Executive summary

At about 1858 on 14 January 2009, a safeworking irregularity occurred involving two passenger trains, 4SA8, the Indian Pacific, and WT28, an XPT, at Tarana in NSW. Both trains had been authorised to occupy the single line within the Tarana interlocked area at the same time. Fortunately, each driver saw the opposing movement and brought their trains to a stand about 524 m apart. After a short wait, the trains were authorised to continue their respective journeys.

The investigation determined that the West Board network controller located at Broadmeadow train control centre, did not adequately plan the intended train movements through the sections Wallerawang to Tarana and Bathurst to Tarana or determine a specific limit of authority on the Special Proceed Authority (SPA) number 37 issued to the driver of the XPT, WT28. The West Board network controller also issued SPA number 38 to the driver of train 4SA8, even though it overlapped the authority of SPA number 37.

The investigation report indentified three safety issues relating to the risks of using a manual train management system, inadequate auditing of safeworking systems, and ambiguous authority limits.

Abstract

At about 0930 on 21 May 2009, a crew member on board the general cargo ship Thor Gitta was fatally injured while attempting to secure lashing bins in the cargo hold. At the time, the ship was about 390 miles northwest of Fremantle, Western Australia.

The investigation found that a risk analysis had not been undertaken before the bins were introduced into service and that the bins had been inadequately secured in an area where there were no dedicated lashing points. It also found that the crew member was probably affected by fatigue as a result of the duty roster and the ship's movement in the heavy seas.

As a result of this accident, the ship's manager has implemented a range of measures on all its vessels to improve the security of bin lashing arrangements and manage the risks of carrying out tasks associated with operation of the bins. The company has also introduced a different rostering system to better manage the fatigue of watchkeepers when the ship is at sea.

The ATSB has issued one safety recommendation to the Danish Maritime Authority relating to the use of the 6 hour on/6 hour off work routine and the effect that that work routine has on a crew member's level of fatigue.

Abstract

At about 0100 on 16 April 2009, the bulk carrier F & K collided with the Australian fishing vessel Jolly Roger off Groote Eylandt, Northern Territory. While F & K was undamaged, Jolly Roger listed heavily to port as a result of the collision and its crew of three had to abandon the vessel.

The ATSB investigation found that despite Jolly Roger being the 'give-way vessel', its skipper took no action to avoid the collision because there was no lookout being kept on board. Consequently, he was not aware of the ship's presence until immediately before the collision.

The investigation also found that F & K's bridge team had detected Jolly Roger 20 minutes before the collision. However, they mistakenly assumed that their ship was overtaking the fishing vessel because they had not used appropriate means to determine whether a risk of collision existed.

Preliminary report released 14 April 2009

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 0312 on 11 March 2009, the Hong Kong registered container ship Pacific Adventurer lost 31 containers overboard in gale force weather conditions and large swells. The ship was about seven miles east of Cape Moreton, Queensland.

All the containers, carrying ammonium nitrate prills, sank. However, two of the ship's fuel oil bunker tanks were holed as the containers went overboard. In all, Pacific Adventurer lost about 270 tonnes of fuel oil into the sea as a result of the damage caused to the bunker tanks.

Executive summary

At 2200 on 6 February 2009, a coastal pilot boarded the products tanker Atlantic Blue for its intended eastbound transit of the Torres Strait. The ship was nearly fully laden with a cargo of unleaded petrol and was bound for Townsville, Queensland.

The passage progressed normally and at 0130 on 7 February, Atlantic Blue's heading was altered to 066º (T). However, no allowance was made for the 25 knot north-westerly wind abaft the port beam and the east-going tidal stream. Consequently, the ship made good a course of 070º (T) and by 0235, it was 1 mile south of the planned track.

At 0237, 0246 and 0256, the pilot made heading adjustments until the ship's heading was 059º (T). These small adjustments did not bring Atlantic Blue back on track as it progressed towards Kirkcaldie Reef. After 0307, as the ship closed on a shoal about 1 mile ahead, the pilot began altering the heading further to port. This course alteration was too little, too late and at 0312, Atlantic Blue's bow grounded on a sandy shoal. The hull remained intact and there was no pollution. At 0700, the ship refloated on the flooding tide and was manoeuvred clear of the reef.

The investigation found that the ship grounded because its progress and position were not effectively monitored by the bridge team and inadequate action was taken to bring it back on track. Bridge resources were not managed effectively, off-track limits were not defined and the bridge team did not have a shared mental model of the passage. The report identifies safety issues in relation to the ship's passage planning procedures; the coastal pilotage check pilot regime and the coastal vessel traffic service's monitoring system. Safety actions to address all the issues have been taken or proposed by the relevant parties.

Preliminary report released November 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 approximately 1335 on 4 November 2008, freight train 3DA2 derailed about 6 km south-west of Katherine in the Northern Territory. Six wagons derailed and sustained minor damage and about 1,300 m of track was destroyed. There were no injuries.

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.