On 28 November 2003, Pacific National freight train 2PW4-N travelling between Perth and Wollongong via Melbourne derailed two wagons after traversing a buckled rail at Ararat in Western Victoria. No injuries resulted from the derailment.

Ararat is located on the main railway corridor between Melbourne and Adelaide, approximately 265 kilometres from Spencer Street Station in Melbourne.

Executive summary

At about 15:58 on 23 May 2003, the Sunlander passenger train 3C37 collided with a Ford Falcon station wagon at the Hesp Road/Bennett Road public level crossing on the North Coast railway line approximately 700m south of the small town of Aloomba, south of Cairns North Queensland.

There were three occupants in the car, a woman, who was driving, and her two male children, of seven and five years in the rear seats. The seven year old, was seated on the left hand side with a seat belt fastened, the five year old was on the right hand side in a purpose designed child seat and restraints. The seven year old male child was pronounced dead at the scene. The woman and five year old child were taken to hospital, the child suffering from severe head injuries.

Although the driver of the car initially stopped, she either did this in automation mode and did not check that the line was clear, or she did not see the train before starting over the level crossing.

The investigation established some problems with the approach angle and sighting distance of cars approaching the crossing from Moller Road and Fixter Road. There was also an absence of pavement markings associated with the passive protection for this level crossing.

The signage at the Hesp Road/Bennett Road level crossing has been upgraded and pavement markings renewed following this accident.

The investigation recommends that in accordance with the requirements of the Level Crossing Upgrade Program, the crossing be re-assessed in light of this report and that the proposals to meet the risk threshold and compliance be implemented as a matter of priority.

Executive summary

On Sunday 16 March 2003, at about 1508:45 Eastern Summer Time, a Pacific National freight train 1SP2N travelling from Sydney to Perth via Melbourne derailed at the 265.115 kilometre point, a location 7.112 kilometres south of Chiltern railway station on the standard gauge railway line. The train was carrying steel products and various other goods.

At about 1512 a V/Line locomotive hauled passenger train 8318, travelling from Albury to Melbourne on the broad gauge railway line, collided with wreckage from derailed train 1SP2N. The collision derailed the locomotive and two carriages of train 8318.

No serious injuries were reported by either train crew or passengers.

Chiltern is located on the main railway corridor between Sydney and Melbourne, approximately 272.227 kilometres from Spencer Street Station. The rail corridor contains two tracks, one broad gauge and one standard gauge. The standard gauge track is controlled and managed by the Australian Rail Track Corporation (ARTC) located in Adelaide. The broad gauge track is controlled and managed by Freight Australia located in Melbourne.

The derailment of train 1SP2N was caused by a 'screwed journal' on a wagon located in the 15th position of the train consist. The wagon had reportedly been in storage for several years and had been reintroduced into service. The screwed journal was the result of a failed wheel bearing due to a loss of interference fit on the axle journal. Heat (from friction) built up to a point at which the bearing seized and the journal detached from the axle. The wheelset then became unstable causing the derailment.

Maintenance schedules for the bearing were based on distance travelled, rather than a combination of distance and time. The maintenance history for the wagon was significantly degraded as a result of time and changes of ownership. The lack of bearing history allowed an ineffective analysis of the history and points to a deficiency in the system that may indicate poor practice at that time.

There was an about two minute window from the time train 1SP2N came to a stand, up to the time the driver of train 8318 applied the emergency brake, to try and stop train 8318 before the derailed train. In that time the drivers from train 1SP2N had repeatedly tried to warn train 8318, but were unsuccessful. The drivers also followed procedure by notifying ARTC train control but the message was delayed by four minutes before being relayed to the broad gauge train control(Centrol), not in time to prevent the collision.

A number of reports from previous incidents at Hexham, Elders Block Point and Wodonga were reviewed by the investigation team for any similar factors. In both the past incidents and the derailment at Chiltern, deficiencies were evident in the emergency communications between train control centres.

The investigation identified a number of contributing factors including wagon maintenance; inadequate industry standards or 'best practice'; and communication systems, condition, procedure and use.

Pacific National has already initiated changes to the maintenance procedures for wagons.

The report makes a number of safety recommendations in Section 6.1 relating to:

• Bearing maintenance based on distance and time;
• Reviewing procedures for rolling stock entering service after extended periods of storage;
• A review of communications procedures between train control centres;
• A review of emergency train radio procedure training;
• Consideration of communication system update and/or upgrade; and,
• Consideration of the implementation of minimum standards for roller bearings.

Executive summary

Shortly before 2118:17¹ on 3 February 2003 a driverless empty suburban train, numbered as 5264, rolled away from Broadmeadows Station under the influence of gravity and subsequently ran largely downhill for 16.848 kilometres to Spencer Street Station. At about 2133 train 5264 collided with the stationary Bacchus Marsh train 8141 at platform two on Spencer Street Station. The estimated speed at impact with the Bacchus Marsh train was 75kph. The leading car of train 5264 was extensively damaged, as was the locomotive of the Bacchus Marsh train. Both trains were derailed as a result of the impact, the Bacchus Marsh train being forced back some 22 metres in the process. The driver of the Bacchus Marsh train and a V/Line employee jumped clear seconds before impact.

Emergency services, including the police, fire and ambulance services attended the scene. There was no fire, no fuel spill or trapped persons. Eight passengers in the two occupied carriages of the Bacchus Marsh service were injured. Four of the injured persons were treated on site and four were conveyed to local hospitals. None of the injuries were serious.

Train 5264 rolled away from Broadmeadows Station due to a release of brakes as the driver was using the station amenities in the process of changing ends in preparation for the return journey to Melbourne. All passenger doors were open, all carriage saloon lights were illuminated and the passenger indicator display on Broadmeadows platform was displaying the correct information for the intended journey of train 5264. The gradient between Broadmeadows Station and Spencer Street Station is predominantly falling, there being an overall height difference of 116 metres between these two stations. The runaway train reached speeds in excess of 100kph and passed through level crossings and pedestrian crossings well in excess of design speed.

The investigation team has determined that the release of brakes was due to the manner in which the driver's controls were isolated and that the unplanned movement was due to the park brake not being applied.

The investigation team determined that it was not possible for Metrol officers² to control or stop the runaway movement. Metrol officers did not know whether or not there were passengers on the train and this constrained their assessment of options such as seeking to derail the train or route it into a siding. Metrol officers were forced to formulate contingency measures 'on the run'. The efforts of Metrol officers in this regard were severely hampered by the lack of visual indication of the train position and a system of voice communications that is not optimised for contingency broadcasts. For the majority of the journey, Metrol officers were relying on third party information being relayed from station and signalling personnel in the field.

In addition, the speed of the runaway train was significantly in excess of normal scheduled services. Consequently, many of the people involved experienced difficulty in adjusting their mental model of where they expected the train to be between Broadmeadows and its final destination at Spencer Street Station, compared with third party reported sightings.

Train 5264 came within a second of being placed on a collision course with the previous Broadmeadows to Flinders Street Station train, number 5262, in the vicinity of North Melbourne. Train 5262 had between 30 and 40 passengers on board.

The investigation team determined that Metrol officers made a conscious decision to route train 5264 into the unwired precinct of Spencer Street Station. If they had not done so, the train would most likely have continued into the 'heart' of the Melbourne suburban network towards Flinders Street Station.

No advance warning of the impending high-speed arrival of train 5264 was conveyed to railway personnel or members of the public at Spencer Street Station. The investigation team found that a number of factors played an important role in this failure.

The investigation established that neither train maintenance nor track maintenance was a factor in the accident. Safety systems designed to stop trains in the event of unauthorised movement are foot and hand pilot valves (often referred to as dead man's handle and pedal), trackside signals and train stops. These devices are effective only when the driver's controls are activated and a driver is in attendance. In this instance the driver's controls were isolated and no driver was in attendance.

Fatigue and the medical condition of the driver of train 5264 and relevant Metrol and field employees were not factors in the accident.

A number of remedial and positive safety actions have been taken or are under way through the Victorian Department of Infrastructure.

The report's recommendations in section 6.2 relate to:

• engineering an automatic application of the park brake when the driver's controls are isolated;
• reviewing and consolidating procedures for changing ends;
• mandating the application of the park brake when the driver's cab is vacated in all instances;
• auditing of driver's actions, isolating driver's controls;
• voice communications across the Melbourne network to be critically examined;
• visual indications in the form of 'real time' display of train movements at the Metrol control centre;
• general training for Metrol staff on train characteristics;
• maintenance on suburban electric trains;
• updating the 'Emergency Response Plan Trains Division';
• training in relation to the 'Emergency Response Plan Trains Division'; and
• minimising the potential for roster induced fatigue.

¹ This is the time recorded by the POTS transponder located at the Up end of Broadmeadows platform. The POTS system tracks train position and records data via interaction between train and track transponders. For a description of the POTS system see section 3.14.5 of this report.

² Metrol officers - network control officers, train controllers, signallers and so on who staff the metropolitan train control centre.

On 7 September 2003, two crew members on Pacific Wisdom were injured and one subsequently died. The two men fell about 12 metres to the bottom of an empty cargo hold after a scaffold on which they were working collapsed.

Summary

At 0400 on 21 August 2003, the Maltese flag bulk carrier Lancelot was off Diamond Head, on the New South Wales coast, heading south to Newcastle. The visibility was good and the second mate had earlier sighted the lights of a group of four fishing vessels to starboard. He used the automatic radar plotting aid (ARPA) to assess their movements. When the mate took over the watch, he too used the ARPA to plot the movements of the approaching fishing vessels.

The ARPA indicated that the nearest fishing vessel was on a reciprocal course and that its closest point of approach (CPA) was more than one and a half; miles¹ to starboard. Soon afterwards, however, the mate noticed that it was crossing from starboard to port. He altered the ship's course to starboard, clearing the other vessel, before ordering the original course resumed.

The mate then realised that the second fishing vessel was on a collision course, and he ordered the helm 'hard to port', attempting to steer away from it. However, the fishing vessel continued to close with the ship and, when the mate realised that a collision was imminent, he ordered full starboard rudder to minimise the angle of impact. At 0427 the two vessels collided.

The four fishing vessels had sailed from Forster earlier that night. At 0230, on board Jenabar, the second vessel in the group, the skipper, who had kept the initial watch, handed over to one of the deckhands. The watch changed again at 0330 when a second deckhand took over. The vessel, on autopilot on a north-easterly course, was heading for an area off Port Macquarie with the other fishing vessels. At 0425 the deckhand, who was seated at a table in the wheelhouse, said that he had checked the radar and had seen no sign of a ship. However, a minute or so later, when he looked out, he saw the dark shape of a ship, extremely close, on the starboard bow. Before he could get to the helm and disengage the autopilot, the fishing vessel had collided with the ship.

Though the fishing vessel was extensively damaged above the water line, none of its crew of four was injured. The ship turned to assist but, after being informed by Jenabar's skipper that assistance was not required, resumed its voyage to Newcastle. Jenabar returned to Forster to have the damage surveyed and to organise repairs.

This report concludes that:

• There was no evidence that Jenabar had made any significant change of course in the hour before the collision.
• The mate on Lancelot did not check compass bearings of the approaching fishing vessels to assess the risk of collision nor were his alterations of course to port to prevent the collision at about 0420, and again at 0423, appropriate.
• The moderate seas and the size and construction of Jenabar would have adversely affected its radar detectability.
• The bright deck lights on the fishing vessels obscured their navigation lights.
• The deckhand on watch on Jenabar at the time of the collision was not keeping an adequate or effective lookout and, as a result, only noticed the ship moments before the collision.

The report recommends that:

• Ship owners, operators, managers and masters, fishing vessel owners, operators and skippers should ensure that the requirements for watchkeepers to keep a proper lookout, visually and by radar are understood and complied with
• The National Marine Safety Committee (NMSC) and State and Territory marine authorities should review the minimum qualifications for watchkeepers on fishing vessels
• The NMSC and State and Territory marine authorities should ensure that guidance on procedures for watchkeeping and safety of navigation applies to all vessels
• Radar manufacturers' operating manuals should contain explicit instructions for setting up ARPAs for collision avoidance.

¹ Miles refers to nautical miles. One nautical mile = 1852 metres.

On 20 October 2003, a class society surveyor was conducting a safety equipment survey on board the Panamanian tanker Port Arthur at the bulk liquid berth at Port Botany, NSW. During the survey, the hooks of the starboard lifeboat released and the boat fell almost vertically, bow first, into the harbour. Its crew of four suffered various injuries.

Summary

At about 0001 on 29 May 2003 the 225 m long Panama flagged bulk carrier Asian Nova fouled the warps of the Australian fishing vessel Sassenach. The prawn trawler was dragged against the hull of the bulk carrier, damaging its port quarter and causing it to capsize and sink.

Sassenach's skipper lost his life as a result of the collision, his body was recovered from the sunken trawler on 5 June 2003. The deckhand was able to jump clear at impact and was rescued some five hours later by a searching fishing boat.

Immediately after the collision Asian Nova's master was called to the bridge, the vessel was stopped and the incident reported. Asian Nova remained on scene until released by Reefcentre.

The report concluded:

1. The third mate's course alteration to starboard just after 2330 was insufficient to provide an adequate passing distance astern of Sassenach.
2. The third mate's decision to make the relatively small alteration to starboard was made on the basis of information provided by the ARPA but was not in accordance with the company's instructions or good watchkeeping practice.
3. The third mate had sufficient sea room to make a bold alteration.
4. The proximity of the fishing vessel at the change of the watch meant that the third mate should not have handed over control of the watch until passed and clear of the fishing vessel.
5. Neither the second nor third mates followed the recommended practice, nor company requirements, or the ship's standing orders when handing over control of the navigational watch.
6. The second mate resumed the course marked on the chart before properly assessing whether it was safe to do so.
7. The second mate did not keep a proper lookout.
8. Inter-personal relations were possibly a factor in the deficient hand-over between the third and second mates.
9. The assessment by the fishing vessel crew that Asian Nova was passing clear was made on scanty information.

On 17 May 2003, three engineers were burned, one severely, while the Panama flag bulk carrier Medi Monaco was alongside in the port of Geelong, Victoria. The engineers were burned when the auxiliary boiler furnace 'flashed back' four times in succession during maintenance.

Executive summary

On 22 September 2002 the catastrophic failure of the main engine turbocharger disabled the cement carrier Goliath in Bass Strait. The replacement turbocharger failed in a similar manner on 12 February 2003, only four and a half months later, when Goliath was off Jervis Bay, again disabling the ship.

At 0107 on 22 September 2002, the Australian flag bulk cement carrier Goliath experienced a main engine turbocharger failure while the vessel was en route from Newcastle to Devonport when the turbocharger 'exploded' and disabled the ship's main engine.

At 1543 on 12 February 2003, while Goliath was en route from Devonport to Sydney, the turbocharger failed again. This time, the failure was witnessed by the second engineer who heard the rapid acceleration of the turbocharger before it exploded. Once again, the turbocharger had been damaged beyond repair and the ship was disabled.

The investigation report concludes that both turbocharger failures were similar and had occurred when the compressor discs burst due to overspeed. While it is not possible to state with certainty, the most likely mechanism leading to both overspeeds was a scavenge fire in the engine.

The ATSB delayed the release of these final investigation reports because of litigation involving the parties and because the investigations preceded and were not protected under the Transport Safety Investigation Act 2003.