Rail safety investigations & reports

Derailment of train 3MP5 at Rawlinna, WA on 21 April 2016

Investigation number:
Status: Completed
Investigation completed

Final Report

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What happened

On 21 April 2016, at about 1115[1], train 3MP5 (travelling from Melbourne to Perth) derailed while traversing the eastern points at Rawlinna. The points failed to restore to the normal position after the last train departed the loop line, leaving the points in an unsafe open position. The colour light point indicator system worked as designed by displaying a red indication when the points were unable to be detected and locked in a safe position.

There were minor injuries sustained by the crew. About 200 m of track infrastructure was damaged, and the main line between Adelaide and Perth was blocked until 1351 on 25 April 2016.

What the ATSB found

The ATSB found the driver’s expectation that the system was likely set for the main line contributed to train 3MP5 travelling at a speed where it could not be stopped before the open points. Additionally, it was likely a common practice for drivers to approach crossing locations without slowing when authorised for the main line. Compounding this was the points enhancer sighting distance being less than the effective braking distance of trains travelling at line speed, thereby increasing the risk of overrun if not displaying a green aspect.

The ATSB also found that the crew van did not meet the requirements of AS 7522-2012 - Railway Rolling Stock Access and Egress, since the occupant could not access any escape paths without external assistance and additional equipment.

What's been done as a result

Pacific National have reviewed operational instructions, audited enhancer sighting distances between Cook and Kalgoorlie, and reviewed emergency egress arrangements. The Office of the National Rail Safety Regulator will look further into the possibility of prescription glasses with progressive lenses altering the perception of signal colours.

Safety message

The common practice of approaching safety critical zones at higher speed probably affects multiple operators. The effective sighting distance of safety critical locations (enhancers, targets, etc) being less than the effective braking distance of trains represents a physical gap or limitation of the system. This limitation places more reliance on procedures to cover the gap. Although the Australian Rail Track Corporation and Pacific National have procedures in place, not all operators have the same requirements. Other operators may instead rely on one layer of procedural protection provided by the track manager, increasing the likelihood of an occurrence.

Derailed locomotives
 Derailed locomotivesSource: Driver 3MP5Derailed locomotivesSource: Driver 3MP5What happenedSource: Driver 3MP5



  1. The 24-hour clock is used in this report. Local time was Western Standard Time (WST)
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Safety analysis


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General details
Date: 21 April 2016   Investigation status: Completed  
Time: 1115 WST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Rawlinna    
State: Western Australia    
Release date: 18 July 2017   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: Minor  

Train details

Train details
Line operator Australian Rail Track Corporation (ARTC)  
Train operator Pacific National  
Train registration 3MP5  
Type of operation Freight  
Sector Freight  
Damage to train Substantial  
Departure point Melbourne, Vic.  
Destination Perth, WA  
Last update 03 April 2020