Executive summary

On the evening of 24 January 2006 Global Peace entered Gladstone harbour for the transit to the Clinton Coal Terminal. The plan was for the ship to berth at Clinton number three berth with the assistance of three harbour tugs.

As the ship was approaching the berth, the pilot ordered all three tugs to stop pushing and to lay alongside. The master of the aft tug, Tom Tough, laid the tug alongside the ship, with the tug at an angle of about 15 degrees to the ship's side. The tug's bow was in line with the front of the ship's accommodation.

At about 2354, Tom Tough's starboard main engine unexpectedly shutdown, and the tug's stern swung sharply to starboard. The tug's starboard quarter made heavy contact with the ship, puncturing the ship's shell plating in way of the port heavy fuel oil tank. Oil immediately began to flow into the harbour.

The investigation found that a crack in the tug's starboard main engine clutch oil discharge pipe resulted in the system being emptied of oil. The resultant loss of system pressure activated the engine shutdown.

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

Executive summary

On 5 February 2006, Pacific Sun berthed at number eight wharf Darling Harbour, Sydney. The weather was fine with little wind. The twelve to four quartermaster was assigned to clean rust streaks from the outside of the port bridge wing windows. At 1205 the senior second officer checked the safety harness and completed a work permit, as required by the working aloft procedure, but no workplace risk assessment was used in planning the job.

The quartermaster, wearing the safety harness, then started work on a catwalk outside the port bridge wing. At about 1249 he fell approximately 24 metres onto the wharf below. He died as a result of the injuries sustained from the fall. He was an experienced seaman who had been inducted in the ship's safety management system and had done this task many times.

The ATSB's investigation report concludes that the quartermaster's harness was not properly attached to the grab rail when he probably lost his footing and fell. The contributing factors to the incident include an inadequate safety harness, the design of the catwalk, an inadequate workplace risk assessment and procedures, the ineffective use of personal protective equipment and that the quartermaster may have been distracted from the task at the time by non-work-related issues. There was no evidence to support a suggestion that he may have committed suicide.

The ATSB has made several safety recommendations with the aim of preventing further incidents of this type.

Executive summary

Desh Rakshak arrived off Port Phillip on the morning of 4 January 2006, with about 80 000 tonnes of crude oil cargo on board, and at 0800 a pilot boarded the ship for the transit from sea to the Melbourne outer anchorage.

The pilot planned to enter the port to the west of the track marked by the main leading lights, to keep the ship out of an opposing tidal flow for as long as possible. When the ship was almost abeam of Point Lonsdale Lighthouse, the pilot thought he could see the high and low main leading lights just open to the west. This indicated to him that the ship was on the edge of the Great Ship Channel. However, the ship was further to the west than the pilot thought.

The ship continued the transit and anchored at 1154. No one on board the ship observed anything that might have suggested that the ship had grounded during the pilotage.

At about 1245, the chief mate found the level in the lower fore peak water ballast tank rising. He told the master, and they decided to pump out the tank and inspect it. The inspection revealed that the tank's shell plating had been holed.

The ship berthed in Geelong on 5 January and temporary repairs were carried out before it sailed for Singapore on 19 January, where it was dry-docked for permanent repairs.

The investigation found that the ship probably grounded at about 0825, when it was almost abeam of Point Lonsdale, while transiting from sea to the Melbourne outer anchorage.

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

Executive summary

On Thursday 30 September 2005 at about 0800 hours (Central Standard Time) steel plate, part of a load that had shifted on Pacific National freight train 5MA5, struck a TransAdelaide passenger train 206A at Eden Hills railway station platform. There were no injuries and only minor damage to both trains and track infrastructure.

Eden Hills is located in the Adelaide Hills region approximately 14 km from Adelaide on the Belair railway line which forms part of the Defined Interstate Rail Network corridor. Within the railway corridor there is a standard gauge line managed by the Australian Rail Track Corporation (ARTC) and an adjacent broad gauge line managed by TransAdelaide.

The investigation concluded that the collision occurred as a result of the movement of inadequately secured metal plates on a Transi-flat container located approximately 1250 m from the front of train 5MA5. Based on available evidence, the shifted load had been out-of-gauge from Murray Bridge, 85 km from the point of collision. In addition, the ARTC track at Eden Hills station platform was up to 140 mm closer to the TransAdelaide track than the design clearance. Given the inadequate load securing methods, and the forces to which the load had been subjected during its carriage, there was a relatively high risk of a load shift resulting in an out-of-gauge collision.

Executive summary

At about 0947 on 25 August 2005 a freight train travelling from Acacia Ridge¹ to Sydney, numbered as 5BS7, collided with a stationary track vehicle² at the take-off point³ within the Greenbank⁴ station yard limits. The impact speed was 21.9 km/h and the track vehicle was pushed back 25 metres. There were no injuries as a result of this accident and damage was limited to the front end of the track vehicle.

The track vehicle, with three track workers on board, had arrived on the main line at Greenbank moments before the arrival of the Sydney bound train and was going to the take-off point to be removed from the rail track for road operation. The approaching train was seen and heard by the track workers however they thought they would reach the take-off point and remove the track vehicle before the train arrived. When they realised that they could not, they escaped from the vehicle before the collision.

The two-man train crew of the Sydney bound train were travelling on a proceed signal and had made a routine brake application in preparedness for the mandatory stop at the Greenbank staff hut⁵. As the Greenbank staff station yard came into view they saw the track vehicle and made an emergency application of the train brakes 246 metres from the point of impact.

The train had departed Acacia Ridge under Rail Vehicle Detection authority to travel to Greenbank where the safeworking system changed to electric staff⁶.

The track vehicle was travelling from Bromelton to Greenbank on a routine track inspection on the authority of a Track Occupancy Authority (TOA). This TOA consisted of an electric staff and implied verbal authority to proceed within the Greenbank staff station yard limits to the take-off point.

The potential for simultaneous arrival at Greenbank had not been detected by the QR south-west train controller when developing the train graph. Distractions attributed to teaching a trainee controller and ambiguous communication regarding the departure time of train 5BS7 contributed to this oversight. This ambiguous communication resulted in the train controller believing that the train would not depart before 0945. However, it was intended that 0945 would be the latest departure time.

The investigation also found that longstanding inadequate safeworking practices between Acacia Ridge and Glenapp⁷ allowed the train controller’s oversight to result in this accident. These practices pertain to the operation of track vehicles that are not detected by track-circuitry⁸. The same system of safeworking exists between Glenapp and Casino⁹ with two versions of rules and procedures.

Safety actions recommended as a result of this investigation pertain to QR, Interail and ARTC ensuring that blocking facilities are applied where necessary, rule and procedure conformity on the electric staff territory between Greenbank and Casino, trainee train controller training program structure and enforcement, verbal communication protocols, and locomotive data logger accessibility.

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1. Acacia Ridge – A southern suburb of Brisbane, site of a major rail freight terminal.
2. Track vehicle – A vehicle, usually self propelled, used mainly for inspecting and maintaining infrastructure. In this instance able to operate on rail or road.
3. Take-off point - Staging beside the track for removing track mounted maintenance vehicles or equipment clear of train movements.
4. Greenbank – 17 Kilometres ‘south’ of Acacia Ridge.
5. Staff hut – location where tokens are kept.
6. Electric staff – A metal rod of prescribed design used as a token to authorise train movements into or through a block in electric staff territory.
7. Glenapp – The electric staff station/crossing loop 12 kilometres on the Queensland side of the border.
8. Track-circuitry – An electrical current that uses the rails of a railway track as conductors such that a train electrically connects them by its axles. The absence or presence of this rail to rail connection indicate the absence or presence of a train or item of rollingstock.
9. Casino – A provincial city on the Brisbane to Sydney rail line, about 169 kilometres from Acacia Ridge. Casino is an interface between electric staff working and rail vehicle detection (RVD) safeworking systems.

Executive summary

At approximately 1213 Eastern Standard Time on 11 August 2005, a small motor vehicle drove into the path of a Pacific National locomotive, G535, on the Edith Street level crossing at Horsham in Victoria. The crossing is protected by flashing lights a bell, approach warning signs and road markings. The driver of the motor vehicle was fatally injured as a result of the collision.

The investigation found that the driver of the motor vehicle did not to give way to the train as prescribed in 'Road Rules - Victoria'. Based on available evidence it is believed that the driver of the motor vehicle was distracted by the intersection immediately ahead, Dooen Road, and/or personal issues and was apparently unaware of the train's presence, even though the level crossing warning devices were operating at the time of the accident.

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