Rail safety investigations & reports

Loading irregularity on train 6MC2 near Bowser, Victoria, on 24 July 2015

Investigation number:
Status: Completed
Investigation completed

Final Report

Download Final Report
[Download  PDF: 1.48MB]

What happened

On 24 July 2015, container freight train 6MC2 lost two containers from the train as it passed through Bowser, north of Wangaratta. The two containers lost from the train landed clear of the track on the eastern side. The train continued its journey with the crew unaware of the incident.

At about 0430 the following morning, the driver of another freight train noticed a container and reported it to train control.

What the ATSB found

The ATSB found that it was very likely that the twist locks that secured the containers to the train were ineffective prior to the incident. This condition allowed the unsecured containers to fall from the train. It is probable that strong winds contributed to the movement of the unsecured containers. Other external forces, such as train and track dynamics, may have also contributed to the movement. However, there was no evidence of such contribution.

Given the containers were located some distance behind the locomotives, and that no other train operational systems were affected when they fell from their respective wagons, the train crew were not aware of the incident.

What's been done as a result

As a result of the incident, Pacific National undertook an internal investigation into the incident and has taken action to:

  • initiate a process to include checks for twist lock operation as part of wagon maintenance and inspection
  • develop a twist lock inspection manual
  • update freight loading manuals to include methodology for identifying defective twist locks
  • update wagon maintenance manual to include methodology for identifying defective twist locks
  • update twist lock training materials to include identification of defective twist locks
  • initiate a review of twist lock integrity history
  • initiate a review of twist locks currently in service – supply and type
  • calculate the failure rate of twist locks across the Intermodal fleet for probability and risk mitigation considerations.

Safety message

Rail operators should satisfy themselves that their procedures can ensure that all twist locks are effective at securing freight containers to their respective wagons before the transit of trains.

Download Final Report
[Download  PDF: 1.48MB]

The occurrence

Safety analysis

Safety actions


To download, click the link, then right-click and select Save As.

Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations and should be credited accordingly.

General details
Date: 24 July 2015   Investigation status: Completed  
Time: 1800 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Between Wangaratta and Springhurst    
State: Victoria    
Release date: 19 August 2016   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Australian Rail Track Corporation (ARTC)  
Train operator Pacific National  
Train registration 6MC2  
Type of operation Container  
Sector Freight  
Damage to train Minor  
Departure point Melbourne, Vic  
Destination Ettamogah, NSW  
Last update 14 November 2018