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.

Abstract

At about 0310 on 25 August 2007, while the research ship Geosounder was about 185 miles northeast of Cairns, Australia, en route from New Zealand to Singapore, an off-duty integrated rating (IR) who was skylarking on deck while under the influence of alcohol fell overboard. The crew immediately threw lifebuoys into the water, stopped the ship and launched the fast rescue craft (FRC) but the IR could not be located. While launching the FRC to search for the missing man, another IR broke his ankle.

After a search involving two ships and an aircraft, both lifebuoys were recovered but no sign of the missing seaman was found. In consultation with RCC, the master called off the search at 1835 when it became too dark to continue. The master's decisions to call off the search and take the injured crew member to Cairns for treatment were reasonable considering the very low probability of finding the missing man alive if the search was resumed on 26 August.

The ATSB found that while the Geoshipping safety management system included a 'no alcohol' policy, it was not consistently and effectively implemented on board the ship. The ATSB also found that the haste of the crew to launch the fast rescue craft to locate the missing man overboard resulted in the master and crew performing tasks that they had not regularly practiced, and they did not plan or execute their tasks effectively. Consequently, the chief mate drove the fast rescue craft ahead before it had been released from its hoisting wire.

The ATSB has been advised that safety actions have been taken by DOF Subsea and DOF Management (formerly Geoshipping) to address the safety issues identified in the report. The report issues no recommendations or safety advisory notices.

Executive summary

On 14 August 2007, the Antigua and Barbuda registered general cargo ship BBC Islander anchored off Dampier, Western Australia. One of the tasks the crew was to complete while the ship was at anchor was the removal of steel brackets that had been welded to the hatch covers.

In the process of removing the brackets with oxy-acetylene cutting equipment, a hole was inadvertently cut in the aft cargo hold hatch cover. As a result, sparks and molten metal fell into the cargo hold and onto the pallets of cargo stowed below.

At about 1340, smoke was noticed coming from the aft cargo hold.

The general alarm was sounded and the master decided to use the ship's fixed fire extinguishing system to flood the cargo hold with carbon dioxide.

The harbour master was notified and he arranged for the ship to be brought alongside the wharf.

By 1312 on 16 August, BBC Islander was all fast alongside the wharf and the local fire fighting authorities took control of the response. Initially, they tried flooding the cargo hold with more carbon dioxide.

They then attempted to remove the cargo in order to reach the seat of the fire and extinguish it with the use of fire hoses. Eventually, the hold was filled with high expansion foam. However, none of these actions extinguished the fire.

On 18 August, the fire was finally extinguished when an offshore supply vessel's fire monitor was used to flood BBC Islander's aft cargo hold with about 700 tonnes of seawater.

The ATSB has issued two recommendations and three safety advisory notices to address the identified safety issues.

At about 1640 on 8 August 2007, an able seaman died on board the bulk carrier Oceanic Angel as a result of a fall from the forward ladder in the ship's number three cargo hold. The seaman had been part of a team preparing the hold for an upcoming cargo and had just finished work for the day.

Executive summary

At about 0230 on 16 May 2007, the bulk carrier Ormiston sailed from Melbourne, Victoria, bound for Thevenard, South Australia. At about 0512, the ship rounded the Hovell Pile beacon and entered the South Channel in Port Phillip. At about 0521, Ormiston entered 'The Cut', the narrowest part of the channel, from the east making good about 15 knots.

At about 0230, the second mate on board the roll-on/roll-off general cargo ship Searoad Mersey contacted Point Lonsdale vessel traffic service (VTS) to provide an estimated time of arrival at the entrance to Port Phillip and was advised of the traffic movements within the port. At about 0420, Searoad Mersey's master, who also held a pilotage exemption for Port Phillip and had conducted over 1300 transits of the port, contacted VTS and received updated traffic information, including Ormiston's estimated movements.

At about 0435, Searoad Mersey passed Point Lonsdale lighthouse and entered Port Phillip. At about 0521, when the ship entered 'The Cut' from the west making good about 15 knots, the master had forgotten that Ormiston was approaching and did not see the approaching ship until immediately before the two ships passed. At about 0523, Searoad Mersey and Ormiston passed within 20 metres of each other in 'The Cut' at a combined speed of about 30 knots.

The ATSB investigation found that Searoad Mersey's bridge team members had not effectively implemented bridge resource management principles, were not keeping an adequate lookout and had lost situational awareness. The investigation also found that the ships did not communicate with each other until after the incident and that the Point Lonsdale VTS was not aware of the incident until after it had occurred.

The ATSB has issued four recommendations and one safety advisory notice to address the safety issues identified in the report.