Executive summary

On the morning of 26 January 2007, British Mallard berthed at the BP Kwinana oil refinery jetty, Western Australia, to discharge its cargo.

At about 1750 on 27 January, the ship's engineers attempted to rectify an elevator fault that had been reported earlier in the day. After making some adjustments to the second deck elevator landing door switches, the electrical technician stepped onto the ladder in the elevator shaft. He then asked the second engineer to let the doors close behind him.

Soon after the doors closed, the elevator car travelled upwards and after a few seconds it stopped.

The second engineer could not open the second deck elevator landing doors. He called the third engineer, on his hand held radio, and told him to come to the second deck. The two men tried, unsuccessfully, to open the elevator doors.

The two men then went upstairs and opened the upper deck elevator landing doors. They looked down and saw the electrical technician. He had been trapped by the elevator car and he appeared to be unconscious. Shortly afterwards, the second engineer activated the general alarm.

The master reported the accident to the refinery operator while the crew tried to free the electrical technician.
Assistance arrived from ashore and, at about 1920, the refinery doctor examined the electrical technician and determined that he was deceased.

The report identifies a number of safety issues, safety action already taken, makes one safety recommendation and issues two safety advisory notices with the aim of preventing similar events.

Executive summary

At 0250 on 9 February 2007, about four hours after the Bahamas registered general cargo ship Baltimar Boreas sailed from Newcastle, the ship's fire detection system indicated a fire in the engine room. The second engineer investigated and found that number three diesel generator was on fire. He raised the alarm and discharged a portable extinguisher towards the fire before retreating from the engine room.

The crew mustered and operated the engine room oil tank quick closing valve system. All engine room ventilators, except those at the top of the funnel, were closed. At 0305, the engine room Halon fixed fire extinguishing system was operated and, soon after, the master made a distress call. At 0340, the crew determined that the fire had been extinguished. At 0351, the master cancelled the distress message.

By 0640, the chief engineer had concluded that it was impossible to supply power to the main switchboard due to the burnt electrical cables above the fire damaged generator. The ship was disabled but in no immediate danger and waited for a tug responding to the distress call to arrive.

By 1030, Baltimar Boreas was under tow and heading towards Newcastle. At 1920, the ship berthed in the port where its cargo was discharged.

At 1615 on 10 March, after repairs had been completed and its cargo reloaded, the ship sailed from Newcastle to continue its voyage.

The report issues a number of recommendations and safety advisory notices with the aim of preventing further incidents of this type.

Executive summary

Shortly before 2314 on Thursday 2 November 2006, the driver of a semi-trailer loaded with baled wool lost control of his truck whilst negotiating the approach to the Olympic Highway level crossing at Illabo, New South Wales. The truck overturned and slid along on its side coming to rest on the level crossing, obstructing both of the railway lines at the crossing. After climbing out of the prime mover cab, the driver realised that his truck was obstructing the railway lines and called the '000' emergency number. The '000' operator received the call and transferred it to the police communication centre who then called Junee train control. Junee train control then attempted four times to warn train 9351, which was approaching the crossing, without success.

At about 2324:35 freight train 9351 travelling at about 94 km/h collided with the overturned semitrailer. The leading bogie on leading locomotive GL102 derailed as a result of the collision. There was moderate damage to the leading locomotive and the truck's prime mover. The truck's trailer was destroyed. There was significant damage to the level crossing signals, signage, and auxiliary trackside equipment. There were no serious injuries but the train crew were treated for shock.

In the interest of enhancing future road/rail safety a number of recommendations that address various safety issues including the need to ensure that the primary radio communication system, CountryNet, is operational at all times in the leading locomotive of all trains in New South Wales.

Rail recommendations

[RR20080016] [RR20080017] [RR20080018] [RR20080019]

Safety Advisory Notices

[RS2008001] [RS2008002] [RS2008003] [RS2008004]

Executive summary

At 1653 on Wednesday 15 November 2006, a north-east bound tip truck towing a tri-axle trailer drove into the path of south-east bound passenger train 4AM8, The Overland, at the Barpinba-Poorneet Road level crossing, near Wingeel in southern Victoria.

As a consequence of the collision the driver of the truck was fatally injured. The train sustained only minor damage but was immobilised and this necessitated that all passengers had to be transferred by bus to Melbourne.

The ATSB investigation into the accident established that the truck entered the level crossing and did not come to a halt at the 'Stop' sign as required by the road rules while a train was approaching the level crossing. The driver of the truck was possibly distracted by the presence of the road-junction ahead and was probably unaware of the presence of the train until just before the collision. The investigation also found that when approaching the crossing from the south-west the advance warning signs did not comply with the then operational standard AS1742.7 - 1993. In addition, the viewing angle in the direction from which the train approached the crossing was poor. When coupled with the restricted visibility from the truck's cab, it would have been difficult for the truck driver to see the train without coming to the required stop at the crossing.

Rail recommendations

[RR20070023] [RR20070024]  [RR20070025] [RR20070026] [RR20070027]

Safety Advisory Notice

[RS20070002]

Summary

At about 1005 on Monday 25 September 2006 a Melbourne bound freight train, 6PM9, travelling from Perth to Melbourne, collided with a track mounted excavator conducting track-work near Inverleigh, Victoria. There were no injuries and only minor damage to both the train and the excavator as a result of the collision.

At about 2123 on 1 November 2006, freight train 3DA2K derailed near Tarcoola, SA. Eight multiple-unit freight wagons were derailed but there were no injuries.

Rail recommendation

[RR20080020]

Executive summary

At about 1100 on 4 October 2006, a prime-mover/low loader combination collided with train 4MR1 at the Magpie Drive level crossing, Tailem Bend, South Australia. At the time of the accident the crossing was controlled by passive signs comprising 'Stop' sign assemblies (RX-2) and approach warning signs.

The ATSB investigation into the accident concluded that it is likely that the truck did not come to a halt at the 'Stop' sign controlling the crossing. The driver was possibly distracted by the presence of the road-junction ahead and/or a preoccupation with arriving at his destination on time, which may have diverted his attention from the risks associated with negotiating the level crossing. The investigation also found that the viewing angle to the north-west of the crossing was substandard and coupled with restricted visibility from the truck driver's cab would have made it difficult for the truck driver to see the train without coming to a complete halt at the stop sign.

The investigation established that there was nothing the train crew could have done to prevent the accident. As a consequence of the collision the prime mover was heavily damaged and the trailer was written off, the truck driver suffered minor injuries. Damage to the train was confined to structural damage on the drag box and the onboard electrical system of the lead locomotive.

Rail recommendations

RR2007004 | RR2007005 | RR2007006 | RR2007007 | RR2007008 | RR2007009 | RR2007010 | RR2007011 | RR2007012

Executive summary

At approximately 0523 on 12 September 2006, the crew of the Pacific National hauled Patrick PortLink freight train number 2CM3 advised train control that their train had parted and the lead bogie of freight wagon CQBY 0130N had derailed.

There were no injuries as a result of the train parting or derailment and only minor damage to the track and rolling stock.

The investigation found that the draft key on the 'A' end of wagon CQBY 0118A had dislodged from the coupler shank allowing the coupler to withdraw from the draft pocket and fall onto the track. The dislodged coupler bounced under the train and derailed the wheel set of a trailing wagon.

Rectification work by the wagon owner to prevent a recurrence of this event includes the fitting of new drop forged steel retainer and locking pins to all wagons in the CQBY fleet.

Preliminary report released 14 July 2006

The information contained in this Preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the ongoing investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this Preliminary report. As such, no analysis or findings are included in this report.

At about 0714 on 25 May 2006 a Kenworth K100E truck and dog trailer, loaded with 30 tonnes of citrus pulp, collided with the second locomotive of freight train 4AM3 at the Lismore to Skipton Road level crossing, Lismore, Victoria.

As a consequence of this collision the second and third locomotives, and 41 of the trains 64 wagons were derailed. The driver of the truck was fatally injured in the collision.

Recommendation RR20060034

The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation and VicRoads review the level of short term protection provided3 at the Lismore to Skipton Road level crossing, particularly noting the limited visibility of approaching trains to motorists at or approaching this crossing.

Executive summary

On Thursday 9 February 2006 at about 0351 an XPT passenger train travelling from Melbourne to Sydney derailed near Harden in New South Wales. An inspection by the driver found one wheel on the trailing bogie of the leading power car had derailed. During recovery operations the axle of the derailed wheel was found to have completely sheared with a crack in the radius relief area between the gear and wheel seats.

The ATSB's investigation concluded that impacts from track ballast from unknown location(s) had led to the formation of the cracks in the axles. The investigation also concluded that routine testing of the axles carried out by the operator's maintenance contractor, using magnetic particle inspection (MPI), was ineffective and resulted in the fatigue cracks going undetected for a considerable period of time.

A number of safety actions have been undertaken by RailCorp and the Independent Transport Safety and Reliability Regulator of New South Wales which include measures aimed at the early detection and prevention of axle fatigue cracks in XPT and other diesel fleet rail vehicles to limit the risk of further axle failures. Additionally, the Australian Transport Safety Bureau has issued a safety advisory notice to all rail vehicle operators in Australia that they should consider the risks associated with axle failures as a result of fatigue cracks initiated by ballast strikes and review their maintenance practices accordingly.