Executive summary

At approximately 1417 on 13 December 2007 a tandem tip truck loaded with a 'bobcat' excavator drove into the side of the Indian Pacific passenger train (4SA8) at the passively controlled level crossing of Moloney Road near Virginia in SA. As a result of the collision, the truck driver was seriously injured. The locomotive drivers were shaken but not hurt. There were no injuries to passengers or the train's hospitality staff.

The investigation concluded that the accident occurred because the driver of the truck entered the level crossing while a train was on the crossing and that he did not come to a halt at the level crossing 'Stop' sign. It is likely that the truck driver was not expecting a train at the level crossing and accordingly did not stop.

Safety actions recommended as a result of the investigation include a review of the Australian Level Crossing Assessment Model (ALCAM) with respect to assessing the risks associated with level crossings having a history of incidents/accidents and measures to reduce the road/rail interface risk at the Moloney Road level crossing.

Rail Safety Recommendations [ RR20080026 ] [ RR20080027 ] [ RR20080028 ]

Abstract

At approximately 0935 on 16 November 2007 a small passenger van drove into the path of a Patrick Portlink freight train (6117) at the Moloney Road passive level crossing (Figure 1) near Virginia in SA. As a result of the collision, the two occupants in the van were fatally injured. The locomotive crew were shaken but not hurt. The train sustained minor damage but the van was destroyed.

Executive summary

At about 0400 on 17 August 2007, the 48th wagon of Australian Railroad Group iron ore train 6413 derailed on a right-hand curve in a cutting 595.9 km from Perth in the Stewart to Bonnie Vale section of the Defined Interstate Rail Network in Western Australia. Thirty one wagons in total were derailed and 25 of those wagons were seriously damaged. There were no injuries. The track sustained significant damage and was closed for 4 days.

Train 6413 consisted of three locomotives and 126 wagons loaded with iron ore. It was travelling from Koolyanobbing to the port of Esperance, via Kalgoorlie. Rail traffic in this area includes fast passenger trains, general interstate freight and iron ore trains.

Train 6413 had been authorised by train control to pass a signal that had failed to clear following the passage of the previous train. Both the train controller and the train crew were aware that one possible cause of the signal failure was a broken rail.

The Australian Transport Safety Bureau (ATSB) investigation determined that the derailment occurred when a piece of rail containing a large, previously undetected vertical split head defect, disintegrated under train 6413. A rail insert that had recently been used to replace a section of defective rail found during a routine track inspection probably contained the defect. Alternatively, it was possible, but less likely, that the parent rail on either side of the insert may have contained an undetected vertical split head.

As a result of the investigation, the Australian Transport Safety Bureau identified a number of safety issues concerning train operations, record keeping and rail replacement practices.

Executive summary

At about 1135 on Monday 6 August 2007, a loaded sewage truck drove into the path of the south-bound passenger train, The Ghan (7DA8), at the Murrow Farm level crossing near Two Wells, South Australia. The driver of the truck was seriously injured and the truck was destroyed. The train's lead locomotive was severely damaged in the collision but the train driver was uninjured. Two minor injuries were recorded by passengers on the train and there was minor damage to the track.

The investigation found that there was insufficient sighting distance for the truck driver to see The Ghan approaching from the north before he crossed the railway track. There was vegetation growing adjacent to the rail track which impeded the sighting for the driver of the truck and the maintenance practices for the clearing of vegetation at the Murrow Farm level crossing were inadequate to maintain effective sighting of trains. Programmed works that had identified the vegetation as a sighting hazard which was to be rectified within 28 days, had not been carried out in accordance with the relevant maintenance specification. The maintenance priority had been revised from 28 days to 180 days without a reassessment of the sighting hazard.

As a result of this investigation, the ATSB has identified safety issues primarily related to maintenance practices for the control of vegetation in the rail corridor which require action to reduce the risk of future collisions at this and other level crossings. The ATSB also acknowledges safety action already undertaken by the Australian Rail Track Corporation in response to identified safety issues.

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At about 0040¹ on Sunday 10 June 2007, westbound freight train 6MP9 derailed at the 716.7 km mark² near Bates in SA.

There were no injuries as a result of the derailment, however, there was significant damage to the track and rollingstock. Of 10 wagons that separated from the train, four overturned.

The investigation found that a broken rail, emanating from a transverse rail defect, had probably caused the derailment.

1 The 24-hour clock is used in this report to describe the local time of day, Central Standard Time (CST).

2 Distance in kilometres from a track reference point located at Coonamia in SA.

Executive summary

At approximately 0428 on 22 May 2007, ballast train 3MR2 derailed near Roopena, SA (between Whyalla and Port Augusta). The derailment occurred about 28 track kilometres north of Whyalla. Twenty seven ballast wagons were derailed but there were no injuries.

The investigation concluded that a number of factors combined to cause the derailment. A crosslevel track geometry defect caused body roll on the first wagon to derail which led to dynamic unloading of the wagon's leading, right-hand wheel. When combined with a horizontal and vertical alignment defect, wheel unloading increased further and the right-hand wheel moved into flange contact with the right-hand rail such that the risk of a flange-climb increased at the point of derailment. Non-compliant side bearer gaps, uneven load distribution and the wagon's sensitivity to spring compression length also combined to cause the front left-hand suspension springs to become fully compressed thereby increasing the amount of wheel unloading at the point of derailment.

All these factors combined to indicate that body roll, spring compression, train speed, wheel unloading and flange contact at the point of derailment were of sufficient magnitude that a flangeclimb derailment would be expected to occur. A range of safety actions were taken or recommended to seek to prevent similar incidents in the future.

Rail Safety Recommendations [ RR20080029 ] [ RR20080030 ]

At 1915 on Monday 14 May 2007 a south-west bound Australian Railroad Group mineral train collided with a south-east bound motor vehicle which was traversing the Chapple Street level crossing in Kalgoorlie, WA. The driver of the car sustained minor injuries, the train drivers were uninjured.

ATSB investigators established that the flashing lights, bells and boom gates did not operate at the time of the accident. The investigation found that a temporary wiring strap had inadvertently been left in place by engineering staff while making modifications to signalling circuitry and while procedures governing the use of the temporary wiring straps existed, this did not prevent the mistake.

In the interest of enhancing future road/rail safety, WestNet Rail, the company responsible for the maintenance of level crossing, has adopted recommendations that address various safety issues, including the need to re-examine risk assessment and engineering maintenance/testing procedures.

Rail Recommendations [ RR20070028 ] [ RR20070029 ] [ RR20070030 ] [ RR20070031 ]

Executive summary

At approximately 1830 on Saturday 10 March 2007, a semi-trailer partially loaded with hay bales drove into the path of empty grain train 3835 at the Tallabung to Back Creek Road level crossing, NSW. The semi-trailer driver was fatally injured in the collision.

The train derailed and, with the crushed semi-trailer underneath the leading locomotive, travelled 144 m further onto and over the timber and concrete rail bridge over the Back Creek watercourse. The leading locomotive came to a rest off the track on the embankment past the bridge; the other two locomotives came to rest on the bridge.

The wreckage caught fire following the collision, ultimately destroying all three locomotives, the bridge superstructure and the semi-trailer. The train crew, although injured, were able to exit the leading locomotive and escape from the fire.

The investigation found that the semi-trailer driver drove into the path of the train without stopping at the level crossing's 'Stop' sign. On the evidence

Executive summary

On the afternoon of 2 December 2007, the Australian registered bulk carrier Endeavour River grounded in Gladstone harbour while attempting a mid-tide berthing at the South Trees Wharf.

The master was attempting to berth the ship on a flood tide, with a following wind, and was unable to position the ship correctly for its approach to the berth. Even with the use of two attending tugs, he was unable to counteract the tidal influence. Throughout the berthing manoeuvre, only the master, the chief mate and the deck cadet were on the bridge.

The ship grounded in the vicinity of A1 beacon at the entrance to the Auckland Channel, destroying the beacon in the process. Despite the assistance of all five of the port's tugs, the ship could not be refloated at that time.

On 7 December, Endeavour River was successfully refloated on the morning high tide and manoeuvred with the aid of tugs to South Trees Wharf.

The investigation found that bridge resource management principles were not practiced by the bridge team and that no monitoring of the passage took place during the time leading up to the grounding. In addition, the bridge team lost situational awareness prior to the grounding. They became fixated on trying to berth the ship and were not responsive to other cues which would have alerted them that the ship was being set down into an area of shallow water.

The report identifies a number of safety issues and acknowledges safety actions which have been taken by ASP Ship Management and Maritime Safety Queensland to address those issues.

Abstract

At about 0036 on 30 November 2007, the liquefied petroleum gas (LPG) tanker Namhae Gas collided with the fishing vessel Rexandra. At the time, both vessels were about 30 miles northeast of Mooloolaba, Queensland.

Neither Namhae Gas's watch-keeper nor duty lookout was keeping a proper lookout in the time leading up to the collision. They also assumed that a collision between their ship and Rexandra had not occurred. Consequently, the second mate did not immediately report the incident to the ship's master, and he made no attempt to contact the damaged fishing vessel.

While Rexandra's skipper was aware that the ship was approaching the fishing vessel, he did not take early action when he became aware that a risk of collision existed.

Namhae Gas did not sustain any damage during the collision, but Rexandra was taking on water. Fortunately, the fishing vessel's bilge pumps were able to keep up with the ingress of water. After hauling in its three nets, Rexandra set course for Mooloolaba, arriving there at 0900 on 30 November.