Interim Factual report released 25 May 2006

At about 1040 Australian Eastern Standard Time on 2 January 2006, the pilot of a Cessna Airplane Company U206 aircraft, registered VH-UYB, took off from the parachuting centre at Willowbank, QLD. The aircraft was being flown by one pilot as a private flight, carrying three sport parachutists (jump masters) and three passengers who had paid for the proposed tandem parachute jump. Witnesses reported that during the initial climb, the aircraft did not gain height as expected. It impacted a 23 m (75 ft) high tree approximately 1,200 m from the end of the runway before descending from view. Of the seven persons on board, all but two were fatally injured.

Abstract

At about 1540^[1] on 23 March 2009, freight train 7GP1 collided with a school bus after the bus drove onto, and became stuck on, an excavated section of railway track at the Nulla Nulla South Road level crossing near Moorine Rock, Western Australia. There were no injuries as a result of the collision but there was significant damage to the school bus.

The investigation determined that the collision occurred as a result of the bus being driven around road closure signs and onto a level crossing worksite which was closed for the purpose of replacing rail that was embedded in the road surface. A minor safety issue, unrelated to the development of the accident sequence, was identified during the investigation and has been brought to the attention of the train operator. That safety issue relates to overdue safe working qualifications of train staff. The ATSB is satisfied that the action taken and proposed by the train owner, including the introduction of more robust procedures for checking the currency of operator competencies, will adequately address the safety issue.

Executive summary

At about 1515 on 30 January 2009, northbound freight train 6MB2, owned and operated by Pacific National, derailed near the beginning of a left-hand curve located near the 8.915 track km point in Tottenham, Victoria. In total, 8 wagons derailed and about 400 m of timber sleepered track was damaged. Damage to rolling stock was minimal and there were no injuries as a result of the occurrence.

At the time of the derailment, major infrastructure works between Melbourne and Sydney were being carried out to improve the general track condition and operating efficiency on the standard gauge rail corridor.

Train 6MB2 derailed as it passed over a section of mainline track in the Tottenham Yard precinct that contained a build up of longitudinal rail stress after three consecutive days of very high ambient temperatures. Due to the extreme weather conditions, the Australian Rail Track Corporation had implemented heat speed restrictions for train operators between Tottenham and Albury, restricting trains to speeds not greater than 60 km/h.

When train 6MB2 approached the left-hand curve near the Ashley Street Bridge, the train crew observed that a small lateral misalignment had developed in the track. During the passage of the train the dynamic movement of the rail vehicles added sufficient force to increase the size of the misalignment as the train passed over it. A container flat wagon (NQKY 34695L), 31st in the consist, was the first vehicle to derail and it was positioned near the rear of the train.

No evidence was found that defective rolling stock components had contributed to the derailment and minor damage to the rolling stock was sustained during the derailment sequence.

The investigation found that as part of the project works, the Tottenham standard gauge passing loop was converted for mainline operation on 28 July 2008. A safety issue was identified where this section of track was not tested after the conversion to mainline to determine if any residual stress was present in the rails and if any treatments were necessary to reduce the likelihood of track misalignments.

Other safety issues identified that creep monuments had not been installed at the east end of the curve near where train 6MB2 derailed and the rails had not been punch marked to allow track inspectors to detect rail creep. In addition, a record of two rail welds carried out at the 8.351 km point on the 30 January 2009 had not been documented for future reference. Attention to both of these items were specific requirements of the V/Line Infrastructure Civil Engineering Circular 3/87.

Following the derailment, the Australian Rail Track Corporation reconstructed this section of track and replaced the timber sleepers with concrete sleepers as part of the Tottenham to Dynon infrastructure track upgrade.

Abstract

At approximately 1031 on Friday 30 January 2009, freight train 5PS6, operated by Pacific National (PN), derailed near Golden Ridge, about 43 km east of Kalgoorlie in Western Australia. The two locomotives, the crew van and 18 wagons (including 7 multiple platform freight wagons) derailed.

There were only minor injuries to the train crew as a result of the derailment. However, there was significant damage to the derailed rolling stock and about 200 m of track was destroyed.

The investigation determined that heavy rainfall to the east of Golden Ridge on the morning of 30 January 2009 led to localised flash flooding which damaged the track formation and ballast, resulting in the derailment of train 5PS6. A number of minor safety issues were identified during the investigation and have been brought to the attention of the track manager and train operator. Those issues relate to track drainage, identification of severe weather events, availability of hand-held communication devices and escape from the damaged locomotive cabin. The train operator has taken or proposed safety action in relation to train evacuation and communication issues. In addition, the Australian Transport Safety Bureau has issued three safety advisory notices to the track owner.

Executive summary

At about 1858 on 14 January 2009, a safeworking irregularity occurred involving two passenger trains, 4SA8, the Indian Pacific, and WT28, an XPT, at Tarana in NSW. Both trains had been authorised to occupy the single line within the Tarana interlocked area at the same time. Fortunately, each driver saw the opposing movement and brought their trains to a stand about 524 m apart. After a short wait, the trains were authorised to continue their respective journeys.

The investigation determined that the West Board network controller located at Broadmeadow train control centre, did not adequately plan the intended train movements through the sections Wallerawang to Tarana and Bathurst to Tarana or determine a specific limit of authority on the Special Proceed Authority (SPA) number 37 issued to the driver of the XPT, WT28. The West Board network controller also issued SPA number 38 to the driver of train 4SA8, even though it overlapped the authority of SPA number 37.

The investigation report indentified three safety issues relating to the risks of using a manual train management system, inadequate auditing of safeworking systems, and ambiguous authority limits.

Abstract

At about 0930 on 21 May 2009, a crew member on board the general cargo ship Thor Gitta was fatally injured while attempting to secure lashing bins in the cargo hold. At the time, the ship was about 390 miles northwest of Fremantle, Western Australia.

The investigation found that a risk analysis had not been undertaken before the bins were introduced into service and that the bins had been inadequately secured in an area where there were no dedicated lashing points. It also found that the crew member was probably affected by fatigue as a result of the duty roster and the ship's movement in the heavy seas.

As a result of this accident, the ship's manager has implemented a range of measures on all its vessels to improve the security of bin lashing arrangements and manage the risks of carrying out tasks associated with operation of the bins. The company has also introduced a different rostering system to better manage the fatigue of watchkeepers when the ship is at sea.

The ATSB has issued one safety recommendation to the Danish Maritime Authority relating to the use of the 6 hour on/6 hour off work routine and the effect that that work routine has on a crew member's level of fatigue.

Abstract

At about 0100 on 16 April 2009, the bulk carrier F & K collided with the Australian fishing vessel Jolly Roger off Groote Eylandt, Northern Territory. While F & K was undamaged, Jolly Roger listed heavily to port as a result of the collision and its crew of three had to abandon the vessel.

The ATSB investigation found that despite Jolly Roger being the 'give-way vessel', its skipper took no action to avoid the collision because there was no lookout being kept on board. Consequently, he was not aware of the ship's presence until immediately before the collision.

The investigation also found that F & K's bridge team had detected Jolly Roger 20 minutes before the collision. However, they mistakenly assumed that their ship was overtaking the fishing vessel because they had not used appropriate means to determine whether a risk of collision existed.

Preliminary report released 14 April 2009

This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

Abstract

At 0312 on 11 March 2009, the Hong Kong registered container ship Pacific Adventurer lost 31 containers overboard in gale force weather conditions and large swells. The ship was about seven miles east of Cape Moreton, Queensland.

All the containers, carrying ammonium nitrate prills, sank. However, two of the ship's fuel oil bunker tanks were holed as the containers went overboard. In all, Pacific Adventurer lost about 270 tonnes of fuel oil into the sea as a result of the damage caused to the bunker tanks.

Executive summary

At 2200 on 6 February 2009, a coastal pilot boarded the products tanker Atlantic Blue for its intended eastbound transit of the Torres Strait. The ship was nearly fully laden with a cargo of unleaded petrol and was bound for Townsville, Queensland.

The passage progressed normally and at 0130 on 7 February, Atlantic Blue's heading was altered to 066º (T). However, no allowance was made for the 25 knot north-westerly wind abaft the port beam and the east-going tidal stream. Consequently, the ship made good a course of 070º (T) and by 0235, it was 1 mile south of the planned track.

At 0237, 0246 and 0256, the pilot made heading adjustments until the ship's heading was 059º (T). These small adjustments did not bring Atlantic Blue back on track as it progressed towards Kirkcaldie Reef. After 0307, as the ship closed on a shoal about 1 mile ahead, the pilot began altering the heading further to port. This course alteration was too little, too late and at 0312, Atlantic Blue's bow grounded on a sandy shoal. The hull remained intact and there was no pollution. At 0700, the ship refloated on the flooding tide and was manoeuvred clear of the reef.

The investigation found that the ship grounded because its progress and position were not effectively monitored by the bridge team and inadequate action was taken to bring it back on track. Bridge resources were not managed effectively, off-track limits were not defined and the bridge team did not have a shared mental model of the passage. The report identifies safety issues in relation to the ship's passage planning procedures; the coastal pilotage check pilot regime and the coastal vessel traffic service's monitoring system. Safety actions to address all the issues have been taken or proposed by the relevant parties.

Preliminary report released November 2008

This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

Abstract

At approximately 1335 on 4 November 2008, freight train 3DA2 derailed about 6 km south-west of Katherine in the Northern Territory. Six wagons derailed and sustained minor damage and about 1,300 m of track was destroyed. There were no injuries.