Executive summary

At approximately 1317 Central Summer Time¹ (CSuT) on Wednesday 2 February 2005, a Specialised Container Transport² (SCT) employee was seriously injured whilst undertaking shunting operations at the SCT Rail Yards, Regency Park, South Australia. On the day of the accident, he was directing the shunting activities of locomotive T345.

At the time of the accident, locomotive T345 was propelling³ a rake of nine wagons. Towards the conclusion of this movement, approximately 1319, the driver of T345 called the shunter using his hand held radio to establish his whereabouts. When the shunter failed to respond to several radio calls, the driver decided to stop the train, leave the cab and look for the shunter. As the driver left the cab he saw the shunter lying face down, parallel to the track, within the ‘four foot’⁴, the right hand side of his body was partly straddled across the rail lines. The shunter had sustained serious injuries.

SCT staff and emergency services personnel reacted quickly and efficiently to the accident.

Based on the analysis of available evidence it is concluded that it is likely that either:

• the shunter fell from the end step of the leading container flat wagon  CQMY 3008N, whilst locomotive T345 was propelling a rake of wagons in  a northerly direction, heading out of the SCT marshalling loop; or

• the shunter was run over by CQMY 3008N just before or as the shunter  attempted to board the end step.

The investigation found that work procedures in the Regency Park rail yard allowed a shunter to ride on the end step of a wagon while being shunted and did not require that the driver confirm that the shunter was safe and/or in a safe position before starting a shunt movement.

In the lead-up to and post accident, SCT was conducting a review of their shunting procedures at its various intermodal sites. This included the Regency Park site in South Australia. They have subsequently modified shunting arrangements to incorporate the use of a small ‘All Terrain’ vehicle by shunters and the riding of wagons is no longer permitted. SCT has also enhanced its radio communications on T345 by providing a fixed radio with an external speaker as well as an on board CCTV system to assist with driver peripheral vision. Although these new initiatives are likely to prevent a similar accident, the investigation has identified further opportunities to improve railway operational safety.

The ATSB recommends that SCT:

1. develop arrangements that do not require employees to ride a locomotive/wagon whilst it is being shunted, this should be done without compromising the safety of shunt movements; or if not feasible develop a restraint mechanism/workstation to protect a shunter from falling from a locomotive/wagon whilst carrying out a shunt movement.

2. develop procedures that ensure a driver validates the position of a shunter, before proceeding with a shunt movement, and procedures that also regularly validate the wellbeing/whereabouts of a shunter whilst undertaking shunting activities.

3. undertake a thorough risk assessment of its shunting activities, including communication protocols. Translate this into a comprehensive safe working procedure and develop/provide an associated and accredited training program. Provide regular retraining of employees with respect to safety critical activities.

4. remind employees of their Occupational Health and Safety (OHS) responsibilities with respect to their personal safety, which includes a requirement to regularly check/replace worn personal protective equipment (PPE) such as safety boots/shoes and compliance with prescribed safety policies.
5. undertake/record results of regular audits of employees working practices to ensure that they are complying with documented safe working procedures and training directives.
6. ensure mandated medical instructions/restrictions are implemented. If the intent of a medical directive cannot be fully achieved consult with the medical practitioner to ensure any proposed alternative is effective.

The ATSB recommends that the South Australian Railway Safety Regulator:

1. Actively monitor the actions initiated by SCT in response to this investigation.

2. Recognise that the findings of this investigation may be relevant to other organisations, and take the appropriate actions to ensure they are advised accordingly.

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1. All times throughout this report is Central Summer Time (CSuT). However as times from various sources differ marginally, all times have been referenced to the Hasler clock roll (locomotive data logger) from T345.
2. Throughout the report, Specialised Container Transport (SCT) refers to ‘Twentieth Superpace Nominees Pty Ltd, trading as SCT Logistics.
3. ‘propelling’ - any reversing movement other than setting back at a platform after a partial overrun. (Source: Glossary for the National Codes of Practice and Dictionary of Railway Terminology).
4. ‘four foot’ – the area between the rails of a standard gauge railway. (Source: Glossary for the National Codes of Practice and Dictionary of Railway Terminology)

Executive summary

At 1500 on 30 January 2005, Pacific National freight train 6MP4 derailed at Koolyanobbing, approximately 200 kilometres west of Kalgoorlie, Western Australia. Freight train 6MP4 consisted of two locomotives leading 48 freight wagons, was 4108 tonnes in total train weight and 1685 metres in length. A total of 23 wagons (a train length of 803 metres) derailed, with the main wreckage located over a turn-out and a road level crossing.

On the same day at 1605, Pacific National freight train 6SP5 derailed near Booraan, approximately 360 kilometres west of Kalgoorlie. Freight train 6SP5 consisted of two locomotives leading 46 freight wagons, was 3739 tonnes in total train weight and 1740 metres in length. A total of 19 wagons (a train length of 605 metres) derailed, with the main wreckage located to the east of a road level crossing. Both freight trains had been travelling to Perth on the Defined Interstate Rail Network (DIRN), 6MP4 having started its journey in Melbourne and 6SP5 in Sydney. Both derailments occurred on the section of DIRN managed by WestNet Rail. No serious injuries were sustained due to either derailment.

The investigation determined that the most probable cause for each derailment was track misalignments in the form of track buckles on a very hot day. The investigation also determined that a number of factors combined to contribute to each derailment, any one of which may not have resulted in a derailment in its own right.

Executive summary

At approximately 1956 Eastern Summer Time on Wednesday 19 January 2005, wagons of a Pacific National (PN) operated freight train collided with a RailCorp operated Express Passenger Train (XPT) passenger train at South Dynon, Melbourne, about 2.3 km from Spencer Street Station. The wagons were being marshalled to form train 4MP5 on sidings in the South Dynon yard when the two leading wagons were propelled at a speed of 9 km/h into the side of the passenger train running on the main line at a speed of about 13 km/h.

There was damage to three XPT cars and minor damage to two freight wagons but no reports of injury to the 220 passengers, the crew on board the XPT or to the PN crew.

The wagons were being marshalled to form a train of 1415.4 metres in length. This involved joining two separate strings of wagons from two adjacent sidings. The rear portion of 697 metres was being propelled by a PN yard locomotive (pilot locomotive) from one siding to another at the eastern end of the yard. The front portion of the train was then to be drawn forward from an adjacent siding and attached to the rear portion.

There were three employees engaged in the propelling movement: a locomotive driver, a terminal operator riding on the pilot locomotive and a trainee terminal operator (trainee), located at the eastern end of the rear portion. Other employees were working elsewhere but were not required for the propelling movement.

With the pilot locomotive propelling the rear portion, the intention was for the trainee to guide the shunting movement and to stop the wagons short of a signal protecting the main line. The trainee did not fully understand his role. He went to the rear of the train before the movement started and remained there instead of guiding the leading wagon. As a result, the leading wagon passed the signal and although catch-points derailed three bogies on the two leading wagons, the wagons were propelled into the side of the passing XPT.

The investigation found that the trainee’s task had not been clearly specified. The accident sequence had developed because of a lack of defined procedures covering the marshalling of long trains, the breakdown in communication between terminal operations employees and the lack of structure in the task. In addition, although the catch-points derailed the leading wagons, they were not effective in deflecting the wagons away from the main line.

As a result of the investigation, the ATSB has issued recommendations with particular focus on:

• revision of the safety management system particular to the marshalling of trains in South Dynon yard.
• revision of the safety management system to incorporate the need for a supervisory structure in relation to trainees in terminal operator teams.
• consideration of the level of performance of the catch-points.
• a revision of the safety management system to include a documented standard or policy to define the requirements and function of catch-points.
• consideration of the development of specifications for catch-points and similar devices for inclusion in the Code of Practice for the Defined Interstate Rail Network.

Safety Actions

Actions Taken

As a result of the occurrence, the ATSB consulted with Pacific National and the Australian Rail Track Corporation in relation to safety issues that had become apparent during the initial stages of the investigation and issued interim recommendations. The interim recommendations are contained in 5.1.1 and 5.1.2.

Executive summary

In the afternoon of 14 October 2005, the six metre Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) vessel Malu Sara was returning from Saibai Island at the northern extreme of the Torres Strait to its home community on Badu Island. During the mid-afternoon, the skipper reported that he was lost in reduced visibility. There were five people on board: the two male DIMIA crew, two adult females and a four-year-old girl.

There was no suggestion of panic or distress. With the onset of darkness, at about 1915 on 14 October, the Thursday Island Police took over coordination of the search for Malu Sara. The skipper was instructed to activate the boat's emergency position indicating radio beacon and the boat's position was eventually established. Later the skipper reported that he was close to an island and could see a shore light. It appeared that Malu Sara was in a sheltered position. At 0215 the skipper again made contact by satellite telephone and reported that the boat was taking on water and sinking.

Despite an extensive search over six days, involving the Queensland Police Service and the Australian Maritime Safety Authority's Rescue Coordination Centre, no trace of the boat was found. The body of one of the females on board was recovered by Indonesian fishermen near Deelder Reef about 50 nautical miles west of Malu Sara's last known position and landed to Indonesian authorities. The body was subsequently repatriated to Australia for burial.

The investigation report covers key aspects of the tragedy including the seaworthiness of Malu Sara, the equipment it carried, fatigue and decision-making and regulatory oversight.

Supplementary Report PDF

Summary

River Embley arrived at the anchorage off Gladstone at 0902 on the morning of 14 October. After 'finished with engines', the diesel alternator was put online and the steam plant was shut down to allow for repairs on the number two turbo alternator exhaust steam valve.

At about 1010, after checking that the exhaust steam system had drained, the chief engineer and third engineer started working on the valve. A short time later, while they were dismantling the valve a thousand litres of pressurised hot water unexpectedly started to spray from the valve and onto the chief engineer standing on staging below.

In an effort to escape the hot water spray the chief engineer tried to jump clear of the staging but became entangled in the securing rope which had formed a barrier.

The ship's crew mounted an immediate first aid response and the master organised a helicopter evacuation. The chief engineer was transported to Gladstone Hospital and later transferred to the Royal Brisbane Hospital intensive care unit.

The report concludes that the engineers did not fully assess the exhaust steam piping system and its drainage arrangements, or allow sufficient time for the exhaust steam system to completely drain before starting to work on the valve.

The ship's work permit system and job safety analysis procedures were not utilised by the engineering crew and deficiencies in safety management were not identified in two audits prior to the accident.

It is also considered that a sizable experience gradient between the chief engineer and the other engineers along with a lack of team training allowed a series of 'single person' errors to go unchecked and unquestioned.

The ATSB has made several safety recommendations aimed at preventing further accidents.

Executive summary

Safe Concordia is a dynamic positioning, self-propelled, semi-submersible accommodation platform that uses four electrically driven thrusters to maintain its position. The platform's construction was completed, and its delivery trials were carried out, in March 2005.

During its voyage from Singapore to Bass Strait, Australia, the platform experienced two electrical fires in its thruster power system. On 12 September 2005, after it had entered Bass Strait a fire started in the platform's number four thruster transformer. On 18 September, a fire occurred in an electrical cabinet that was providing power to the number one thruster motor.

The investigation found that the transformer fire was probably the result of an internal short circuit that occurred when the insulation failed due to overheating. The cabinet fire was the result of an electrical arc that occurred because the work bridging out of some electrical equipment was not adequately undertaken.

It was also considered that Safe Concordia was not fit to fulfil its charter obligations in view of the unresolved faults in the thrusters' electrical power systems and the design of the platform did not allow for effective and safe fire fighting in the thruster rooms.

The report makes several recommendations to address these issues.

Summary

At about 1600 on 22 July 2005 Leeuwin II grounded on an uncharted shoal during a voyage under motor from Careening Bay to Hunter River in the Kimberly region of Western Australia.

Less than two months later, on 16 September, Leeuwin II again grounded on an uncharted shoal. On this occasion in Shark Bay, Western Australia, during a passage from Denham to Monkey Mia.

Both groundings were investigated by the ATSB, and because of the similarities in the key factors which led to both incidents, the reports have been combined.

Summary

At about 1630 on 15 September 2005, a fire broke out in the engine room workshop on board the bulk carrier Opal Naree.

A fitter had been allocated the task of weld repairing the sewage system save-all base, while the duty oiler was assigned to standby in the workshop below and keep a fire watch. The oiler left the workshop to answer the telephone, and then attended to a ballast pump fault that the second mate had alerted him to.

During this time the fitter continued to work, and it appears that molten metal from the welding process fell into the workshop, landing on coiled electrical cables, causing them to ignite.

The fire was detected by the fitter and the emergency alarm was raised.. The crew mustered and the master contacted the port authority, who, in turn contacted the fire and emergency services.

The crew closed all the engine room doors and fire dampers while the master and chief engineer assessed the situation. They decided to use the fixed fire extinguishing system, and at 1700 carbon dioxide was released into the engine room.

By 1800 two fire fighting tugs were standing by the ship and the fire and emergency services authority (FESA) were on board.

At 2153 the ship's crew and FESA commenced the first of two inspections of the engine room.

There was no sign of fire and by 2310 the ship's crew had begun ventilating the engine room.

Summary

At about 1600 on 22 July 2005 Leeuwin II grounded on an uncharted shoal during a voyage under motor from Careening Bay to Hunter River in the Kimberly region of Western Australia.

Less than two months later, on 16 September, Leeuwin II again grounded on an uncharted shoal. On this occasion in Shark Bay, Western Australia, during a passage from Denham to Monkey Mia.

Both groundings were investigated by the ATSB, and because of the similarities in the key factors which led to both incidents, the reports have been combined.

Abstract

At 0939 on 24 June 2005, the bulk carrier Pilsum collided with another bulk carrier, China Steel Growth, while dragging its anchor. The two ships were anchored off the New South Wales port of Newcastle.

On the morning of 24 June, a southerly weather front came through the anchorage. At 0900 on 24 June, the officer of the watch on Pilsum detected that the ship was dragging its anchor. The master was informed, and he decided to weigh anchor and depart the anchorage.

Pilsum’s crew encountered difficulties recovering the anchor. During the anchor retrieval process Pilsum drifted towards China Steel Growth, which was anchored to the north.

At 0935 Pilsum pitched heavily, the propeller came clear of the water and the main engine was shut down by the overspeed trip. Pilsum’s main engine was restarted, however at 0939 Pilsum collided with China Steel Growth. The two ships moved apart and then made contact a second time before Pilsum finally made its way clear.