driver of the car did not see the train approaching and did not abide by the passive level crossing warning signs. The ATSB considered it was very unlikely that further investigation would identify any systemic safety issues. Consequently, the ATSB has discontinued this investigation.
On 21 July 2017, a loaded coal train derailed at a level crossing on the Western Line between Oakey and Jondaryan, Queensland. The hauling locomotives and 18 wagons came off the track, destroying about 300 m of rail infrastructure.
It is very likely that the underframe of a low-clearance heavy road vehicle collided with the railway infrastructure as it traversed the level crossing soon before the coal train reached the crossing. The impact with railway infrastructure resulted in the lateral displacement of rail lines, which consequently derailed the coal train.
What the ATSB found
The rail infrastructure manager’s monitoring and inspection process at the Dunkeld Access Road level crossing did not ensure the approach roads within the rail corridor and the crossing surface were maintained within safe operating limits throughout its lifecycle. As a result, the elevated gravel-based level crossing road and crossing surface deteriorated to a point where the underframe of a low-clearance heavy road vehicle collided with the exposed head of each rail as it traversed the crossing.
The driver of the heavy road vehicle did not report the collision with rail infrastructure to the asset owner (Queensland Rail) or the local police in accordance with the Queensland Government road transport guidelines. Therefore, the relevant authorities were not in a position to contact the driver of the train before reaching the level crossing.
At the time of the derailment, there was no interface agreement between the rail infrastructure manager and a responsible road authority.
What's been done as a result?
Following the derailment, Queensland Rail (QR) repaired the level crossing and installed a sealed asphalt surface on both sides of the crossing to mitigate the risk of erosion and deterioration. QR also advised that it had taken or was undertaking a series of actions to improve its inspection processes of level crossings to ensure that more focus is placed on inspecting the condition of the approach roads at the crossings. In addition, QR is reviewing its safety standards and relevant documentation in relation to identified defects at level crossings and how the defects are recorded and managed.
QR also advised it had a state-wide audit program in place to assess the current safety status of all private crossings, and upgrade them to the QR standard and/or seek to enter interface agreements.
Safety message
Rail infrastructure managers, who are responsible for the management of the rail corridor, need to ensure that approach roads and the crossing surface at level crossings are subject to regular and effective inspection and monitoring processes. This is particularly relevant for level crossings with gravel-based road surfaces and inclined approach roads.
If rail infrastructure is damaged due to a road accident, it is vitally important that the driver responsible report the matter to the local police or the asset owner as soon as possible.
The occurrence
At about 1550 Eastern Standard Time[1] on 21 July 2017, loaded Aurizon coal train 9869, operating on the Queensland Rail network, departed from the Jondaryan Coal Siding for Fisherman Islands, Queensland (Figure 1). The train was crewed by two drivers, and the consist included two locomotives and 41 wagons.
Figure 1: Jondaryan Coal Siding to Fisherman Islands rail route
The image shows the projected journey of train 9869 from Jondaryan Coal Siding to Fisherman Islands. Source: Queensland Rail (QR)
At about 1534, prior to the departure of the train, a low-clearance heavy road vehicle (prime mover and low-loader) was travelling west along the Warrego Highway between Oakey and Jondaryan. The driver of the heavy road vehicle made a right turn off the highway on to Dunkeld Access Road and passed over level crossing ID 2309, which provided a connection from the highway to McKenzie Road (Figure 2). The level crossing was located at the 38.620 km[2] mark on the Western Line.
Figure 2: Travel direction of the heavy road vehicle over level crossing ID 2309
The image depicts the movement of the heavy road vehicle (white arrows) and the passageway of train 9869 (white solid line) in relation to the level crossing. Source: Google Earth - annotated by Australian Transport Safety Bureau (ATSB)
A member of the public saw the heavy road vehicle come to a sudden stop as it passed over the level crossing. According to the witness, the driver left the driving cab of the prime mover and inspected under the low-loader while it was stopped on the level crossing. The heavy road vehicle then continued on its journey, proceeding east along McKenzie Road.
At about 1557, as train 9869 approached level crossing ID 2309, the driver operating the train detected something on the track ahead. Initially, he thought a bird or small animal on the rails had distorted the appearance of the track, which is a common sight in this region. However, as the train neared the level crossing, the driver noticed a ‘kink’ in both rails. At that point, the speed of the train was 55 km/h, which was within the relevant limit for that section of track.
The driver reported that, as soon as he noticed the kink in the rails, he attempted to stop the train. At about 1558, the data logger on the locomotive recorded a full service brake application, which was initiated by the train driver to control the train to stop. The driver stated that the lead locomotive shuddered as it passed through the level crossing, and through the side mirrors he observed a number of wagons derail as the train slowed.
There were no injuries to the train crew or members of the public. A visual inspection of the train identified both locomotives and 18 coal wagons had derailed. There was also damage to about 300 m of rail infrastructure (Figure 3).
Figure 3: Derailed coal wagons of train 9869
The image shows derailed coal wagons of train 9869 – all wagons in the scene were in a derailed state.
In 1948, the Commissioner for Railways in Queensland, at the request of a local property owner, closed the occupation level crossing at the 124 miles 52 chains Western Line and relocated it to the 124 miles 70 chains, opposite the property owner’s farm. The relocation of the crossing provided the property owner with ready access to the Warrego Highway. Over time, the property was subdivided into smaller farms, which border the northern side of McKenzie Road and the Western Line.
Level crossing ID 2309 is currently located midway between Oakey and Jondaryan on the Western Line. Although the location of the level crossing has not changed in 70 years, under the metric system, its position is at the 38.620 km mark Western Line. It was categorised as a private (occupation) level crossing.[3] At the time of the derailment, the crossing was used by the general public, including heavy road vehicles.
Queensland Rail (QR) has been the sole contributor to maintenance for both the level crossing and the approach roads within the rail corridor[4] since the relocation in 1948.
Maintenance requirements for private level crossings
QR’s Level Crossing Safety Standard MD-10-115 stated that QR was responsible for audits, inspections, maintenance and testing at private level crossings. The maintenance responsibilities included (in part):
• erecting and maintaining all signs immediately adjacent to the tracks as set out in the level crossing agreement, deed or license (if applicable);
• maintaining the road surface within the rail corridor…
In the case of level crossing ID 2309, QR had no interface agreement with the road manager(s) and therefore it was responsible for the maintenance of the approach roads within the rail corridor (also see Level crossing interface agreements).
Maintenance of level crossing ID 2309
QR records showed that in October 2011, repair work was undertaken to eliminate longstanding drainage issues at level crossing ID 2309. In addition, the approach roads to the level crossing were upgraded (Figure 4).
Figure 4: Dunkeld Access Road / level crossing ID 2309 upgrade in October 2011
The images show the condition of the approach road surface on the day of the upgrade (October 2011). Source: QR
In July 2012, an assessment of the level crossing identified problems with the condition of the crossing surface. In the July 2012 assessment report, there was an ‘Observations’ section and a ‘Proposals’ section. A comment in the ‘Observations’ section stated:
Crossing gravel surface is breaking up. Track is “pumping”[5] and contributing to surface deterioration… [Figure 5]
Figure 5: An image taken by the assessor during the July 2012 assessment of level crossing ID 2309
The assessors report recorded that the crossing gravel surface is breaking up and the track is ‘pumping’ and contributing to surface deterioration. Source: QR
In the ‘Proposals’ section of the report, the assessor noted:
Repair gravel surface in accordance with QR Standard Drawing No.2586. Carry out track maintenance works to address track ‘pumping’ issue.
Queensland Rail’s Standard Drawing No.2586, as referred to by the assessor in the report, is a civil engineering standard for public level crossings. In part, it stated:
Road pavement to be sealed with asphaltic cement or a similar material for a minimum distance of 10m on both sides of the railway.
An asphaltic cement prevents road surface deterioration, which is common with gravel-based road surfaces, particularly when the approach road is steeply inclined as it was at level crossing ID 2309. In addition, a sealed surface reduces the risk of low clearance vehicles striking the tracks as they cross. In the case of level crossing ID 2309, the assessor’s proposal was not actioned and the road surface remained unsealed (see Level crossing assessments).
Between October 2011 and the derailment in July 2017, there were two track defects recorded near the crossing:
a low priority defect recorded in November 2015, which went untreated until after the derailment
a critical track alignment issue recorded on 28 August 2016, which was rectified the following day.
Although the critical track alignment was not directly connected to the deteriorated condition of the level crossing, it is possible that the maintenance rectification work included some type of repair to the crossing surface. However, the extent of the repair work at the level crossing between July 2012 and August 2016 could not be determined based on the available records.
Accident site examination
Examination of approach roads
On 22 July 2017, the day after the derailment, the ATSB examined the accident site, which included the level crossing and approach roads to the crossing.
The approach roads to the level crossing were unsealed and constructed from compressed gravel road base. The on-site examination identified noticeable wheel furrows cut into the road surface on the approach to the level crossing from both sides (Figure 6).
Figure 6: The condition of the gravel-based road surface at the crossing on 22 July 2017
The images show the deteriorated state of the road surface and evidence of wheel furrow marks cut into the road surface. Source ATSB
Australian Standard 7658:2012 Railway Infrastructure: Railway Level Crossings stated:
The level crossing surface shall be flush with the top of rail, planar[6] between the two rails and flush with the approach roads.
When inspected by the ATSB following the derailment, the head of each running rail at the level crossing was standing noticeably proud above the crossing surface. In some areas, the web[7] of the rail was exposed (although see Examination of rail track). This was particularly noticeable where the wheel furrows in the road surface intersected with the rail lines (Figure 7).
Figure 7: The exposed railhead and rail web at level crossing ID 2309
There was evidence on both sides of the approach road of a pair of dual wheel tread marks, consistent with a large road vehicle having recently passed over the crossing. The tread marks followed the path of the wheel furrows. There was no evidence of gouge/score marks in the gravel-based road surface between the wheel furrows approaching the rail lines on either side of the crossing surface.
To provide guidance for underbody clearance for rolling stock and road vehicles at level crossings, QR developed civil engineering drawings. Level crossing civil drawing No.2587 defined road-grading limits at private level crossings. Where the approaches to a level crossing had a maximum incline of 6 per cent, the crossing surface design was to exhibit a level plane for 3,000 mm on either side of the track centre line.[8]
The rail track in the area near the level crossing was elevated above the surrounding terrain. Measurements using a laser scanner identified that the approach roads (Dunkeld Access Road) on either side of the level crossing were inclined at about 5 per cent. However, the crossing surface did not exhibit a level plane on either side of the track centre line in accordance with the civil engineering drawing No. 2587. That is, the 5 per cent incline in the approach roads extended all the way up to the edge of the sleepers.
Examination of rail track
The site examination identified lateral displacement to the rails and significant gauge variation at the level crossing. There were side impact marks to the head of each rail at the point of lateral displacement.
The rail on the Warrego Highway side of the level crossing, which took the initial impact, was broken at the impact mark. The matching impact mark to the head of the parallel rail showed distortion to the gauge face, resulting in a gauge disparity of 55 mm (Figure 8).
Figure 8: Damage to the rails at level crossing ID 2309
The image shows corresponding impact marks in the head of each rail, which distorted the gauge and compromised the track integrity. Source: ATSB
The impact marks to each rail were located in the middle of the level crossing, between the wheel furrows made by road vehicles as they passed over the level crossing.
The impact marks covered the entire height of the head of each rail. Together with the absence of gouging/scoring in the road surface, this confirmed that the head of the rails were exposed at the point of impact.
As noted in Examination of approach roads, the site examination identified that the web of each rail was partially exposed at the level crossing and was clearly visible above the crossing surface. This was at least partly due to the low clearance vehicle colliding with the rails together with the derailment lifting the rails and displacing the gravel-based material previously surrounding the rails. Therefore, the extent to which the rail webs had been exposed, prior to the impact, was not able to be determined. However, it was noted that, where the wheel furrows intersected with the rails, the top of the rail webs had a distinctly different appearance to the lower sections of the webs, indicating that they had been exposed for some time.
Laboratory testing of a section of the damaged rail and the analysis of fracture propagation marks indicated that a factor external to the rail environment was involved in the lateral displacement of the rails. More specifically, the impact marks on each railhead indicated that the underframe of a low-clearance heavy road vehicle struck the track at some stage prior to the derailment. The impact marks confirmed that the road vehicle involved entered the level crossing from the Warrego Highway side.
Evidence relating to train activity on the day of the derailment confirmed that the condition of the track at the level crossing was free from damage at 1530. An empty coal train (9L16) passed through the level crossing at this time and did not encounter an issue with the track. Therefore, it is very likely that the underframe of a low-clearance heavy road vehicle collided with the rail infrastructure as it traversed the level crossing sometime between 1530 and 1557 on 21 July 2017.
Road vehicle information
Heavy road vehicle information
On the afternoon of 21 July 2018, the driver of a heavy road vehicle (prime mover and low-loader) was delivering a front-end loader to a worksite adjacent to the Devon Park Road level crossing just west of Oakey. QR had engaged a transport company to deliver the front-end loader to the worksite for the purpose of planned track maintenance work.
The heavy road vehicle was operating under the provisions of Guideline for Excess Dimension Vehicles Carrying Indivisible Articles in Queensland – Form Number 4 (Version 8) February 2013. The gross load capacity of the low-loader (trailer) was 55,000 kg, and the weight of the end-loader was under 20,000 kg. Therefore, the low clearance heavy road vehicle was not overloaded when traversing the level crossing.
The driver of the vehicle stated that he had delivered heavy earthmoving machinery to this location on many occasions. He further stated that on all occasions the same prime mover and low-loader combination had been used to deliver the machinery.
The driver stated he normally turned off the Warrego Highway at Devon Park Road to reach the worksite, passing over the level crossing and unloading the machinery on the northern side of the rail corridor. He added that he would then continue along McKenzie Road, and turn left at level crossing ID 2309 to gain access to the Warrego Highway (Figure 9).
Figure 9: The preferred route after delivering heavy machinery to the worksite
The image shows the route normally taken by the driver of the heavy road vehicle after delivering earthmoving machinery for planned maintenance work during 2017. Source: Google Earth, annotated by the ATSB
However, on this particular occasion, due to traffic build-up at the Devon Park Road level crossing, the driver of the heavy road vehicle chose to use an alternate route. He chose to continue along the Warrego Highway, turn off at the next level crossing (ID 2309) and proceed along McKenzie Road in order to reach his destination.
In this instance, by travelling the alternate route, the low-clearance heavy road vehicle was passing over level crossing ID 2309 in a loaded condition, rather than an unloaded condition as it normally would. It was also entering the level crossing from a different direction to normal (that is, it was entering from the Warrego Highway side).
The driver of the heavy road vehicle stated that he recalled passing over level crossing ID 2309, but insisted that the vehicle did not collide with the rail infrastructure at the crossing.
Additional evidence relating to the movement of the heavy road vehicle
At about 1534 on 21 July 2017, video footage recorded by a camera fitted to a private vehicle travelling east on the Warrego Highway showed a prime mover and low-loader combination travelling west on approach to level crossing ID 2309. The heavy road vehicle was transporting a yellow front-end loader (Figure 10).
Figure 10: Dash camera footage from a private vehicle
The image shows a prime mover and low-loader carrying a front-end loader as it approached level crossing ID 2309. The time stamped on the image is 1534:22 on Friday 21 July 2017. Source: private vehicle operator
A short time later, a member of the public, who provided information to the local police, stated that he observed a prime mover and low-loader combination, transporting a front-end loader, come to a sudden stop as it passed over level crossing ID 2309 from the Warrego Highway side.
The witness stated that the heavy road vehicle appeared to have ‘bottomed-out’ on the crossing. He also stated that the driver of the heavy road vehicle left the driving cab of the prime mover and checked the underframe of the low-loader while it was stopped on the level crossing.
Reporting damage or safety incidents at level crossings
There were ‘incident reporting signs’ in place at the level crossing on the day the railway infrastructure was damaged. The signs provided an emergency contact number for reporting faults or safety incidents at the level crossing (Figure 11).
The Queensland Department of Transport and Main Roads has provided guidelines for the operation of excess dimension vehicles in Queensland. It detailed the responsibilities of the driver if a vehicle causes damage at a level crossing. It stated:
The driver of the vehicle must immediately report any damage caused to the asset owner and in the event that it presents a dangerous situation, to the local police.
On the day of the derailment, no advice of rail infrastructure damage at the level crossing was received by QR or the local police.
Figure 11: Incident reporting sign at level crossing ID 2309
The image shows the incident reporting sign and the emergency contact number, in place at level crossing ID 2309 on the day of the derailment. Source: ATSB
Inspections and assessments of level crossing ID 2309
Scheduled inspections of rail corridor
Inspection is the process by which QR collects and records information on the condition of the track and its components. Inspection must commence when the track is new and continue through its operational life.
QR’s Civil Engineering Track Standard, Module 1 – TrackMonitoring, prescribed the regime to inspect the condition of the track[9] and track components in accordance with its standard. It lists three inspection types relevant to the inspection of track, each of which includes level crossings as an element for inspection. The three inspection types were:
Scheduled patrol inspection (maximum interval between inspections is 96 hours). On the Western Line, these inspections were conducted by a single infrastructure worker driving an on-track vehicle through the rail corridor. The inspection was to detail all elements within the rail corridor including level crossings, stopping as required to inspect recorded defects. A scheduled patrol inspection occurred on 20 July 2017, 1 day prior to the derailment, with no defects identified at level crossing ID 2309.
Scheduled general inspection (maximum interval between inspections is 4 months). On the Western Line, these inspections were typically conducted with two infrastructure workers, who travelled through the rail corridor using an on-track vehicle. The inspections detailed all elements within the rail corridor including level crossings, stopping as required to inspect recorded defects. The two scheduled general inspections undertaken prior to the derailment occurred on 16 January 2017 and 17 July 2017. Neither of the inspections identified issues at level crossing ID 2309.
Scheduled detailed inspection (maximum intervals between inspections was 48 months). These inspections were typically conducted by walking the rail corridor. In addition to the requirements for general inspections, detailed inspections must be at a level of detail sufficient to record the condition of the track for specific purposes such as determining required repairs or remedial actions. The last scheduled detailed inspection occurred on 18 May 2016, with no defects at level crossing ID 2309.
In accordance with QR’s Civil Engineering Track Standard, the infrastructure workers conducting these inspections were required to keep a lookout for obvious unsafe conditions, changed conditions or evidence of high rates of deterioration, which indicated unacceptable risk to operations.
Workers who conducted these inspections informed the ATSB that they stopped at all level crossings to inspect the lights, boom gates and guardrails where applicable. They advised that they also inspected the road surface and crossing surface of level crossings to ensure the safe passage of trains and vehicles. Workers advised that they could not readily distinguish between public and private level crossings without referring to documentation. Additionally, the infrastructure workers were unable to determine the balance of responsibilities of the rail infrastructure manager and the road manager at a level crossing if an interface agreement existed.
Level crossing assessments
QR undertook ‘assessments’ of level crossings
…to determine the appropriate level of control to reduce the risk of collision between a road vehicle/pedestrian and a train as far as is reasonably practicable.
QR’s Level Crossing Safety Standard MD-10-115 stated:
If a private crossing has substantial public use, the recognised level crossing risk assessment model (ALCAM) shall be used. For this purpose, public traffic is defined as vehicular traffic which is not owned or strictly controlled by the Responsible Road Manager…
Private, maintenance and temporary construction level crossings will be reviewed by Queensland Rail at not more than five yearly intervals. These reviews shall be carried out to ensure compliance with the controls approved following the initial assessment for the crossing, and verify that the conditions applying at the time of the initial assessment are still current and the controls are still effective.
These level crossing assessments are separate from the scheduled inspections of the rail corridor discussed in the previous section.
Documentation provided by QR showed that the last assessment/review undertaken at level crossing ID 2309 was on 2 July 2012. The next review should have occurred prior to 2 July 2017. However, this did not occur and, at the time of the derailment on 21 July 2017, the review was overdue.
A notation recorded by the assessor within the July 2012 assessment report stated:
Whilst at present this is a private (occupation) level crossing, it has been assessed as a public level crossing.[10]
The report was brief in nature, and there was no explanation within the report on the decision, for the purpose of the assessment, to upgrade the level crossing from private (occupation) to public. In accordance with the requirements for public level crossings in QR’s Level Crossing Safety Standard MD-10-115, the assessor used the Australian Level Crossing Assessment Model[11] (ALCAM) to evaluate the level crossing.[12]
QR’s level crossing database contains information relating to individual level crossings. After an assessment/review or audit, the assessor updates the system by populating information into the values and fields sections relevant to the level crossing. The system has the capacity to produce a characteristics report. The report reflects on the condition and characteristics of the level crossing at the time of the last entry.
On 15 August 2017, at the request of the ATSB, QR provided the latest characteristics report relating to the level crossing. The last recorded entry date in the comments section of the level crossing database was on 2 July 2012 (following the assessment). In part, the characteristics report stated the crossing condition was ‘bad’.
Based on the evidence supplied by QR, there was no record entered into QR’s asset management database to indicate whether any action regarding the assessor’s proposals in July 2012 to repair the approach road and crossing surface in accordance with QR Standard Drawing No.2586 (see Maintenance of level crossing ID 2309) was approved or actioned. Other proposals in the assessment report (such as installing advance warning signage and incident reporting signage) were actioned at some stage, but not recorded as being actioned in the asset management database.
Other level crossings
The ATSB did not conduct a detailed review of other level crossings in the area. However, it did examine level crossing ID 2310, located 1.5 km west of level crossing ID 2309. This was a private level crossing, and only supported traffic to and from a private property. There were noticeable wheel furrows on the approach roads. In addition, a significant portion of the railhead and web were exposed.
Level crossing interface agreements
An interface agreement is a written agreement between the rail infrastructure manager and road manager and sets out the responsibilities, mutual understanding and arrangement for the management of risks to safety at the shared level crossing interface.
Legislation, introduced in 2010 and current at the time of the derailment, stated the rail infrastructure manager (in this case QR) must identify, so far as is reasonably practicable, risks to the safety of persons arising or potentially arising from railway operations for a private road.
If the rail infrastructure manager forms the opinion that it is necessary to manage the identified risk in conjunction with the responsible road manager, the rail infrastructure manager should reasonably seek to enter into an interface agreement with that responsible road manager.
Alternatively, if the rail infrastructure manager forms the opinion that it is not necessary to manage the identified risks in conjunction with the responsible road manager, then the rail infrastructure manager for the road should keep a written record of the reasons for forming that opinion. The legislation stated that a responsible road manager for a private road meant the owner of the road.[13]
The Dunkeld Access Road was a private (occupation) road passing over a railway. It joined two public roads, the Warrego Highway and the nearby McKenzie Road (Figure 2). In effect, QR was the road owner within the rail corridor and was responsible for the inspection and maintenance of the level crossing. In addition, there is evidence that QR was maintaining the Dunkeld Access Road outside the boundary of the rail corridor.
At the request of the ATSB, QR provided correspondence stating that there was no interface agreement with a responsible road manager for level crossing ID 2309. There was also no evidence provided to indicate that QR had attempted to enter into an interface agreement with either the owner of the nearby property or a road authority. Nor was there a written record regarding the reason QR chose not to manage the risks in conjunction with a responsible road manager.
The loaded coal train derailed at level crossing ID 2309 due to the misalignment of the rail track. No factors associated with the operation of the train or the rolling stock contributed to the derailment.
This analysis will discuss the factors associated with the rail track misalignment. These include the condition of the level crossing, the collision of a heavy road vehicle with the rail infrastructure, the absence of reporting the collision and the processes used to ensure the condition of the level crossing.
Condition of level crossing ID 2309
The railway track at the level crossing was elevated above the surrounding terrain. The approach roads on either side of the level crossing were inclined at about 5 per cent, which was within but close to the maximum allowed incline of 6 per cent. This incline, and the fact that the road and crossing surface were constructed of compacted gravel-based material, meant the crossing was vulnerable to erosion and deterioration.
The available evidence suggests that local traffic and heavy road vehicles used the crossing, and the condition of the level crossing deteriorated over a period of time. The assessment of the level crossing in July 2012, 8 months after a comprehensive upgrade in October 2011, noted that the crossing surface was breaking up and deteriorating. The report included a proposal to replace the gravel-based road surface with asphalt or a similar sealed surface, but this was not done. It is possible some repair of the gravel-based road surface was done at this time, or after this time, such as when a critical track irregularity was identified and repaired in August 2016. However, the extent of any repair work could not be determined based on the available records.
An examination of the level crossing on 22 July 2017, the day after the derailment, identified that the approach roads to the level crossing were in a deteriorated state. There were significant wheel furrows in the gravel-based approach roads, which lowered the underframe of vehicles relative to the road surface, if they followed the furrows. In addition, there was not a level plane over the crossing surface, with the 5 per cent incline in the approach roads extending up close to the rails. The available evidence also indicated that the head and probably some of the web of each rail was exposed above the crossing surface, although the extent the webs were exposed could not be determined. Collectively, these factors, in the period leading up to the derailment, presented a significant risk associated with low-clearance road vehicles and agricultural machinery passing over the level crossing and damaging the rail infrastructure.
Collision with rail infrastructure at level crossing ID 2309
An examination of the accident site identified identical impact marks to the head of each rail at the level crossing. The lateral impact distorted both rails resulting in misalignment of the rail track. Analysis of the marks indicated that they were the result of impact from a low-clearance road vehicle that turned off the Warrego Highway and passed over the level crossing from that direction. The available evidence also indicated that the collision occurred between 1530 and 1557 (just prior to the train reaching the crossing).
It is very likely that the vehicle involved in the collision was the low-clearance heavy road vehicle (prime mover and low-loader combination) delivering the front-end loader to a worksite on the northern side of the rail corridor. It was observed approaching the level crossing at 1534, and a witness saw the low-clearance road vehicle come to a sudden stop at the level crossing shortly after.
It is possible that another low-clearance heavy road vehicle was involved in the collision. However, no other vehicles were sighted passing over the level crossing in the relevant period. In addition, although the same low-clearance heavy road vehicle had crossed the level crossing on previous occasions without incident, it is notable that on those occasions it had crossed without a load and crossed from the other direction.
Collision with rail infrastructure not reported
The heavy impact marks to the head of each rail and the resulting rail infrastructure damage suggests that the collision was significant. Therefore, it is highly likely that the driver of the low-clearance heavy road vehicle that caused the damage would have been aware that the vehicle struck the rail track.
Any damage to rail infrastructure such as rail track misalignment can have very adverse consequences. Accordingly, it is vitally important that any suspected damage is reported as soon as possible. The requirements for reporting such damage have been promulgated, and were also posted at the level crossing. In this case, had the damage been promptly reported, it is likely that advice of the potential problem could have been provided to the train crew prior to the train reaching the level crossing.
Scheduled inspections relating to level crossing ID 2309
The fact that the level crossing had deteriorated outside safe operating parameters suggests it was not being appropriately maintained. It is possible that the condition of the level crossing had only recently deteriorated. However, the level of deterioration that occurred between the upgrade in October 2011 and the assessment in July 2012 suggests that the crossing had a significant potential to degrade over time. The available information suggests that road vehicles, including heavy road vehicles, regularly used the level crossing. Together with factors such as the relatively steep incline and the gravel-based surface, this created the potential for degradation of the crossing surface and the approach roads.
In order for the level crossing to be maintained, the deterioration had to be detected through an assessment or review or scheduled inspections. The last assessment was conducted just over 5 years before the derailment. If an assessment had been done on or just prior to the scheduled date, it is likely that it would have detected the deterioration. Nevertheless, a slight extension to the 5-year timeframe would not be unreasonable in most circumstances (if requested). In addition, there was the significant potential for the problem with the access roads to have developed within 5 years. Therefore, the scheduled inspection processes played an important role in detecting problems before they reached a significant level of deterioration.
According to QR’s documented procedures, level crossing ID 2309 should have undergone a series of scheduled inspections at 96-hour, 4-month and 48-month intervals. The level of detail required in each inspection varied, but they all required aspects of the level crossing, including the road surface within the rail corridor, to be examined.
Overall, there should have been more than 540 combined inspections undertaken at the level crossing between the upgrade in October 2011 and the derailment in July 2017. A number of different personnel would have undertaken these inspections. However, none of these inspections identified the deterioration of the level crossing, which strongly indicates that the inspection process for detecting deficiencies associated with the approach roads and level crossing surface was inadequate. The ATSB also notes that the condition of the approach roads of another private level crossing, located near ID 2309, also had deteriorated to the extent that a significant portion of the railhead and rail web was exposed.
The benefit of an interface agreement
Other than an indemnity agreement between a local property owner and the Commissioner for Railways in 1947, there is no record of an interface agreement involving QR and a road manager(s) at level crossing ID 2309. In the absence of an interface agreement with the road manager(s), QR’s responsibility within the rail corridor was to monitor, inspect and maintain the condition of the road and level crossing throughout their operational life.
Alternatively, QR could have entered into an agreement with another entity to manage the road at the level crossing. As the level crossing forms a connection between a local council road and national highway, the responsible road manager could be either the local road authority, state government or both.
Although level crossing ID 2309 was classified as a private (occupation) level crossing, its unrestricted access as a thoroughfare between two public roads likely presented a level of risk similar to that of a public road crossing. The available evidence also indicates it was frequently used as a public road. In addition, the person who undertook the assessment of the level crossing in July 2012 conducted the assessment as if it was a public crossing. This presented an opportunity for QR to reconsider its classification of the crossing, and/or consider entering into an interface agreement with a responsible road authority.
The benefit of an interface agreement is that both QR and the road manager(s) would have shared the identified risks through a controlled process. Accordingly, if responsibilities for inspecting the condition of the road surface by a road manager at regular intervals was appropriately documented and controlled, this could have increased the potential to identify the developing problem.
However, without knowing exactly how the responsibilities within the rail corridor would have been documented and controlled, it is difficult to determine whether an interface agreement by itself would have led to the identification of the deterioration in the approach road and crossing surface on Dunkeld Access Road prior to the collision with rail infrastructure and subsequent derailment. Ultimately, QR was still responsible for inspecting the approach roads within the rail corridor, and had not identified the deterioration.
It should be noted that the QR network has more than 1,000 private level crossings. A substantial number of these do not have an interface agreement. Consequently, QR’s inspection processes need to be adequate when inspecting approach roads and crossing surfaces at such locations.
Findings
From the evidence available, the following findings are made with respect to the derailment of train 9869 at level crossing ID 2309, near Oakey, Queensland on 21 July 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.
Contributing factors
The condition of level crossing ID 2309 was degraded, with significant wheel furrows in the approach roads, the absence of a level plane over the crossing surface, and the head of both rails was exposed. Some of the web of the rails was also probably exposed.
It is very likely that the underframe of a low-clearance heavy road vehicle collided with the exposed head of the rails as the vehicle traversed level crossing ID 2309.
As a result of the collision by a low-clearance heavy road vehicle, the rail lines at level crossing ID 2309 were laterally displaced, creating the potential for a derailment.
The driver of the low-clearance heavy road vehicle that collided with and damaged the rail infrastructure at level crossing ID 2309 did not report the occurrence to the relevant authorities.
Queensland Rail’s track monitoring and inspection processes were not effective in identifying significant deterioration in the condition of level crossing ID 2309 and its approach roads to ensure the safe operating limits of the level crossing throughout its lifecycle. [Safety issue]
Other factors that increased risk
Queensland Rail had not entered into an interface agreement with a responsible road authority at level crossing ID 2309, even though Dunkeld Access Road and the level crossing were in effect being used as a public thoroughfare. It is likely that an interface agreement would have resulted in a co-ordinated approach to managing the shared risks at the level crossing.
Safety issues and actions
The safety issues identified during this investigation are listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.
Depending on the level of risk of the safety issue, the extent of corrective action taken by the relevant organisation, or the desirability of directing a broad safety message to the rail industry, the ATSB may issue safety recommendations or safety advisory notices as part of the final report.
All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.
Descriptions of each safety issue, and any associated safety recommendations, are detailed below. Click the link to read the full safety issue description, including the issue status and any safety action/s taken. Safety issues and actions are updated on this website when safety issue owners provide further information concerning the implementation of safety action.
Safety issue description: Queensland Rail’s track monitoring and inspection processes were not effective in identifying significant deterioration in the condition of level crossing ID 2309 and its approach roads to ensure the safe operating limits of the level crossing throughout its lifecycle.
Additional safety action
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.
Queensland Rail
Following the derailment, Queensland Rail (QR) repaired the level crossing. During this repair, a sealed asphalt road was installed, covering both sides of the crossing surface.
In its response to the draft investigation report in April 2019, QR advised that since the derailment it had attempted to enter into an interface agreement with a local land owner (who did not want the crossing closed) and the local council (who did not want to make the crossing public).
In April 2019, QR also advised the following in relation to interface agreements:
QR has an audit programme in place to assess all private crossings, upgrade them to the QR standard as necessary, and seek to enter into interface agreements.
QR have requested that the land owner for this crossing enter into an interface agreement with Queensland Rail for the safe operation and use of this level crossing.
An Interface Agreement for Occupational Crossing ID 2309 (Dunkeld Access Road, Oakey (38.62km Western Line) was sent to the private land owner on 9 April 2019. Receipt of the letter was acknowledged on 15 April 2019.
In relation to the ongoing audit programme, audits so far have been completed within the North, Central, North Coast/ Wide Bay/ Burnett regions of Queensland. To date, the audits have identified 72 crossings for closure (as they are no longer required by any party), 28 crossings will be changed from private to public status crossings (as they appear to be used by the general public), 7 crossings will be changed from private to maintenance status crossings and 3 crossings have been identified as requiring relocation. Also to date, licence/interface agreements for 411 have been sent to relevant parties in the regions noted above and 174 licence/interface agreements have been formalised.
Sources and submissions
Sources of information
The sources of information during the investigation included:
Aurizon (train operator)
Queensland Police Service
Queensland Department of Transport and Main Roads
Queensland Rail (track owner)
rail traffic crew of train 9869.
Submissions
Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the Australian Transport Safety Bureau (ATSB) may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.
A draft of this report was provided to Queensland Rail, the driver of the heavy road vehicle, the operator of train 9869 (Aurizon), the crew of train 9869 and the Office of National Rail Safety Regulator (ONRSR).
A submission was received from Queensland Rail. The submission was reviewed and, where considered appropriate, the text of the report was amended accordingly.
Purpose of safety investigations
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.
On 25 June 2017, the ATSB commenced an investigation into a near collision between a Track Maintenance Vehicle (TMV) NK83 and freight train 4190N due to a signal irregularity at Islington Junction, NSW.
At approximately 1020 (AEST) on 25 May 2017, a TMV NK83 travelling to Port Waratah was stopped by the Australian Rail Track Corporation (ARTC) train control at Signal IJ25. The crew in the rear locomotive of NK83 noticed that although they were foul of the Up main, the signals were clear for rail traffic to pass through. Soon after this, freight train 4190N was seen operating on the Up main headed towards NK83. The crew in the rear locomotive of NK83 made an urgent request to move NK83 forward to avoid a being struck by 4190N. NK83 moved forward and avoided being struck by 4190N.
ATSB’s preliminary evidence collection revealed:
The signalling system at Islington junction was upgraded in 2007. The upgrade of the interlocking system did not include a risk control which previously prevented conflicting train movements at the junction.
ARTC have since changed the interlocking system to manage the risk of conflicting movements at Islington Junction.
Since the incident, ARTC have inspected similar crossings and confirmed that the missed interlocking risk control was isolated to the crossing at Islington Junction.
Following ARTC’s confirmation that the incident was isolated to the crossing at Islington Junction, the ATSB considered it was unlikely that further ATSB investigation would identify any systemic safety issues. As such, the ATSB has discontinued this investigation.
At about 1035 on 11 July 2017, a Pacific National freight train (8426N) departed Broken Hill, New South Wales (NSW) toward Condobolin (NSW). Train 8426N consisted of two locomotives (8184, 8249) and 27 wagons loaded with lead and zinc. The train was 437 m in length with a trailing mass of 1,998 t.
At about 1540 Eastern Standard Time,[1] train 8426N was entering the Ivanhoe crossing loop and approaching the Cobb Highway level crossing, located about 2.1 km south-east of the Ivanhoe township. The Cobb Highway level crossing was equipped with flashing lights, an audible warning device (bell) as well as passive warning signs posted on the road approaching the crossing.
The Cobb Highway level crossing flashing lights activated at 15:43:16 with the approach of train 8426N. The train was travelling at 69 km/h and was about 300 m from the crossing when the train driver sighted the warning lights ahead were operating. The driver also saw a truck hauling two trailers (road-train) approaching the crossing from the south. The road-train was a Mack Superliner loaded with 43.7 t of road-base material.
The road-train driver was negotiating a sweeping right-hand bend before the road alignment straightened toward the crossing (Figure 1). The road-train driver reported travelling at about 70 km/h approaching the crossing (the posted speed limit was 80 km/h).
Figure 1: Aerial view of Cobb Highway level crossing and road approaches
Source: Google Earth, annotated by ATSB
According to the road-train driver, he saw the flashing lights when the road-train was within 180 m of the crossing. He started to brake but assessed that the road-train might not stop in time, so accelerated to cross ahead of the train.
The train driver saw the road-train decelerate and then increase speed. The driver reported that he sounded the locomotive’s horn when it was about 190 m from the crossing. Shortly after, he saw the road-train enter the level crossing. Data from the train’s event recorder showed that about 100 m from the crossing, the train driver made an emergency brake application and activated the ‘emergency in progress’ alarm on the train radio. The train crew then relocated to the floor of the locomotive cab in preparation for a collision.
Train 8426N subsequently collided with the near side rear corner of the last trailer of the road-train (Figure 2), travelling a further 319 m before stopping. Shortly after, the train driver reported the collision to the Australian Rail Track Corporation Junee Network Control Centre. The train crew and the driver of the road-train were shaken but otherwise unhurt.
Figure 2: Collision damage to the locomotive and the last trailer of the road-train
Source: NSW Police, annotated by ATSB
Australian Standards
Australian Standard AS 1742.7:2016 Manual of uniform traffic control devices – Railway crossings prescribes the requirements for road markings, roadside signs and configuration of active traffic controls at railway crossings throughout Australia.
The traffic controls installed at the Cobb Highway railway crossing comprised flashing lights, an audible warning device (bell) as well as road surface markings and passive warning signs on the road approaches to the crossing. The active traffic controls at the Cobb Highway railway crossing were consistent with the requirements of AS 1742.7.
Australian Standard AS 1742.7:2016 required that flashing signals commence activation a minimum of 20 seconds prior to the arrival of a train. Australian Standard AS 7658:2012 Railway Infrastructure -Railway Level Crossings stipulated that flashing light warning signals commence activation a minimum of 25 seconds prior to the arrival of a train.
The intent of the two standards (when lights commence flashing) is to allow road vehicles:
to stop before entering the crossing,
if unable to stop, to traverse and clear the crossing, before a train arrives.
AS 7658:2012 – item ‘4. Track & Civil’, section 4.1 clause 2(a) and 2(b) refers to the Austroads guidelines and at clause 3(a) sight distances, obstructions, and clause 3(b) time for road vehicles to traverse and clear the railway crossing. However, there are no specific guidelines for assessing sighting distance requirements for locations with active/flashing light control, or for locations where the requirement to negotiate curved approaches creates potential for compromised driver perception.
The flashing lights at the Cobb Highway level crossing were operating for 39 s before the arrival of train 8426N at the crossing. NSW Road Rules 2014, Part 10, Section 123 stipulates that a road user must not enter a railway crossing if the warning lights (or bell) are operating.
Road-train driver
The driver of the road-train reported being very familiar with the crossing, having used it on many occasions over the previous month, including multiple times on the day of the occurrence. During this time, the driver recalled only two instances of encountering a train.
On the day of the occurrence, the driver had completed a number of trips across the Cobb Highway level crossing. He noted that when travelling in a westerly direction later in the afternoon, a combination of sun glare and dust on the prime mover’s windscreen can reduce visibility ahead.
The driver stated that the alignment of the sweeping ‘S’ bend road approach and roadside vegetation meant that sighting of the flashing lights was also restricted until the vehicle had travelled through the bend and was within 180 m from the crossing. On sighting the level crossing operating, the driver assessed that there was now insufficient distance to stop the road‑train prior to it entering the crossing.
Previous occurrences
The ATSB has investigated 28 accidents at level crossings since 2002, many involving heavy road vehicles. On 23 September 2015, a collision occurred between a road-train and grain train at a protected level crossing near Narromine, NSW. The road approach to the level crossing contained a sweeping right-hand curve. The road-train driver sustained fatal injuries in the collision. The ATSB report, RO-2015-016Collision involving road-train truck andtrain 8834N is available from the ATSB website.
The ATSB found that although the truck driver was probably travelling too fast for the prevailing conditions, the driver’s attention was probably focused on negotiating a sweeping right-hand curve that preceded the crossing, at a critical time when he needed to check for the activation of the crossing. The ATSB concluded that it was likely that when the driver perceived that the flashing lights were operating, he was too close to the crossing to stop, and collided with the train.
The ATSB identified a number of areas of potential improvement related to road design signage and standards associated with railway crossing traffic control, especially with respect to curved approaches before railway crossings. In response to the ATSB findings, Standards Australia commenced a review of AS 1742.7:2016, with respect to railway crossing approaches, in particular curved approaches, and the location signage.
Standards Australia received the project proposal for a Revised Text Amendment (RTA) to AS 1742.7:2006 in early 2017. The committee met on 9 August 2017 to initiate the project and established a working group to commence drafting the RTA. It is anticipated the standard will be published in the last quarter of 2018 subject to Standards Australia standards development process. The committee reviewed a draft of the ATSB investigation report for the 11 July 2017 occurrence and concluded there was no need to carry out any further amendment for update to AS 1742.7 beyond the scope of the current revision.
Safety analysis
The active level crossing warning equipment was consistent with the requirements of both AS 1742.7:2007 and AS 7658:2012. The driver of the road-train was traversing a sweeping bend on the approach to the Cobb Highway level crossing when he noticed the flashing lights were operating during his approach. The driver believed there was now insufficient time to stop the vehicle before entering the level crossing. He accelerated in an attempt to clear the level crossing ahead of the approaching train 8426N and avoid the potential for a collision between the prime mover or trailers and the train. However, the train collided with the rear trailer of the road-train. It is likely that one or more of the following factors affected the truck driver’s timely recognition of the flashing lights:
focus on negotiating the curved approach to the crossing
roadside vegetation
frequent use of the level crossing combined with infrequent train presence.
Findings
These findings should not be read as apportioning blame or liability to any particular organisation or individual.
It is likely that the truck driver did not look for, or sight, the activated flashing lights until relatively close to the crossing. This was probably due to one or more of: focus on negotiating the curved approach to the crossing, roadside vegetation and/or not expecting a train to be present.
On sighting the level crossing lights and approaching train, the truck driver assessed there was insufficient available distance to stop the heavily laden road-train truck before the level crossing. Consequently, the truck driver accelerated and entered the crossing while the flashing lights were operating, contrary to the New South Wales road rules.
Safety message
It is imperative that road vehicle drivers always approach railway crossings with extreme care. The level of care and attention required increases as road vehicle gross mass increases.
Although motorists are primarily responsible for avoiding a collision with a train at railway crossings, prudent road design and/or advance warning of a train’s presence at railway crossings should be considered as a strategy to lower the risk of road and rail vehicle collisions.
Road and rail authorities should consider measures to enhance the awareness of motorists approaching railway crossings, especially at locations with restricted sighting due to curved approach roads.
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, a limited-scope, fact-gathering investigation was conducted in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
On March 12, 2017, at about 1015 UTC a pilot and a passenger departed on a private flight from Margate Airport (FAMG) to Light flight Airfield, Cato Ridge, South Africa in a Jabiru UL registered ZU-FIC. The pilot reported that twelve minutes into the flight the aircraft started to lose airspeed. The pilot then set the power to idle and observed the propeller detach from the engine. During the subsequent forced landing in a cane field, the right main wheel broke off. The aircraft then veered to the right and impacted an embankment at which point the nose gear collapsed. The pilot and passenger both sustained minor injuries while the aircraft sustained substantial damage. The South African Civil Aviation Authority (SACAA) commenced an investigation.
As Australia is the State of Design of the aircraft, the ATSB requested to be appointed as an accredited representative to the SACAA investigation in accordance with clause 5.18 of Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation. An ATSB investigator was appointed as accredited representative to the SACAA. To facilitate support to the SACAA investigation, the ATSB also initiated an investigation under the Australian Transport Safety Investigation Act 2003.
The CAA have released the final report into this investigation. Any enquires relating to the investigation should be directed to the SACAA at: http://www.caa.co.za/Pages/Default.aspx
At 0901 Eastern Standard Time[1] on 14 July 2017, the Spirit of Queensland (tilt train V976) departed Cairns bound for Roma Street station in Brisbane. The train travelled largely on schedule apart from some minor delays at Tully, Townsville, Bowen Junction, Proserpine, and Mackay.
At about 0047 hours (about 8 minutes ahead of schedule) on 15 July 2017, the train approached the intersection of Denison and William Streets, Rockhampton at 21 km/h (below the posted train speed limit of 25 km/h). Both of the train’s drivers identified that the intersection and its approaches were clear. When the train was in the intersection, both drivers heard a loud bang and a jolt to the power car[2] cab. The operating driver immediately applied the brakes and the train stopped after travelling about 40 m. The driver alighted from the train and found that the train had struck a road vehicle, a white Toyota Camry (Figure 1).
Figure 1: Vehicle and train front cowling damage
Source: Queensland Rail
The train struck the driver’s side of the vehicle causing it to spin and collide with the right-hand side of the train in the direction of travel.
Shortly afterwards, the Queensland Police Service (QPS), Queensland Ambulance Service (QAS) and Queensland Fire and Emergency Services attended the scene.
There were four occupants in the vehicle, two females and two males. The three passengers were conveyed by QAS to Rockhampton Base Hospital with non-life-threatening injuries. The vehicle’s driver was breath tested by QPS and returned a reading below the blood alcohol concentration limit. The vehicle driver also underwent drug testing returning a zero reading. The QPS issued the driver of the road vehicle with a traffic infringement notice.
Both train drivers underwent a QPS breath test for alcohol at the scene, and were also tested for alcohol and other drugs by an authorised Queensland Rail (QR) tester, at Rockhampton station. All tests returned zero readings.
Road vehicle
The vehicle involved was a white, 2015 Toyota Camry rental vehicle. A suitably licensed driver was operating the vehicle. The driver did not live in Rockhampton but visited regularly for work. The driver had previously used another active level crossing over Denison Street but had never used the passive William Street intersection.
According to the driver, the vehicle’s windows were open at the time of the incident. Its occupants were actively engaged in conversation and none of them heard the train’s horn. The driver stated that the vehicle was slowed almost to a stop as it approached the intersection before accelerating to cross it. Neither the driver nor the passengers noticed the train until immediately before the collision.
Train V976
Train V976 was the QR-operated tilt train passenger service travelling from Cairns to Roma Street station, Brisbane. The train consisted of two power cars and seven passenger cars, in a push-pull configuration (that is, power car, seven passenger cars, power car). It had a gross mass of 448 t and a length of about 200 m. The train was carrying 148 passengers, with six QR on-board personnel and two drivers.
The train was fitted with a forward-facing video camera and a data event recorder. The video camera footage (Figure 2, sequential frames as identified) showed that the:
A. Train entered a clear crossing with no signs of approaching traffic.
B. Vehicle (indicated by the red arrow) entered the crossing from William Street, ahead of the approaching train.
C. Vehicle continued across the intersection.
D. Vehicle continued with no indication of slowing.
E. Vehicle moved in front of the train, just prior to impact.
F. Train collided with the right-hand side of the vehicle (the smashed glass from the vehicle sprayed over the train windshield).
The data event recorder from the train records various parameters, including time, speed, horn, and lights. The recorded data confirmed that the train’s:
speed was 21 km/h (below the limit of 25 km/h)
driver used the horn in accordance with the rules and procedures, including the approach to the William Street intersection
headlight was on and the flashing visibility lights were activated
driver reacted immediately by applying the brake.
Figure 2: Forward-facing train video camera sequential frames (red arrow shows the position of the road vehicle)
Source: Queensland Rail, annotated by ATSB
The level crossing
The level crossing at William Street, Rockhampton was a public level crossing located at the 639.805 km mark on the North Coast Line, Rockhampton. The North Coast Line at this location consisted of a single bi‑directional track, which runs between and parallel to the two vehicle carriageways on Denison Street. The designated maximum track speed was 25 km/h. There were about 28 train movements per day on this section of the track. The majority of those movements were freight.
The intersection of Denison and William Streets was a level crossing with passive controls (stop and warning signs), Figure 3. Queensland Rail defined passive control as:
Control of the movement of road vehicles or pedestrians across a crossing by signs and devices, none of which are activated by the approach of a train and rely entirely on the road user / pedestrian observing the signs and detecting the approach or passage of a train by observation.
Figure 3: The level crossing intersection (the red arrow indicates the train movement and the yellow arrow indicates the movement of the road vehicle)
Source: Google Maps
There were warning signs on William Street situated appropriately along the road in the approach to Denison Street (Figure 4). The designated speed limit on Denison Street was 50 km/h and 60 km/h on William Street. Queensland Rail found the approach signage was serviceable and appropriate.
Figure 4: Intersection signage
Source: Google Maps
Additionally, the required sighting distances met the minimum requirements for the type of protection and road rail approach speeds. The intersection of Denison and William Streets level crossing had undergone regular inspections and maintenance by QR.
Figure 5: Intersection sighting
Source: Google Maps
Previous incident
At 0225 on 23 February 2012, the southbound tilt train collided with a vehicle at the intersection of Denison and William Streets. Three occupants of the vehicle suffered non-life-threatening injuries. The circumstances of that past incident were very similar to this one in 2017.
Following that occurrence, on 22 March 2012, QR surveyed the intersection using the Australian Level Crossing Assessment Model (ALCAM). The survey identified several minor non-conformances with sighting distance and signage. Queensland Rail and the Rockhampton Region Council resolved these issues by March 2013.
Safety analysis
Level crossings are the physical interface between road and rail traffic. Both modes of transport operate as separate entities and have different rules, procedures, characteristics and operational limitations. Most importantly though, neither vehicle has advance knowledge of when the other will be encountered at the crossing.
Level crossings with active warning devices are intended to provide road users with a higher level of safety. Even at crossings with active devices (for example, flashing lights and bells), however, the warning of an approaching train is available to the motorist at, not in advance of, the crossing.
Passive control level crossings control the movement of vehicular or pedestrian traffic using signs and devices (such as Give Way and Stop signs), none of which are activated during the approach or passage of a train. These controls rely on motorists (and pedestrians) detecting the approach or presence of a train by direct observation. There are more than 6,000 passive level crossings in Australia. This type of protection is generally used where the volume of road and rail traffic makes the risk of a collision relatively low.
Stop sign traffic control is used at level crossings where the sighting distance is such that a motorist is unable to see an approaching train in time to stop before its arrival at the crossing. This traffic control method requires a motorist to stop at the crossing, visually look in both directions and, if no train is seen or heard, then safely proceed. If a train is seen or heard, the motorist must remain stationary at the Stop sign until it is safe to proceed. Motorists are required to have this knowledge for a driver’s license and drivers encounter Stop signs routinely and follow the same process of stop, check, and wait/go. Despite that requirement, there have been many accidents at Stop sign-protected crossings because of the motorist’s failure to stop.
Findings
These findings should not be read as apportioning blame or liability to any particular organisation or individual.
The driver of the road vehicle did not see or hear train V976 approaching the level crossing and drove in front of the train immediately before the collision.
Safety action
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.
Queensland Rail
Queensland Rail has advised the ATSB that the Manager, Road Rail Interface will conduct a review of the level crossing at the intersection of Denison and Williams Streets, Rockhampton.
Safety message
This incident is a reminder that all road vehicle drivers using railway level crossings equipped with passive controls need to be vigilant, observe road-warning signs, obey road rules and look out for trains.
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
Ownership of intellectual property rights in this publication
Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia.
Creative Commons licence
With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence.
Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work.
The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau
Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.
On 4 July 2017, a Eurocopter AS350-BA helicopter, registered VH-PHU and operated by Professional Helicopter Services, was chartered to conduct a flight between Moorabbin Airport and the Jack Rabbit Vineyard helicopter landing site (HLS)[1],[2] on the Bellarine Peninsula, Victoria. At about 1415 Eastern Standard Time,[3] while landing at the HLS, the tips of the helicopter’s main rotor blades struck an encroaching bush (Figure 1).
Figure 1: Smart phone footage of the main rotor blade tip strike (into bush)
Source: Allister Gleeson
History of the flight
At about 1310, the pilot volunteered at short notice to conduct the charter flight to the Jack Rabbit Vineyard. As the pilot had not previously flown to this HLS (a tennis court), he discussed the landing site with another experienced company pilot. Their discussions included consulting Google earth and ascertaining the safest way in and out of the landing site (Figure 2). The pilot also spoke with staff at the vineyard to inform them of his planned arrival and, at their request, confirmed that he would make his approach from the north, so as not to overfly the vines.
At about 1340, the flight departed Moorabbin Airport about 40 minutes later than originally planned. With two passengers on board, the pilot flew south for a scenic coastal flight via Port Phillip Heads, to the Bellarine Peninsula. The reported weather for the flight was for visibility greater than 10 km and a northerly wind at 10-15 kt.
On arrival, the pilot recognised the features of the HLS from his pre-flight planning and conducted a north-to-south, downwind approach,[4] which was appropriate for the conditions on the day.
During the approach, the pilot identified the key boundaries of the landing site, which included a brick wall at the southern end of the site, but he did not see a large bush that encroached into the HLS. When established in the HLS, and believing that he had to make way for another helicopter, the pilot slowly hover-taxied the helicopter forward towards the south‑west corner of the landing site. During this, the pilot reported that he remained focused on the brick wall ahead (Figure 2).
Figure 2: Jack Rabbit Vineyard HLS
Source: Google Maps, modified by the ATSB
At about 1415, the tips of the helicopter’s main rotor blades struck the encroaching bush (now on the helicopter’s right side) (Figure 3). The pilot initially landed the helicopter, then soon after repositioned clear of the bush.
Figure 3: Encroaching bush in the HLS and the main rotor blade strike area
Source: Operator, modified by the ATSB
The helicopter was subsequently shut down and secured without further incident. There were no injuries. All three of the helicopter’s main rotor blade tip caps were found damaged (Figure 4). The sequence of the incident was captured on a smart phone and subsequently reviewed by the ATSB.
Figure 4: Damage to VH-PHU rotor tip caps
Source: Operator
Pilot comments
Aware of the operator’s mantra to ‘not let commercial pressures influence the way you fly’, the pilot was content to fly the charter and felt adequately prepared for the flight. However, the pilot reported that, as the HLS was easily recognisable from his pre-flight planning and due to over‑confidence, he elected to abbreviate the usual 360° reconnaissance[5] of the site. Instead, he conducted a sweeping 270° turn about the HLS, prior to his downwind approach into the landing site. The approach to the centre of the HLS was as anticipated.
Before manoeuvring within the HLS, the pilot ensured that the area around the helicopter was free of obstacles, but acknowledged that he did not notice the bush and how far it encroached into the landing site. The pilot commented that he was focusing on the brick wall as he moved forward and had discounted the right side of the helicopter.
Operator’s investigation
Professional Helicopter Services conducted an internal investigation into the incident and concluded the following:
The pilot lost situational awareness from focussing on the brick wall during the final stages of the landing sequence and did not ensure adequate clearance from obstacles on the right side of the helicopter.
The pilot, having recently been cleared to fly advanced manoeuvres, may have felt ‘overconfident’ in his general flying abilities at the time of the incident.
The operator was not aware that the pilot had not previously landed at the HLS.
The pilot had mistakenly believed that another helicopter was also required to use the HLS, which was his motivation to hover-taxi.
Safety analysis
The pilot’s confidence in his abilities influenced his decision to conduct an abbreviated reconnaissance of the HLS. This removed an opportunity to observe the encroaching bush. This, combined with the pilot’s focus of attention on the brick wall in front of the helicopter when landing, meant that he was not aware of the bush to his right.
Further, the pilot believed that another helicopter was also landing at the HLS and he elected to hover-taxi to the south-west corner of the site to provide room for that helicopter. However, as the pilot was not aware of the encroaching bush when conducting this manoeuvre, the helicopter’s main rotor blades struck the bush.
Findings
The findings should not be read as apportioning blame or liability to any particular organisation or individual.
An abbreviated reconnaissance of the helicopter landing site, along with a focus of attention on other obstacles within proximity, resulted in the pilot not being aware of a bush encroaching the helicopter landing site and the helicopter’s main rotor blades striking the bush.
Safety action
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action(s) in order to manage and mitigate their safety risk. The ATSB has been advised of the following safety actions in response to this occurrence.
Professional Helicopter Services
As a result of this incident, the operator has advised the ATSB that they have taken the following safety actions:
reviewed internal flight tasking processes
updated and upgraded internally provided HLS documentation, and provided this information electronically (iPad)
learning outcomes from this incident are to be incorporated into future practices and disseminated to all pilots and aircrew.
Safety message
This incident highlights the need for a heightened situational awareness by pilots when operating in the vicinity of obstacles as there is very little or no margin to recover from any unexpected event(s). This is particularly important when operating into a confined area and unfamiliar location.
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, a limited-scope, fact-gathering investigation was conducted in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
Publishing information
Released in accordance with section 25 of the Transport Safety Investigation Act 2003
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Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.
At about 1800 Central Standard Time[1] on 11 July 2017, a SOCATA TB-10 Tobago aircraft, registered VH-YTG, was conducting a scheduled night flying lesson at Parafield airport, near Adelaide, South Australia. On final approach and at about 500 ft above ground level, the aircraft’s right wing struck an object. The instructor heard a loud thud and the right wing suddenly dropped. He radioed the control tower requesting a full stop landing, as they might have hit a bird.
After landing, the instructor conducted an inspection of the aircraft and found minor damage to the right wing. As there were no visible signs of biological matter, he contacted the control tower and reported the incident as a possible drone strike.
Figure 1: VH-YTG showing damage
Source: ATSB
Figure 2: Overhead image highlighting identified surface marks
Source: ATSB
The ATSB conducted an inspection of the aircraft, and swab samples of the impact area were taken by the airport operator, and sent to the Australian Museum for DNA testing. The subsequent DNA test results indicated the sample was most consistent with that of a grey-headed flying-fox, from the bat family.
The ATSB has assessed that there is little potential for the enhancement of transport safety through further investigation of this occurrence. The ATSB has discontinued the investigation.
