Abstract

At about 1655 on Tuesday 11 November 2008, freight train 2PM6 derailed on the Nullarbor Plain approximately 11 km west of Loongana in Western Australia. There were no injuries as a result of the derailment but there was significant damage to rolling stock and track. The investigation found that the combined effects of atmospheric wind and induced wind due to train movement was likely to have been sufficient to initiate the overturning and subsequent derailment of a lightly loaded, double stacked wagon and other vehicles. Two safety issues were identified relating to the suitability for double stacking of certain wagon types, particularly in high-wind operations, and maintenance of container securing mechanisms. The train operator has taken safety action to address those issues.

Executive summary

At approximately 2130 on 1 September 2008, 13 wagons on freight train 1MP9, owned and operated by SCT Logistics (SCT), derailed near Mt Christie, South Australia. There were no injuries, but about 4.5 km of track was damaged.

The investigation concluded that an axle-box bearing on wagon VQCY 0824U had failed and completely seized, causing the bearing journal to separate from the axle (commonly referred to as a screwed journal). Examination of the bearings suggested that inadequate lubrication had contributed to cage failure with the subsequent misalignment of the rollers and jamming of broken cage material in the rolling surfaces causing the bearing to seize. Maintenance records showed that the bearings on wagon VQCY 0824U were new in July 2004 and the wagon underwent servicing in May 2006 and May 2007. However, it is unlikely that the axle-boxes were re-greased during servicing as required by the maintenance procedures.

SCT has implemented a number of actions aimed at reducing their risk of future derailments due to axle-box bearing failures. Those actions included immediate scheduling for regreasing, a program to remove all axle-box equipped bogies from SCT's service and a trial to install on-board monitoring for hot bearings on their freight rolling stock.

Though not contributing directly to the derailment sequence, a minor safety issue was identified in relation to documented procedures at crossing loops. ARTC has proposed relevant safety action to address the issue.

Executive summary

At approximately 0650 on 19 April 2008, freight train 5PS6, travelling from Perth to Sydney, derailed near Bates, SA. The derailment occurred about 13 track kilometres east of Bates. Thirteen wagons were derailed and about 800 m of track was damaged. There were no injuries.

The investigation concluded that an undetected crack at an unused bolt-hole increased in size until the rail completely fractured. The rail probably failed under the previous train (5MP5). As the wheels of train 5PS6 passed over the fracture, the impact forces caused the progressive failure of sleepers, a secondary rail fracture and the ejection of a small section of rail. Once a section of rail was missing, the impact forces on the rail increased significantly, causing the progressive failure of rail and sleepers until the freight wagons inevitably derailed.

The investigation acknowledged that new maintenance procedures were issued to reduce the risks related to bolt-hole cracks. However, the Australian Transport Safety Bureau has issued two safety advisory notices, concluding that there were further opportunities for improvement relating to:

• additional development of the ultrasonic testing process aimed at reducing operator dependence
• the relationship between heat-affected metal and stress concentration when specifying how far a bolt-hole should be from the rail ends before welding.

Preliminary report released 4 September 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 approx 2030 on 31 July 2008, Pacific National (PN) steel freight train 5WX2N (Wollongong to Port Augusta) derailed at about the 204 km post from Melbourne (about 8 km north of Benalla, Victoria) near Winton in the section between Beltana & Glenrowan Loop.  No person was injuried but approximately 800 to 1000 m of track was damaged and 13 wagons were derailed.  Of these, approx 6 remained upright, the other 6 or 7 were on their side, some down an embankment, and 2 or 3 were fouling the broad gauge line.  The first derailed wagon was about 25th in the consist.

Abstract

At about 1932¹ on 30 March 2008, freight train 1MA6Q, travelling from Melbourne to Adelaide, derailed on the Mt Emu Creek bridge near Pura Pura, Victoria. Twenty-one wagons derailed, coming to rest on the track past the bridge abutment. As a result of the derailment, some containers burst spilling their contents onto the rail corridor and the adjacent public road.

The investigation determined that the derailment occurred as a result of a failed rail due to fatigue cracking emanating from an unused bolt-hole.

Rail safety recommendations

[ RO-2008-004-SR-011] [ RO-2008-004-SR-012]

1. The 24-hour clock is used in this report to describe the local time of day, Eastern Daylight Tme (EDT), as particular events occurred.

Abstract

At 0750 on 11 March 2008 a northbound freight train, numbered 2WB3, passed the outer home signal at red without authority at Gloucester, NSW. Gloucester is located about 140 km north of Broadmeadow (suburb of Newcastle) on the main Sydney to Brisbane rail line. There were no injuries or damage as a result of this incident.

Executive summary

At about 1815 on 24 December 2008, the Australian registered floating storage and offloading tanker, Karratha Spirit, began disconnecting from its mooring buoy at the Legendre Oil Field, about 60 miles north of Dampier, Western Australia, because of an approaching tropical cyclone.

The master was on the forecastle, directly controlling the operation. Before the mooring hawsers could be released from the ship, the import hose drifted under the hawsers and he ordered the main engine to be run astern for about 1 minute in an attempt to pull the hose clear. At about 1954, after the wire suspending the oil import hose parted suddenly, the master ordered the crew to finish letting go the hawser pickup lines so that the ship could depart the mooring buoy.

An integrated rating applied the port winch drum's brake to stop the drum moving and then stepped between the cheeks of the drum to cut the lashing that held the end of the heavy hawser pick line on the drum. At about 1958, when the lashing parted, the last three turns of heavy line rapidly unwound from the drum, striking the rating on the head and throwing him under the winch drum. He died as a result of his injuries.

The ATSB investigation found the procedures for connecting and disconnecting from the mooring buoy had not always been followed and that the difference between the procedures and shipboard practice had not been identified during any shipboard review and the risks associated with this amended practice had not been assessed.

The investigation also found that it is possible, under some circumstances, that facilities like Karratha Spirit can fall outside the jurisdiction of the safety regulators. The report issues one recommendation and one safety advisory notice to address these safety issues.

Abstract

At about 14151 on 10 March 2008, train 6MP9 was carrying containerised general freight from Melbourne to Perth when it derailed 11 wagons near Hines Hill in Western Australia. Although there were dangerous goods on the train, they were not involved in the derailment.

The investigation determined that wagon ABFY2797U derailed due to a 'screwed journal' as a result of a wheel bearing failure.

Executive summary

At 1428 on 13 December 2008, the Hong Kong registered container ship APL Sydney's starboard anchor was let go in Melbourne anchorage. Four minutes later, the pilot left the bridge and by 1436, he had disembarked the ship. The 35-knot south-southwest wind was gusting to 48 knots. A submarine gas pipeline lay 6 cables (1.1 km) downwind.

By 1501, after dragging its anchor, the ship was outside the anchorage boundary. The master advised harbour control he intended to weigh anchor and was instructed to maintain position and wait for a pilot. At 1527, when weighing anchor was started after receiving permission from harbour control, the ship was within 50 m of the pipeline. While weighing anchor, the anchor dragged across the pipeline, snagged it at about 1544 and, subsequently, the anchor windlass failed.

At 1603, the pilot returned to the ship and, after discussions with the master and harbour control, he decided to dredge the anchor clear. At 1621, less than 1 minute after APL Sydney's main engine was run ahead, the pipeline ruptured. There were no injuries, and the pipeline was isolated.

The investigation found that the rupture was the result of attempting to dredge the anchor instead of slipping it. The anchor had also been let go too close to the pipeline in the poor weather conditions. The report identifies safety issues in relation to the port's risk management with respect to the pipeline and anchorage boundaries and its shipping control procedures; the ship's safety management system with respect to passage planning, the master's authority, crew familiarisation and the working language; the pilotage company's procedures for anchoring and mobile telephone use; and the windlass failure. Safety actions to address all the issues have been taken or proposed by the relevant parties.

Executive summary

At about 2117 on 24 November 2008, while preparing the ship to sail from Townsville, Queensland, a crew member on board the Maltese registered container ship Spirit of Esperance was injured after falling about 4 m during an operation to stow the number three cargo crane hook.

Immediately following the fall, the crew member was treated by the ship's crew and, shortly afterwards, by ambulance officers. He was then transferred to hospital where he later died as a result of the injuries he had sustained.

The Australian Transport Safety Bureau (ATSB) investigation found that the design of the cargo crane hook cradle did not allow for unassisted stowage of the hook when the ship had a stern trim in excess of 2.1 m; there were no guidelines or procedures available on board the ship to assist the crew with the task of stowing the cargo crane hook when it was misaligned from its cradle; the crane operations job safety analysis did not identify the risks associated with stowing the hook in these circumstances; and when the ship's stern trim was in excess of 2.1 m, the ship's crew routinely violated the working aloft procedure by climbing the emergency ladder adjacent to the hook's cradle without a permit or appropriate personal protective equipment.

The investigation also found that the deceased crew member was probably under the influence of alcohol at the time of the accident, and this may have adversely affected his reaction time, balance and cognitive ability. The ATSB acknowledges the safety actions taken by ASP Ship Management to address these safety issues and, in addition, has issued three safety advisory notices.