Rail safety investigations & reports

Derailment of grain train 9156 at Ouyen, Victoria on 29 December 2015

Investigation number:
RO-2015-029
Status: Completed
Investigation completed

Final Report

Download Final Report
[Download  PDF: 2.53MB]
Alternate: [Download  PDF: 2.53MB]
 

What happened

On 29 December 2015, Pacific National grain train 9156 was travelling on the V/Line regional network from Carwarp in north-western Victoria to Geelong. The train consisted of two locomotives and 40 wagons.

At about 1713, the train was passing over the William Street level crossing in Ouyen travelling at about 40 km/h and was braking to stop at Ouyen Railway Station. As it crossed William Street, 12 loaded grain wagons located mid-consist derailed. The train came to a stand straddling the crossing. There were no injuries to train crew or members of the public.

There was extensive damage to the derailed wagons, trackside infrastructure and about 200 m of track. Community power, water and gas services were also disrupted. The level crossing was closed for three days and the rail line closed for five days.

What the ATSB found

The ATSB found that the derailment was probably the result of a track lateral misalignment that developed during the passage of train 9156. Over time the track had bunched at the William Street level crossing increasing the potential for a lateral misalignment in the hot conditions of that day.

Several safety factors were identified in this investigation that were similar to factors found in the investigation of a derailment at Nunga (8 km south of Ouyen) that had occurred seven weeks earlier. The asset management systems used to identify problematic levels of rail creep (the longitudinal movement of rail over time) did not incorporate algorithms to flag rail creep that had accumulated over an extended period. In addition, the management systems did not adjust creep measurements for fixed points. The network relied on this asset management system to identify problematic creep and there was no other supplementary system of identifying rail creep in jointed track.

V/Line had also identified deficiencies in the training and development of track maintenance personnel across its network and had commenced restructuring its training to address these deficiencies.

What's been done as a result

Given that this event occurred shortly after a similar derailment at Nunga (RO-2015-022), several safety actions are common to both occurrences. Following both events, V/Line made changes to its asset management system to better address cumulative creep and to correct for fixed points.

V/Line has also updated its network standard for the inspection and assessment of lateral stability, developed training materials for rail adjustment and the management of stress in rail, and undertaken additional training of track maintenance personnel.

Safety message

Asset management systems, track standards and training should provide a complementary suite of systems for the effective management of rail creep of jointed track and track stability in extreme weather conditions.

Download Final Report
[Download  PDF: 2.53MB]
 
 
Alternate: [Download  PDF: 2.53MB]
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Photos

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: 29 December 2015   Investigation status: Completed  
Time: 1713 EDT    
Location   (show map): Ouyen   Investigation type: Occurrence Investigation  
State: Victoria    
Release date: 12 July 2017    
Report status: Final    
Expected completion: 3rd Quarter 2017   Highest injury level: None  

Train details

Train details
Line operator V/Line  
Train operator Pacific National  
Train registration 9156  
Type of operation Freight  
Sector Freight  
Damage to train 406  
Departure point Carwarp, Vic.  
Destination Geelong, Vic.  
Last update 14 November 2018