Preliminary investigation was undertaken into a category 4 occurrence where fumes were detected in an Airbus A330-300 fare paying passenger flight and the crew diverted to Adelaide. Subsequent inspection by maintenance personnel showed no evidence of fire or burning and there have been no reports during subsequent flights.

Status: Downgraded the occurrence to category 5 and investigation discontinued.

Overview

This is an interim report, into the derailment of Queensland Rail's diesel tilt train and is based on information that has been gathered during the initial stages of the joint independent accident investigation being undertaken under the chairmanship of the Australian Transport Safety Bureau (ATSB) in conjunction with Queensland Transport (QT). The investigation is being conducted under the Queensland Transport Infrastructure Act 1994 (as amended), herein after referred to as The Act.

The ATSB was formed in July 1999 and is an operationally independent body within the Australian Government Department of Transport and Regional Services. The bureau is entirely separate from transport regulators and service providers.

Rail safety in Queensland is regulated by QT. All railway managers and/or railway operators within Queensland are required to be accredited in accordance with The Act. QT's role in rail safety also includes investigation of transport accidents and other safety occurrences.

Upon completion of the accident investigation a final report will be published that could possibly amend some of the information contained in this interim report.

Queensland Rail (QR) is the principal manager/operator of rail transport services in Queensland. As part of its regular passenger services QR operates two high speed diesel tilt trains on the North Coast Line between Brisbane and Cairns, the 'Spirit of Cairns' and the 'Spirit of Townsville' over a distance of 1,655km with a scheduled journey time of approximately 24hr 55min.

At 2355 Eastern Standard Time on 15 November 2004 the 'Spirit of Townsville', VCQ5, a 'down movement', derailed 419.493km from Brisbane (Roma Street), north of Berajondo on the Bundaberg to Gladstone line. The lead power car, No. 5403 and all remaining seven trailer cars derailed. The trailing power car No. 5404 was the only unit to remain substantially upright although the leading bogie set (in direction of travel) was partially derailed.

There were 157 passengers and crew on board the train. No one was fatally injured; however, there were some significant injuries.

Download Final Report from Queensland Transport.

Executive summary

At approximately 1006 on 21 November 2004, Pacific National freight train 7MP5 derailed in the Adelaide Hills near Glenalta. Train 7MP5 consisted of four locomotives leading 72 freight platforms1 and wagons and was travelling from Melbourne to Adelaide on the Defined Interstate Rail Network (DIRN). The total train length was 1474m, with approximately 2960 tonnes trailing the locomotives.

The derailment occurred over a 3.7km section of standard gauge track between Belair and Glenalta, located approximately 23 to 19 kilometres from Adelaide respectively. The track exhibits a steep 1 in 45 down gradient with a series of 190- 350m radius curves, except for the standard gauge crossing loop located at Belair where the track is relatively straight with only a slight down gradient. Immediately adjacent to the DIRN is Adelaide’s broad gauge metropolitan passenger rail network.

Freight train 7MP5 had negotiated a 240m radius left hand curve that leads immediately into the Belair crossing loop at 42 km/hr, 8 km/hr below the posted speed limit. While access to the crossing loop was via a right hand turn-out, the straight ahead main line route had been selected over the facing points. The point of derailment occurred at the turn-out, where markings indicated that a wheel had ridden over the check-rail allowing the opposite wheel to travel up the wrong side of the Vee.

Freight train 7MP5 continued for approximately 3.7km, progressively derailing other bogies. At Glenalta the derailing bogies struck a concrete pedestrian crossing panel and the bitumen road edge of a level crossing causing the freight wagons to jack-knife. The impact at the level crossing alerted the locomotive drivers who immediately applied braking, finally stopping the locomotives and four platforms of the first 5-unit wagon, approximately 200m beyond the Glenalta station. The brakes on the remaining wagons applied automatically due to loss of brake air pressure. However, the gradient and momentum prevented the wagons from stopping before colliding (jack-knifing) with the wagons coupled immediately behind the locomotives. A total of 10 platforms and wagons were derailed, with five obstructing the passenger track and four coming to rest down an embankment into private residential properties.

While no person was injured, the potential for injury was high. The accident occurred adjacent to Adelaide’s operational metropolitan rail network with derailed vehicles causing significant damage to publicly accessible rail infrastructure such as pedestrian crossings, a passenger platform and a road level crossing. In addition, had metropolitan passenger trains been in the vicinity at the time of derailment, the risk of potential injury would have increased significantly.

The investigation determined that the most likely direct cause for the derailment of 7MP5 was significant wheel unloading as a wheel made contact with a check-rail at the entrance to the Belair crossing loop.

The investigation determined that a number of factors combined to contribute to this particular derailment. Any one factor in its own right is unlikely to have resulted in a derailment, but the four factors acting together greatly increased the likelihood of derailment.

• Wagon RQZY7066, with three empty platforms, was coupled immediately following the locomotives of 7MP5. Almost 2900 tonnes of trailing load was present behind the empty platforms, which exceeded the limit of 2600 tonnes stipulated by the Australian Code of Practice’s marshalling requirements.

• The use of dynamic braking as the sole means of controlling train speed on the descending grade exerted significant longitudinal compressive forces on the RQZY wagon with three empty platforms coupled immediately behind the locomotives.
• In tare condition, the RQZY wagon is relatively light weight, rides on very stiff vertical suspension, and exceeds the maximum constant contact side-bearer (CCSB) pre-load recommended by the ACOP. It is likely that the very stiff vertical suspension reduces the ability of an empty RQZY wagon to absorb discrete wheel impacts, such as the interface with a check-rail.
• Track geometry influenced the oscillating motion of rollingstock, causing the right hand wheel flange into rail contact as the left hand wheel came into contact with the check-rail. It is likely that track irregularities only served to influence the timing of this movement, such that peak lateral forces occurred as the wheel came into contact with the check-rail.

Safety actions have already been implemented by Pacific National. A review was conducted, and a revised procedure for loading and marshalling issued in December 2004.

The ATSB makes a number of additional recommendations relating to:

• procedures for train loading, marshalling and handling
• functionality of software management tools
• review of rollingstock design and performance acceptance requirements
• review of civil infrastructure design and maintenance requirements
• review of documented standards
• implementation and monitoring of safety actions.

Executive summary

Train 4VM9-V operated by Freight Australia, derailed at 0444 Eastern Standard Time (EST) on Thursday 23 September 2004 as it was travelling southwards between Glenrowan and Benalla, Victoria. The train departed from the Blue Circle Southern Cement Ltd works at Berrima, New South Wales the previous day and was proceeding to Somerton, Victoria.

Four of the 15 wagons carrying dry bulk cement on the train derailed. The train passed through a section of track where an infrastructure restriction (IR) and a temporary speed restriction (TSR) of 80 km/h had been in place due to weak track structure and geometry. The IR and TSR had been imposed on the section of track by the infrastructure maintainer as a result of earlier track inspection.

The 12^th wagon in the train was first to derail. The leading wheel set’s right-hand wheel climbed up and over the western side rail as it passed over two consecutive track dips in the IR area. Track damage caused a loss of gauge retention and the spread of the eastern side rail which in turn led to the rear bogie of the wagon and the bogies of the last three wagons on the train dropping between the rails.

The driver became aware of the derailed state of the train and controlled the locomotive power and the induced emergency brake application to bring the train to a stop. Train speed at this time was approximately 79 km/h. The first derailed wheel set travelled a distance of approximately 525 metres from the point of derailment until the train stopped.

Up to 400 mm of rain had fallen on the area between 1 July 2004 and 16 September 2004. Inadequate drainage of the track structure resulted in further deterioration of the track geometry at the occurrence site. Although a TSR had been in place at the occurrence site, track inspection had apparently not identified the potential for derailment or the need for a lower TSR speed limit as a consequence of this deterioration.

The track geometry was measured by the ‘AK’ track recording car (AK Car) less than two months prior to the derailment. Data from the AK Car was compared against the AK Car Defect and Response Tables, Standard and Victorian (AK Geo.). The track was also compared to the common Victorian Civil Engineering Circular (CEC) standards in use at the time.

Track inspection and recording had not identified the potential for derailment at the dips. Both the AK Geo. and CEC standards suggested the need for track geometry to be considered as a whole, and all geometrical parameters to be considered together to identify the potential for track condition that could lead to a derailment. Although analysis of the AK Car data showed no AK Geo. exceedances, a survey was made of the track after the derailment and CEC exceedances were identified.

Approximately 530 metres of track was damaged as a result of the derailment. No injuries were reported and no hazardous conditions resulted.

The report concludes that train 4VM9-V derailed as a result of the deteriorated condition of the track. The TSR imposed was not appropriate to the conditions existing at the time. A combination of infrastructure flaws associated with severe track twist faults appearing under rail traffic led to the occurrence. While weak track structure and geometry at the occurrence site were known, appropriate remedial action had not taken place.

Both AK Geo. and CEC standards note the need for track geometry to be considered as a whole. It was apparent that all geometrical parameters were not considered collectively to identify the potential for track conditions that led to the derailment.

Although the AK Car parameter graphs and raw data were available to infrastructure maintainers for further interpretation, no exceedences were identified or considered. In addition, the AK Car calibration, setup, measurement and analysis procedures appeared to have generated data inconsistencies.

The combination of wagon stiffness and compromised infrastructure state associated with track twist created conditions where it was most likely that the 12th cement wagon sustained roll-induced wheel unloading and subsequent flange climb followed by derailment.

Following the occurrence, safety actions corresponding with the evidence determined were initiated by the track infrastructure owner, the Australian Rail Track Corporation.

As a result of the investigation, a number of recommendations have been made in relation to:

• Modifications to track infrastructure inspection
• Track geometry parameters as a whole
• Standardised infrastructure methodology
• Modifications to the methods of assessment and use of the AK Car and its data

Executive summary

At about 1345 on Monday 11 October 2004 freight train DS212, hauling 54 fully loaded coal wagons from the Bloomfield Colliery balloon loop, derailed approximately 300 metres north of Thornton station platform. The majority of the train passed through the crossing before seven wagons derailed over 103 and 104 points at the main rail corridor junction. Three of the derailed wagons tipped over fouling the Up¹ and Down² Coal Roads as well as the Down Main Line.

Thornton is located on the main northern railway corridor between Sydney and Brisbane, 182.2 kilometres from Central Railway Station, Sydney. Thornton is on the railway section³ between Broadmeadow and Maitland, prescribed as part of the Defined Interstate Rail Network (DIRN). The railway corridor contains four standard gauge lines, an Up and Down Coal Road, and an Up and Down Main Line.

The train crew tried contacting Broadmeadow Train Control Centre but were referred to Maitland signal box. The signaller at Maitland noticed the transit lights for the points flashing, indicating that the ‘points detection’ had been lost. The signaller immediately placed all signals in that location at stop and applied blocking facilities. An approaching passenger train 747 on the Down Main Line at Beresfield was stopped by signals before the section of fouled track. The track circuiting⁴ over the Down Main Line was not affected by the derailment.

To assist the investigation an independent railway engineering organisation, Interfleet Technology Pty Ltd, was engaged to inspect the track and train to determine what factors contributed to the derailment.

Other freight train traffic had traversed the line earlier in the day without incident. The first half of train DS212 passed safely over the site before wagon NHRH 50245C derailed. This indicated that although the track-based elements were significant causal factors, it was a combination of the vehicle-based and track-based factors that led to the derailment.

The investigation concluded that the derailment occurred as a result of gauge widening at about 182.527 km due to poor rail fastener condition, in between 104A points and 104B catch points which allowed the right wheel, in direction of travel, of the third axle on the trailing bogie of wagon NHRH 50245C to drop into the four foot⁵. The adjacent right wheel on axle number three rolled the high rail⁶ outwards.

Given the lack of awareness of the poor and deteriorating condition of the high rail stability, a derailment at this location was inevitable without remedial action.

A number of safety actions have been taken, or are underway, through the New South Wales Independent Transport Safety and Reliability Regulator, Pacific National, and the Australian Rail Track Corporation. These safety actions included: the inspection of all branch line turnouts/junctions used by Hunter Valley coal traffic; the implementation of a plan to remediate infrastructure identified as deficient and/or non-compliant; and the inspection of rollingstock for asymmetric wheel profiles. Of the eleven branch line turnout/junction sites inspected, one site was found to be deficient and/or non-compliant. Pacific National found one bogie with significant asymmetric wheel wear and four bogies in the early stages of asymmetric wheel wear, all were at the end of effective service life.

The report makes a number of recommendations on pages 33 and 34 relating to: track monitoring and maintenance; reviewing the effects of asymmetric wheel wear on lateral track forces and rail safety; and reinforcement of network rules and procedures regarding the protection of trains.

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1. An Up line or train is a line or train heading towards Sydney.
2. A Down line or train is a line or train heading away from Sydney.
3. See appendix 6.1 for an area map.
4. An electric circuit that uses the rails of a railway track as conductors such that a train electrically connects them via its axles. The absence or presence of this rail-to-rail connection indicates the absence or presence of a train or item of rollingstock.
5. A colloquial term used to describe the gap between the rails (laid at standard gauge of 1435mm).
6. The high rail is the outer rail of railway track in a curve.

Executive summary

At 0738:06¹ on 20 September 2004 train 8868 passed signal FS66 when it was displaying a stop aspect. Train 8868 was a freight train from central Queensland bound for Fisherman Islands and was crewed by a driver who had signed on at Maryborough at 0050 the same day. Signal FS66 is about five kilometres from Fisherman Islands and about 100 metres from a busy road crossing at Pritchard Road.

Train 8868 reached Lytton Junction at about 0736 and was routed onto the Fisherman Islands branch line for the final section of the journey. The driver recollects passing through this junction and setting one of the train radios to the Fisherman Islands local control channel. He thinks he then fell asleep, as he remembers little until sensing that the train was travelling too slowly. The driver then applied full power until about 15 metres from signal FS66, by which time the train was travelling at 49 km/h. Being momentarily unaware of where he was, applying full power, noticing the cars on the level crossing before realising (when 15 metres away) that the signal was red, indicate only a partial state of arousal. A service rate reduction² of the brake pipe failed to stop the train from passing the signal and proceeding through the Pritchard Road crossing. Because of the rate of reduction and because the brake pipe pressure reduced to 229 kPa, well below the 350 kPa equalised pressure of a full service application, it is concluded that the brake handle was placed in the ‘handle out’ position and not in the emergency position. The ‘handle out’ position is the notch immediately before the emergency position.

As train 8868 passed signal FS66 the protection cycle for the level crossing was only partially complete and the boom barriers were not horizontal. Train 8868 stopped about 175 metres beyond signal FS66 and 74 metres beyond the level crossing.

The emergency response to passing FS66 on a red signal was initiated by the driver, who radioed the Mayne train control centre to tell them what had happened. The Mayne train controllers had no indication of what aspect signal FS66 was displaying, or whether the SPAD³ had occurred, as this signal was controlled by the area coordinator at Fisherman Islands. The area controller at Fisherman Islands did receive a SPAD alarm at his workstation but had not responded to it by the time the Mayne train controller called. Train 8868 remained across the level crossing for nearly 40 minutes until a relief driver arrived and moved the train.

The investigation found that the driver of train 8868 was probably experiencing microsleep episodes on the approach to signal FS66 and that this was the principal contributing factor in this incident. The investigation was unable to determine if this fatigue was ‘personally induced’ or ‘task induced’.

The investigation also found that the interface procedures between the Mayne train control centre and Fisherman Islands local control in combination with the structure of the Fisherman Islands area coordinator/station officer’s role have the potential to inhibit emergency response. Additionally, the lack of certain track and train secondary protection devices was considered to be an absent defence.

Safety actions recommended as a result of this investigation include the drafting of a fatigue management standard/policy, evaluation of secondary wayside safety devices, emergency procedure amendments, interface procedure amendments, training in these procedures and a review of attendance at the Fisherman Islands area coordinator/station officer workstation.

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1          0738:06 – Eastern standard time synchronised as described at section 2 of this report.

2          Service rate reduction – brake-pipe air vented to atmosphere at a controlled rate to apply consistent propagation throughout the length of the train.

3          SPAD – An acronym common to the rail industry that stands for ‘Signal Passed at Danger’.

Recommended Safety Actions

As a result of its investigation, the ATSB makes the following recommendations with the intention of improving railway operational safety. Rather than provide prescriptive solutions, these recommendations are designed to provide guidance to interested parties on the issues that need to be considered. Recommendations are directed to those agencies that should be best placed to action the safety enhancements intended by the recommendations, and are not necessarily reflective of deficiencies within those agencies.

RR20050036

The ATSB recommends that QR compile a fatigue management policy/standard to guide managers and workers in how to manage fatigue in planning and operational situations. This policy/standard should also provide guidance on how to deal with reported instances of fatigue.

RR20050037

The ATSB recommends that QR evaluate the installation of wayside secondary protective/prompt device/s in advance of signal FS66. Such device is to be compatible with all operators. This recommendation is made in light of the position of FS66 and the number of SPADs that have occurred at this signal.

RR20050038

The ATSB recommends that QR amend the emergency response procedures applicable to Fisherman Islands to ensure that initial notification of a SPAD is sent to the officer who has control of the signal in question.

RR20050039

The ATSB recommends that QR amend the interface procedures between Mayne train control centre and Fisherman Islands with the intention of ensuring that all trains are contactable by the Fisherman Islands area controller/station officer when in signalled territory controlled by the Fisherman Islands area coordinator/station officer. Boundaries of signalled territory should be clearly defined and current discrepancies in regard to radio channels and signal control should also be amended.

RR20050040

The ATSB recommends that QR undertake training of all concerned in regard to emergency response and interface procedures between the Mayne train control centre and Fisherman Islands.

RR20050041

The ATSB recommends that QR examine methods of ensuring continued attendance by appropriately qualified employees at the Fisherman Islands area coordinator/station officer workstation.

RR20050042

The ATSB recommends that the Queensland Railway Safety Regulator actively monitor the actions initiated by QR in response to this investigation.

Executive summary

Train Y245 passed signal MR5 at stop by 81.8 metres, about 500 metres short of a conflicting freight train movement. The driver of Y245 had previously passed a caution signal but, when only 439 metres from signal MR5, increased power as if proceeding on clear signals. When about 200 metres from signal MR5, an emergency brake application was made. The train controller supervising this section of track was temporarily absent from the workstation and this contributed to the 16 seconds it took to relay an emergency 'stop' radio transmission.

Train Y245 was crewed by a driver as the sole crew member and, apart from the locomotive vigilance devices, there were no secondary protection devices such as Automatic Warning System, Automatic Train Protection or Automatice Train Control at this location. The driver of train Y245 died on 26 October 2004 following a severe coronary episode. This and his previous involvement in SPAD incidents, where loss of concentration had been cited as a causal factor, led to the examination of this driver's state of health. This in turn led to an examination of the medical standards applicable to Queensland Rail drivers.

The investigation found that, while it was unlikely that partial incapacitation was a factor in the SPAD at signal MR5, the possibility could not be ruled out. It was also found that the investigations reports into the driver's previous SPAD incidents focused on the active factors in lieu of latent or systemic factors. Additionally, it was found that the process of returning this driver to full duties following previous SPAD's seemingly followed set patterns. Once returned to full driving duties, little evidence of additional monitoring or supervision was produced during this investigation.

Executive Summary

At 0335:08 on 15 March 2004, the trailing bogie of the second to last wagon of train 6SM9V, operated by Freight Australia, derailed as it departed the crossing loop at Alumatta. This train was a scheduled service from Sydney to Melbourne on the standard gauge network. There were no reported injuries as a result of this derailment either in the active or recovery stages, nor was there any adverse environmental impact.

6SM9V came to a stand at 0339:58, having travelled 5.579 kilometres from the point of departure at Alumatta. During this time four level crossings and one bridge were traversed and a maximum speed of 69 kph was attained. For 4.795 kilometres of this distance this train was travelling in a derailed state thereby inflicting damage to these installations, track, associated infrastructure and the two trailing wagons. At the final level crossing the derailed bogie became dislodged, causing the last wagon to lift, separate from the train and roll over to the eastern side of the track. The consequential loss of air and the actions of the driver brought the train to a stop about 895 metres beyond this level crossing. The train crew then used the local UHF radio to warn any broad gauge trains that may have been in the vicinity that train line air had been lost and the train may be foul.

Initially, the driver suspected a ruptured air hose and left the cab to find the fault and repair it. Advice of this occurrence and proposed actions were forwarded to the ARTC train controller at 0342:10. At 0353:10 the driver advised the ARTC train controller that he had reached the rear of the train and that the second last wagon was derailed and the last wagon was not in sight. At 0353:40 the ARTC train controller rang the Central train controller and instructed that no broad gauge trains be allowed into the vicinity.

This accident occurred on a section of the corridor where standard and broad gauge tracks parallel each other only metres apart. Both of these tracks are operated independently, having separate train control centres and differing safeworking systems with little readily identifiable transparency between them. The investigation has determined that the time taken to notify the Central train control centre was not in accordance with the existing safety management system requirements.

The investigation has determined that the probable cause of this derailment was the geometry of the track combined with the excessive speed of the rear of train 6SM9V as it exited the crossing loop. This led the left wheel of the third axle of the second last wagon to climb the eastern stock rail at the toe of the point blade of the cripple siding. It is probable though that neither of these two factors was, in itself, sufficient to cause the derailment.

Safety actions recommended as a result of this investigation are aimed at revising track standards and maintenance procedures, ensuring the rear of trains do not exceed speeds of curves or turnouts and improving communications between trains on what are essentially two separate rail corridors in one.

Executive summary

At 1303 on Wednesday 25 February 2004 an empty Endeavour passenger train D743 was placed on a collision course with a stationary loaded coal train LD166 at Sandgate. The crew of train D743 realised that number 157 points were in the wrong position and made an emergency brake application. Train D743 stopped about 75 metres short of train LD166.

Sandgate is located on the main northern railway corridor between Sydney and Brisbane about 170 kilometres from Central Railway Station, Sydney. The rail corridor contains four standard gauge tracks for non electric powered trains.

Train D743 was a relief train from Newcastle provided to render assistance to passenger train 604 which had broken down on the Up Main line at Beresfield station platform. The following two passenger trains 736 and 738 on the Up Main line were diverted to the Up Coal Road at Thornton to bypass train 604. Trains 736 and 738 were diverted back onto the Up Main line at Sandgate through number 157 points.

The wrong direction movement of train D743 via the Up Main line was controlled by a Special Proceed Authority (SPA) issued by the train controller at Broadmeadow and Yard Working authorised by the signaller. Train movements in the Sandgate area are controlled by a signaller located at Hanbury Junction signal box, 2.575 kilometres southeast from Sandgate station. Normal signal protection (unidirectional) could not be used for the wrong direction movement. The movement was manually controlled by the signaller. In addition to delayed trains and increased traffic movements, there were a number of factors competing for the signaller's attention.

The investigation concluded that the incident occurred because the signaller did not check the intended route for train D743 thoroughly or apply blocking facilities to the greatest effect to protect the route. Number 157 points were in the reverse position after the passage of train 738. Blocking facilities are physical devices used as memory aids for the signaller to prevent inappropriate issue of Proceed Authorities, or signalling or point equipment operation.

Summary

On 7 October 2004 two crew members were killed and three others seriously injured when Lowlands Grace's port lifeboat became detached from its falls during a lifeboat drill. The ship, a Hong Kong registered cape-sized bulk carrier, was at anchor off the port of Port Hedland, Western Australia, at the time of the accident.

Investigation revealed that the lifeboat's after hook had failed where it was attached to the keel while the boat was being lowered. The lifeboat's stern had then dropped, and the boat rotated around the remaining forward fall before the forward hook opened under the load of the swinging boat. The lifeboat then fell upside down into the sea approximately 16 metres below.