At 0244 on Tuesday, 29 June 2004, the fishing vessel Ocean Odyssey collided with the container ship P&O Nedlloyd Taranaki in the approaches to Port Botany, New South Wales. At the time of the collision P&O Nedlloyd Taranaki was 'not under command'¹ with a main engine breakdown and was in a position with Cape Banks light bearing 327(T) by 4.7 miles. Ocean Odyssey sustained damage to its hull and deck in the collision and returned to Sydney immediately for repairs. P&O Nedlloyd Taranaki sustained only slight scratching to the paintwork on the ship's side.

¹ 'Not under command', means a vessel which through some exceptional circumstance is unable to manoeuvre as required by the International Regulations for the Prevention of Collisions at Sea, 1972, and is therefore unable to keep out of the way of another vessel.

Summary

At about 0200 on 16 April 2004, the duty engineer on board the Panama registered bulk carrier Harmonic Progress discovered that the main ballast line was leaking, and the engine room bilge was filling with the ballast water. Despite an immediate temporary repair and utilising pumps to try and clear the bilge, the water level continued to rise until it reached a height at which it caused an electrical short in both main engine lubricating oil pump motors, which disabled the main engine.

The master reported the engine room flooding to the ship's managers who arranged for two tugs to take the ship in tow. The ship was in the Coral Sea, approximately 90 nautical miles north of Hydrographers Passage, when it became disabled. During the 43 hours the ship drifted, prior to the arrival of the first tug, it covered 104 nautical miles in a westerly direction. During the time adrift, the ship came to within 30 nautical miles of the Great Barrier Reef.

Harmonic Progress was towed to the Queensland port of Gladstone, where initial repairs were undertaken in order to enable the ship to proceed under its own power to Brisbane. At Brisbane, Harmonic Progress entered dry dock, where inspection, repair and testing of ballast valves and pumps took place. No one on board was injured during the incident and no pollution resulted.

The report concludes that:

• A leak in the main ballast line caused the flooding of the engine room to a level in excess of 1.5 m, which led to the main engine lubricating oil pump motors short circuiting and the vessel becoming disabled.
• A combination of corrosion and erosion caused wastage in the main ballast line, which directly led to the leak.
• Leaking butterfly valves in numbers two and three (port) topside water ballast tanks led to the two tanks draining into the engine room via the leak.
• A crossover valve on the main ballast line in the engine room had not been closed after ballast operations.
• The crew did not isolate the leak by checking associated valves early enough to prevent disabling of vessel.
• Early action was not taken to prevent the water level rising to the point where the lubricating oil pump motors short circuited.
• The crew were unfamiliar with the ballast system and did not use a systematic approach to find the source of the water leaking from the ballast line.
• The pre-delivery inspection of the ship prior to the change of ownership is suspected of being inadequate.

The report recommends that:

• Ship operators and managers ensure sufficient time is made available for handover of information to key personnel when changes of crew or ownership take place.
• Ship owners, operators, manager and masters should revise ISM procedures for ballast operations to ensure they are specific to their ships.
• Classification societies should consider the inclusion of regular ballast line thickness testing around known risk areas, such as 'T' junctions during the enhanced survey program for bulk carriers and oil tankers. This is particularly applicable to ships over 15 years of age.
• The IMO should consider including the possibility of engine room flooding contingency in SOPEP manuals.
• Classification societies and owners acquiring existing ships should make it a condition of sale that all the ship's maintenance records are retained on board.

Summary

At 1900 on 26 February 2004, the Bahamas registered passenger ship Astor let go its mooring lines and departed the Queensland port of Townsville.

The ship, equipped with twin rudders, controllable pitch main propellers and a single bow thruster, did not require a tug for the departure. The master, as is common practice on passenger ships, manoeuvred the ship clear of the berth and then, even though this was his first visit to Townsville, kept the conduct of the ship without consulting the harbour pilot. The pilot adopted an advisory role.

As the ship was turning from the harbour into Platypus Channel, part of the approach channel to the port, it grounded on its port side. The ship heeled three degrees to starboard and, after about three minutes, slid clear of the bank without assistance and continued out of the channel.

After it had cleared the channel, the ship stopped for about two hours to check that the hull was not breached and that all machinery was operating normally. Immediately upon notification of the grounding, the Australian Maritime Safety Authority (AMSA) placed a detention order on the ship until the ship's classification society was satisfied that Astor was seaworthy. When it was confirmed that the hull and machinery were in proper condition the detention order was lifted and the ship then proceeded to Cairns. At Cairns, an underwater survey of the hull was carried out to ascertain the extent of any damage.

Based on the available evidence the report concludes that:

• The investigation has been unable to determine the degree, if any, to which a reported steering malfunction contributed to the grounding.

The following factors, however, are considered to have contributed to the incident on 26 February 2004, independently from any steering malfunction:

• The master did not accept the pilot's advice after the ship left the berth.
• Communications on the bridge were in a language the pilot was not able to understand.
• The ship's master and bridge team members did not employ good Bridge Resource Management practices at any time leading up to the grounding.
• The master had not positioned the ship correctly for a turn to starboard into Platypus Channel.
• The master did not present an outward passage plan to any of those present on the bridge at the time of departure.

The investigation into the grounding of Astor was complicated by the fact that Voyage Data Recorder (VDR) data was not backed up in the time immediately after the grounding (highlighting a deficiency in crew training in this important facet of ship operations) and by the fact that company procedures were not followed with respect to the keeping of bridge records.

The investigation showed that crucial VDR information is easily lost by unintentional actions.

Of additional concern to the safety of navigation and the prevention of pollution on the Australian coast is that the master did not declare any steering defect to the Cairns pilot or port authority and Astor entered the Cairns Channel using only one steering motor on the port rudder without the pilot's knowledge.

This reports recommends that:

• Ship owners, managers, operators and masters of ships ensure that all bridge staff are fully trained in the correct operation of VDR data backup procedures for the particular ship on which they are serving.
• Manufacturers of VDR units should ensure that indicator lights are free of any possible ambiguity and that consideration be given to printing emergency backup instructions on VDR control panels on ships' bridges.
• Masters of vessels should not actively con the ship directly during pilotage unless they are familiar with the port and they do so in full agreement with any pilot.
• Ships' masters should ensure that all bridge orders in pilotage waters are in a language understood by pilots and ships' staff.
• Ship owners, managers and operators should instruct masters and ships's to use all elements of effective Bridge Resource Management at all times.

On 11 March 2004, while assisting with cargo hold repairs at anchor off the Queensland port of Hay Point, an engineer cadet fell from a hold ladder, landing on the tank top about ten metres below. He died from his injuries before an emergency medical helicopter, with a doctor on board, landed on the ship.

At about 0400 on the 5 January 2004, the Malaysian flag bulk carrier Bunga Orkid Tiga and the Australian fishing vessel Stella VII collided near Creech Reef in the Great Barrier Reef. This was the twenty-sixth collision between a trading ship and an Australian fishing vessel since April 1994.

Neither vessel was keeping a proper visual lookout in the time leading up to the collision. This report, as do previous ATSB reports regarding collisions, emphasises the need for all vessels to maintain a proper lookout at all times.

Executive summary

Train 6WP2 operated by Pacific National Ltd (PN) derailed at 2222 (central summer time) on Sunday 9 November 2003 as it was passing through Bates, South Australia. The train had departed Port Augusta that morning and was proceeding to Perth, Western Australia.

The derailment was limited to wagon number RKCX24 positioned 21st in a train of 73 wagons. The condition of a Roller Bearing Unit (RBU) on the right hand third axle of the wagon had progressively deteriorated to a point where friction induced heat caused the portion of axle between the RBU and the wheel to become 'plastic ' causing the RBU to seize where upon the axle separated or 'screwed' off as the axle turned.

After approximately 200 metres in this state, the leading end bogie side frame dropped to the outside of the right hand rail. The wheels did not leave the rails until reaching the western end of Bates where the crossing loop points caused a destabilising effect. The train was brought to a stop in just over 1000 metres by the train crew from a speed at the time of derailment of 77 km/h.

Approximately 1,275 metres of track sleepers and 150 metres of rail were damaged as a result of the derailment. No injuries were reported and no dangerous goods were involved.

It was concluded that train 6WP2 derailed due to the failure of a RBU on wagon RKCX24. A number of causal factors relating to bearing roller assembly cage failure were identified in the investigation associated with: bearing refurbishment and assembly; storage; and handling of the wheel set.

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.