Rail safety investigations & reports

Derailment of grain train 9054 near Pyramid Hill, Vic. on 5 March 2013

Investigation number:
Status: Completed
Investigation completed


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What happened

At 0055 on 5 March 2013, Pacific National grain train 9054 derailed at the O’Tooles Road level crossing near Pyramid Hill in northern Victoria. The train derailed about midway through the crossing at pre-existing fractures in one of the rails.

The train comprised three locomotives and 40 loaded grain wagons. Nineteen of the first 20 wagons derailed resulting in severe damage to wagons, a significant loss of grain load and damage to about 270 m of track. The train crew were uninjured.

What the ATSB found

The ATSB found that a small section of one rail had broken away during the passage of the Swan Hill bound passenger service 8045 at about 2240 earlier that night. The fractures in the rail had occurred as a result of the rail’s heavily corroded and wasted condition.

The poor condition of the rail had not been detected by the network manager, V/Line, which had relied on ultrasonic testing to identify rail defects. The track inspection regime did not include sufficient supplementary systems for monitoring the condition of buried track at unsealed level crossings.

The construction method used at unsealed crossings increased the risk of this type of failure. Burying the rail web and foot with road materials increased the potential for corrosion and limited the effectiveness of above-ground visual inspection.

This derailment follows a similar event at Warracknabeal in 2011 that was also investigated. Action taken by the network manager following that event did not fully address the identified limitations of the inspection regime for unsealed level crossings.

What's been done as a result

Following the incident, V/Line examined 13 per cent of unsealed crossings in its network and the results were used to develop recommendations for other unsealed level crossings across the V/Line network. V/Line asset management systems are to be updated with improved maintenance requirements for unsealed crossings, and a review will be undertaken of crossing construction methods to determine whether the existing standard of construction is the most appropriate method. These safety actions are ongoing and their success at reducing risk will depend on the effectiveness of their implementation.

In addition, the effectiveness of ultrasonic inspection of rail at unsealed level crossings has been improved, including the development of additional procedures and training specific to the identification of corroded rail at level crossings. 

Safety message

The design, construction and inspection of level crossings at unsealed roads should ensure that track remains fit-for-purpose throughout the life of the asset. Inspection regimes must ensure that where technologies, such as ultrasonic testing, have identified limitations other measures are in place to identify track degradation.

Download Final report
[Download  PDF: 3.71MB]

Safety Issues

Go to RO-2013-010-SI-01 - Go to RO-2013-010-SI-02 - Go to RO-2013-010-SI-03 -

Track inspection regime

The track inspection regime did not identify the deteriorated rail condition at the O’Tooles Road level crossing. The regime placed an over-reliance on ultrasonic testing and did not include sufficient supplementary systems for monitoring the condition of buried track at unsealed level crossings.

Safety issue details
Issue number: RO-2013-010-SI-01
Who it affects: Owners and operators of rail infrastructure
Status: Safety action pending

Ultrasonic inspection

The ultrasonic testing regime was not effective in consistently identifying corrosion and wasting of the rail web at unsealed level crossings.

Safety issue details
Issue number: RO-2013-010-SI-02
Who it affects: Owners and operators of rail infrastructure.
Status: Adequately addressed

Construction of level crossing at unsealed roads

The method of constructing crossings at unsealed roads heightened the potential for corrosion and track degradation and limited the opportunity for effective visual inspection. The network standard for crossing construction did not directly address the particular challenges of unsealed roads.

Safety issue details
Issue number: RO-2013-010-SI-03
Who it affects: Owners and operators of rail infrastructure.
Status: Partially addressed
General details
Date: 05 March 2013   Investigation status: Completed  
Time: 0100 EDT   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): O'Tooles Road Level crossing near Pyramid Hill    
State: Victoria    
Release date: 29 April 2015   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator V/Line  
Train operator Pacific National  
Train registration 9054  
Type of operation Freight  
Damage to train Substantial  
Departure point Piangil, Vic  
Destination North Geelong, Vic  
Last update 03 April 2020