Rail safety investigations & reports

Derailment of grain train 8838N, Narwonah, New South Wales, on 1 October 2017

Investigation number:
RO-2017-014
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 1 October 2017, a Pacific National loaded grain train 8838N was travelling on the Australian Rail Track Corporation (ARTC) rail network from Nevertire to Manildra in north-western New South Wales. The train consisted of two locomotives and 23 wagons. The train was travelling south at Narwonah when 11 loaded grain wagons located at the rear of the consist derailed. An emergency brake application occurred due to the uncoupling, which brought the front portion of the train to a stand. There were no injuries but there was substantial damage to nine wagons and track infrastructure.

What the ATSB found

The ATSB found that the derailment occurred at a location with identified poor track condition around a rail joint on the down rail. This, and a short twist defect at the point of mount, contributed to the vertical unloading of wheels on the twelfth wagon in the consist (NGPF35911) and the subsequent derailment of that wagon and 10 trailing wagons.

Previously, there were track defects identified near the derailment site. The maintenance of defects in this section of track was not successful in preventing the defects from re-occurring. The train crew were operating the train at a speed of approximately 80 km/h; this was in excess of the 60 km/h specified by ARTC.

The measurement of three wagons, post-derailment, found that two of the three wagons were loaded in excess of the 81 t as recorded on the consist and that the grain was not loaded evenly in the three wagons.

What's been done as a result

Approximately 300 m of rail, fasteners and sleepers were replaced and 150 m of new formation was required around the derailment site. Thirteen 12-m track panels were constructed on site and lifted into place by cranes. The rail joints were welded and the track readjusted.

Changes have been made to the ARTC maintenance system to address systemic issues. ARTC have also commenced a work program titled ‘Asset Management Improvement Program’; this work focusses on improving the functionality of the Enterprise Asset Management System and its supporting business processes.

The rail infrastructure manager, in consultation with the rolling stock operator, reiterated the requirement for rolling stock to travel within the maximum speed as advertised in the relevant notices and to provide correct train manifest information.

Safety message

The incident highlights the importance of ensuring the track is free from any defects and that trains travel at or below the speed specified in the standards.

Derailed grain wagons

Derailed grain wagons.
Source: OTSI

Source: OTSI

Download final report
[Download  PDF: 2.36MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Appendices

Safety Issue

Go to RO-2017-014-SI-01 -

Track maintenance

There were track defects identified in the vicinity of the derailment site prior to the derailment. The maintenance of defects in this section of track was not successful in preventing the defects from re-occurring.

Safety issue details
Issue number: RO-2017-014-SI-01
Who it affects: All rail operators operating on ARTC track
Status: Adequately addressed
General details
Date: 01 October 2017   Investigation status: Completed  
Time: 1130 EDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Narwonah   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 26 May 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  
Anticipated completion: 2nd Quarter 2020    

Train details

Train details
Line operator ARTC  
Train operator Pacific National  
Train registration 8838N  
Type of operation Freight  
Sector Freight  
Damage to train Substantial  
Departure point Narromine, New South Wales  
Destination Manildra, New South Wales  
Last update 20 July 2020