Rail safety investigations & reports

Derailment of bogie on freight train 4PM6 at Port Augusta, SA, 6 May 2011

Investigation number:
Status: Completed
Investigation completed


Download Final Report
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Alternate: [Download  DOC: 8.14MB]

What happened

On 6 May 2011, the trailing bogie on the 47th wagon of freight train 4PM6 derailed after traversing the Carlton Parade level crossing at Port Augusta, South Australia. The wagon travelled over a second level crossing and re-railed itself when it entered a third level crossing about 1,300 m later.

The train continued towards Adelaide before it was stopped at Winninowie after the network controller had been alerted that the train was emitting sparks and that the half-boom barriers remained down and that warning devices continued to operate at the two level crossings.

What the ATSB found

The ATSB’s investigation found a number of factors affecting the passage of train 4PM6 due to the degradation of the track geometry in a short section of line after the Carlton Parade level crossing. Multiple track defects requiring urgent and priority attention in this short section had been detected by a track geometry car inspection 3 months before the derailment and there was a 30 km/h temporary speed restriction (TSR) in force at the time. However, the defects had not been adequately assessed and controlled in accordance with the Australian Rail Track Corporation (ARTC) Track and Civil Code of Practice and the 30 km/h TSR was probably inadequate to minimise the risk of derailment.

The investigation also found that track geometry defect exceedence reports did not contain fields to record the date and time as confirmation that field inspections had been carried out in accordance with the Code of Practice.

What has been done as a result

The ARTC through its Alliance Partner Transfield Services has undertaken additional training in the ARTC Track and Civil Code of Practice. This includes the responses required when multiple localised geometric defects are found.

The ARTC is also developing an improved reporting format for data from the track geometry car measurements for use in all states following the introduction of the new National Code of Practice - Track Standards.

Safety message

Multiple geometric track defects that are located in close proximity to each other significantly increase the derailment risk to rail traffic. The track condition should be thoroughly assessed and managed to ensure that appropriate speed restrictions are imposed until the track can be reinstated to design standards.

Download Final Report
[Download  PDF: 2.65MB]
Alternate: [Download  DOC: 8.14MB]


Download Preliminary Report
[Download  PDF: 312KB]
Alternate: [Download  DOC: 385KB]

Preliminary report released 21 July 2011

At about 2016 on Friday 6 May 2011, freight train 4PM6 derailed the trailing bogie of the 49th wagon (RQHY 07069C) at Port Augusta, South Australia near the Carlton Parade level crossing (91.559 km). About 1300 m later, the wagon re-railed itself as it entered the road pavement near the Stirling Road level crossing. There were no injuries as a result of the derailment but there was minor damage to rolling stock and track. The investigation is reviewing a number of factors including the condition of the track and rolling stock, train speed and the interaction of rail wagons and the track through this location.

Download Preliminary Report
[Download  PDF: 312KB]
Alternate: [Download  DOC: 385KB]

Safety Issues

Go to RO-2011-008-SI-01 - Go to RO-2011-008-SI-02 -

Assessment of Multiple Geometric Alignment Defects

The urgent and priority category defects detected by the AK Car on 4 February 2011 that were located within a 20 m track section were inadequately assessed and controlled in accordance with the ARTC Track and Civil Code of Practice.

Safety issue details
Issue number: RO-2011-008-SI-01
Who it affects: Rail Infrastructure Owners and Maintainer
Status: Adequately addressed

Exceedence report fields

AK Car defect exceedence reports produced on 4 February 2011 did not include fields to record the date and time of follow-up field inspections and to show that these inspections and assessment of defects were completed in accordance with the ARTC Track and Civil Code of Practice.

Safety issue details
Issue number: RO-2011-008-SI-02
Who it affects: Managers of Rail Infrastructure
Status: Adequately addressed
General details
Date: 06 May 2011   Investigation status: Completed  
Time: 2016 CST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Port Augusta    
State: South Australia    
Release date: 21 January 2013   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Train operator Pacific National  
Train registration 4PM6  
Type of operation Freight train  
Damage to train Minor  
Departure point Perth, WA  
Destination Melbourne, Vic  
Last update 03 April 2020