Executive summary

At 0701 on 28 March 2006, TransAdelaide passenger train H307 passed signal 161 at Adelaide Railway Station while it was displaying a red stop aspect. Train H307 then travelled the wrong direction along the Up track for approximately two minutes before stopping about 600 m past signal 161.

At the same time, Great Southern Railway Indian Pacific passenger train (1PA8) was approaching Torrens Junction where TransAdelaide's broad gauge line crosses the standard gauge Defined Interstate Rail Network (DIRN). The investigation found that the signalling system could not provide an appropriate indication to both trains and thus neither train driver was aware of the potential for a collision. Had train H307 continued on for a further 1000 m the two trains may have collided.

The investigation also concluded that driver distraction, conflicting signal indications (hand and fixed), and inexperience contributed to the occurrence

Rail Recommendations

[ RR20070032 ] [ RR20070033 ]

Executive summary

At approximately 0832 on 26 October 2006 an Adelaide to Melbourne bound Pacific National freight train collided with an elevated platform vehicle containing a worker performing maintenance on the Separation Street overpass at North Geelong in Victoria. The worker was inside the elevated platform vehicle basket which was positioned underneath the overpass and directly above the rail line when it was struck by the train. The worker was seriously injured as a result of the collision.

At the time of the collision the North Geelong site was under the operational control of the North Geelong 'C' signal box with site protection being provided by a qualified track protector.

The investigation found that a deviation from the formally documented and agreed safety plan, combined with a subsequent misinterpretation and the miscommunication of the relevant safe working rules and procedures between operational staff, were the primary factors contributing to the collision.

Rail Recommendations

[RR20080021] [RR20080022] [RR20080023] [RR20080024] [RR20080025]

Executive summary

At approximately 1356 on 12 December 2006, a double trailer road-train truck drove into the path of The Ghan passenger train (1AD8) at the Fountain Head Road level crossing, Ban Ban Springs, Northern Territory. As a consequence, two locomotives, a wagon used for carrying passengers' private vehicles and nine passenger carriages derailed. There were no fatalities, however, the road-train driver and a female passenger were hospitalised and several other passengers and crew sustained minor injuries.

The investigation concluded that the truck was driven through the 'Stop' sign at the level crossing at a speed of about 50 km/h. The driver of the truck traversed the level crossing many times during the course of his 'working day' and had been in the habit of slowing rather than stopping at the level crossing 'Stop' sign. Factors influencing this act were the manner in which the task was normally performed, the expectation that a train would not be present and the operational constraints of road-train vehicles. It was also found that the ability of the road-train truck driver to hear the first two soundings of the train horn may have been compromised by his severe bilateral hearing loss.

The report identifies a number of safety issues and issues recommendations and safety advisory notices with the aim of preventing similar events.

Rail recommendations

[RR20080003] [RR20080004] [RR20080005] [RR20080006] [RR20080007] [RR20080008] [RR20080009] [RR20080010] [RR20080011] [RR20080012]

Rail Safety Advisory Notices

[RS20070001]

At about 1205 (CST) on 20 October 2006, a double trailer road-train truck drove into the path of a south bound freight train (6DA2) at a level crossing near the Elizabeth River Bridge, NT. The locomotive drivers sustained minor injuries while the truck driver was uninjured.

Executive summary

At about 1721 on Wednesday 4 January 2006, the 41st wagon of Pacific National freight train 3AB6 derailed at a track misalignment at Yerong Creek, New South Wales. Eight wagons following the 41st wagon then derailed. There were no injuries. The track sustained significant damage and was closed for 48 hours.

The investigation found that the most likely cause of the derailment was a track misalignment which was caused by a combination of several factors any one of which may not have resulted in the derailment in its own right.

Rail Recommendations

[RR2008001] [RR2008002]

Rail Safety Advisory Notices

[RS2007003]

At about 1540 on 22 September 2006, a flash fire erupted in the high-pressure welding oxygen system on board Searoad Mersey. The trainee engineer received burns to his arms from the flashfire and from molten plastic impinging on his skin when the hoses ruptured. He was wearing overalls at the time, but the sleeves were rolled up. Consequently, the overalls did not protect his arms.

The fire occurred when the heat created by the compression of the oxygen within the system ignited a replacement hose that had been fitted into the system. The hose had a lining made from a material with a low ignition temperature that had been made in an oily environment. It was not fit for its intended purpose and did not comply with any standards for high pressure oxygen hoses.

The hose had been fabricated by a hose supplier who had not been trained about the hazards or standards associated with high pressure oxygen systems and had ambiguous information regarding the suitability of hose materials for the purpose. The report also found that the fixed oxy-acetylene system had not been inspected or maintained in accordance with marine orders.

The report makes several safety recommendations with the aim of preventing further incidents of this type.

Executive summary

At about 0530 on 11 November 2006, a fire started in the engine room on board the Antarctic supply ship L'Astrolabe. The fire was fed by a spray of diesel fuel from a leak that had developed in the starboard main engine fuel system.

The ship's crew closed the remotely operated, fuel system quick closing valves, which shut down all of the main and auxiliary engines, isolated all ventilation to the engine room and then operated the engine room's fixed fire extinguishing system.

By 0620, the fire had been extinguished and the crew worked to restart the ship's main and auxiliary engines. By about 1200, L'Astrolabe had resumed its passage to Hobart using its port main engine and, by 1030 on 12 November, the starboard main engine was also back in service.

The ATSB's investigation found that the fire was caused by a leak of diesel fuel, probably in the form of a spray, from a temporary blanking arrangement on the starboard main engine. The fuel ignited when it came into contact with the hot surfaces of the starboard main engine.

The report identifies a number of safety issues and issued one recommendation and three safety advisory notices.

Executive summary

At 1730 on 10 September 2006, the Hong Kong registered bulk carrier Creciente berthed in Port Hedland, Western Australia, to load a cargo of iron ore.

At about 0245 on 12 September, the almost fully laden ship broke away from the wharf under the influence of a strong ebb tide.

Despite the use of several tugs and the ship's engine, it was not possible to manoeuvre the ship back alongside the wharf. The harbour master decided to hold the ship in the deepest part of the port's entrance channel until the next high tide.

By about 0615 on 12 September, the ship was firmly aground in the channel and, at about 0950, it was successfully refloated.

The ATSB investigation found that the effective holding capacity of the ship's mooring winch brakes was reduced by the number of layers of mooring line on the winch drums and the poor condition of their brakes. The investigation also found that it was highly likely that the brakes had not been sufficiently tightened and that the mooring winches were not effectively monitored in the time leading up to the incident.

The investigation also found that neither the port authority nor the ship's master had identified the possibility of the ship breaking away from its berth and appropriately assessed the risks associated with this potential hazard.

The report issues two recommendations and five safety advisory notices to address the identified safety issues.

Executive summary

At 1400 on 28 August, Massive Tide departed Dampier with a load of bulk cargo for the drill rig Ensco 106. After clearing the berth, the master handed over the watch to the second mate who then remained in charge of the watch for the transit to the drill rig.

The master took over the watch when the ship reached the drill rig at 1950 and the second mate remained on the bridge to operate the bulk-board for the cargo transfer. After the completion of cargo operations, the master handed the watch back to the second mate and then went to bed.

At 0100 on 29 August, the ship departed the drill rig. The second mate checked the global positioning system (GPS) unit and then set the autopilot to follow a course of 129° (T). The weather was good with light winds, slight seas and visibility of about eight miles.

At 0200 and 0400, the second mate recorded the ship's GPS position in the deck logbook but did not plot either position on the navigational chart. At about 0400, the bridge lookouts changed watches, but the second mate decided to leave the chief mate in bed until the ship reached the Dampier Sea Buoy.

At 0445, Massive Tide was making good a speed of 9.8 knots when it grounded on the shoals approaching the western shore of Rosemary Island.

The crew were called out and checks of the ship, its machinery and the surrounding area revealed that no damage or pollution had occurred. Immediate attempts to refloat the ship were unsuccessful and plans were put in place to try again on the next high tide. At 1035, Massive Tide floated free without assistance.

The report identifies a number of contributing factors and makes recommendations to address them.

This investigation was carried out by the Australian Transport Safety Bureau (ATSB) utilising investigation information provided by the Maritime Administrator of the Republic of the Marshall Islands (International Registries).

On 10 April 2006, an able-bodied seaman (AB) was fatally injured when he was struck by a mooring line while operating a winch on the forecastle of Probo Bear during a shift ship operation.

The report identifies a number of contributing factors and makes recommendations to address them.