Rail safety investigations & reports

Track obstruction due to loss of freight involving train 6WM2 and subsequent impact of passenger train 8615 with track obstruction, near Winton, Victoria, on 30 March 2018

Investigation number:
RO-2018-008
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 30 March 2018, a 16 t jumbo (steel) coil became unstable and fell from Pacific National freight service 6WM2 after it crossed the Seven Mile Creek Bridge near Winton, Victoria. After falling from 6WM2, the coil struck and caused damage to both tracks before coming to rest between, and obstructing both tracks at about 204.5 track km. About 10 minutes later, V/Line passenger service 8615, traveling north on the west track, struck the tail of the coil and the damaged west track at about 110 km/h, but did not derail. Two staff on the V/Line train received minor injuries.

What the ATSB found

The ATSB found that the absence of a rubber load mat from one face of the jumbo coil cradle, and the likely failure of the steel unitising straps allowed the centre of the coil to telescope (where the inner layers of the coil move laterally relative to the outer layers), adversely affecting its stability and increasing the likelihood of movement.

As Pacific National’s Freight Loading Manual did not require the use of rubber load mat on cradles, there was no requirement to consider the condition of the load mat during inspections and maintenance. This allowed the continued use of cradles without load mat, decreasing their effectiveness at restraining loads.

The Freight Loading Manual also did not require a configuration of radial unitising straps on jumbo coils so that one strap was always free from contact with the cradle, which would have reduced the risk of straps breaking and therefore, the coil telescoping.

In addition, Pacific National did not demonstrate that the load restraint system provided by their demountable cradles when carrying jumbo coils provided sufficient restraint against lateral accelerations to prevent coils from moving and falling during transit.

What's been done as a result

Following the occurrence, Pacific National updated their Freight Loading Manual to require all coils to have a minimum of two radial and two circumferential unitising straps applied. In addition, PN have drafted a revision to their Wagon Maintenance Manual to include a part specific to inspection of jumbo coil cradles. The manual part relates to demountable type cradles and includes a requirement to 'consider the condition of load mat during inspection and maintenance', and repair or replace as required.

The ATSB has issued two safety recommendations to Pacific National to address safety issues identified in this investigation that have not yet been addressed. The first is to address the risk presented by continuing to allow jumbo coils to be loaded in an orientation where all the radial straps are positioned within the contact zone between the coil and cradle. The second is to review the load restraint system provided by the demountable cradle design to demonstrate that they sufficiently restrain jumbo coils against lateral accelerations and prevent coils from moving and falling during transit.

BlueScope Steel also introduced a requirement to apply a third radial unitising strap to all coils. In practice, they applied the third strap in a position diagonally opposite to the first two. Additionally, they have proposed to work with the carrier to undertake a review of the current load restraint system.

Safety message

Robust load restraint systems are required to protect against movement of loads during transport. This is particularly important for significantly heavy loads, such as jumbo steel coils, as should they fall from the train they pose a significant risk to the safety of other rail vehicles and passengers. The system should also include assessments and documentation that demonstrate appropriate load cases, design requirements, operational and loading requirements have been met, to ensure that the safety of the load restraint is maintained over time.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Preliminary Report

Preliminary report published 19 November 2018

Sequence of events

On 30 March 2018, at about 1440 Eastern Daylight-saving Time,[1] a 16 t jumbo (steel) coil[2] fell from Pacific National (PN) freight service 6WM2, which was traveling south toward Melbourne, Victoria on the east track of the Defined Interstate Rail Network (DIRN).[3] After falling from 6WM2, the coil struck and caused damage to both tracks before coming to rest between, and obstructing both tracks at about the 204.5 km mark[4] near Winton, Victoria (Figure 1). Subsequently, at about 1450, V/Line passenger service 8615, traveling north on the west track, struck the tail of the coil and the damaged west track at a speed above 100 km/h, but did not derail. The driver of 8615 notified the Australian Rail Track Corporation (ARTC)[5] train control that they had struck the coil and reported minor damage to the train and no injuries to passengers.

Figure 1: Location of track obstruction and associated track features on the DIRN
Figure 1: Location of track obstruction and associated track features on the DIRN. Source: Google earth, annotated by the ATSB

 

Source: Google earth, annotated by the ATSB

Loading at Port Kembla, NSW

On 27 March 2018, Bluescope Steel loaded jumbo coil number 1H8S2486 onto the ‘A-end’ (trailing) cradle of PN wagon number NQJF-21574 along with another coil in the ‘B-end’ (leading) cradle. Information provided to the ATSB by Bluescope Steel indicated that coil 1H8S2486 weighed 16.04 t, was 1.93 m in diameter, 0.8 m wide and comprised a wound sheet of 3.2 mm gauge steel that was unitised with steel strapping (two circumferential and two radial straps).

On 28 March 2018, loaded wagon NQJF-21574 was inspected by PN terminal operators and moved to South Yard, Port Kembla, New South Wales (NSW). On 29 March 2018, the wagon was marshalled as the 35th wagon of train 6WM2.

Train 6WM2 comprised four locomotives hauling 75 wagons for a combined length of 1,275.3 m and total weight of 5,131.8 t. The train was inspected by PN terminal operators who provided a completed brake certificate[6] to the outgoing train crew. Train 6WM2 departed Port Kembla at 2354 and received a roll by[7] inspection from PN terminal operators with no issues reported.

Journey

Train 6WM2 was a scheduled service carrying steel products from Port Kembla (Wollongong) to Melbourne Freight Terminal. Train 6WM2 travelled north from Port Kembla to Sydney Freight Terminal before traveling on the DIRN for the remainder of its journey to Melbourne.

On 30 March 2018, at about 0300, train 6WM2 arrived at Chullora, NSW for a crew change with a two-man crew from Junee, NSW relieving the Port Kembla drivers. The disembarking crew reported that the train was running well and conducted a roll-by inspection of the departing train with no issues reported.

At about 1055, train 6WM2 arrived at Junee for its second crew change with a two-man crew from Melbourne taking over. Again, the disembarking crew reported that the train was running well and conducted a roll-by inspection of the departing train with no issues reported.

On its journey from Junee to Wangaratta, Victoria, train 6WM2 crossed[8] passenger train ST24 and freight train 6MC7, who both conducted roll-by inspections of 6WM2 with no issues reported. Closed circuit television footage captured from a platform at Wangaratta Station at about 1427 identified that all jumbo coils on train 6WM2 were present and not grossly out of place. The quality of the footage was not sufficient for the ATSB to determine whether the unitising straps were still attached to the coils on wagon NQJF-21574, but it did show that the incident coil in the trailing cradle had not unwound, tipped or shifted drastically.

The incident

At about 1440, train 6WM2 passed the incident site (204.5 km) at a speed of about 76 km/h. Track grade leading to the incident site was relatively flat and the driver had been maintaining moderate traction power (throttle between notches 2 – 5) for approximately 2 minutes prior to the loss of the coil. The drivers of 6WM2 reported nothing remarkable about the train’s behaviour at the incident location and were not aware that the coil had fallen off at that time.

At about 1448, train 6WM2 proceeded south and crossed the northbound V/Line passenger service 8615. The crew of 8615 conducted a roll-by inspection of 6WM2 with no issues reported.

At about 1450, the driver of train 8615 saw the coil obstructing the track and applied the emergency train brakes. Train 8615 subsequently struck the unravelled tail of the coil and associated damaged west track at a speed above 100 km/h, but did not derail. Figure 2 shows the damaged west track (foreground) and jumbo coil between the tracks (background). The photo is oriented southbound towards Melbourne on the west track. This is facing against the direction of travel of train 8615.

Figure 2: Incident location 204.5 km - looking south on the west track

 

Figure 2: Incident location 204.5 km - looking south on the west track. Source: ARTC

Source: ARTC

After bringing the train to a stand, the driver of 8615 advised ARTC train control that they had struck a steel coil from 6WM2 and that there was significant damage to the west track. In response, ARTC train control applied signal blocks to both tracks and requested that the drivers of 6WM2 stop and investigate their train.

Post-incident inspections

At about 1454, the driver in control of 6WM2 stopped his train at the next suitable location, coming to a stand at 190.475 km. Between 1517 and 1600, the second driver inspected train 6WM2 and reported to ARTC train control and PN that a coil was missing from the 35th wagon, NQJF-21574. The driver also reported that 39 trailing wagons had been damaged to varying extents. The damage to trailing wagons included damage to steps, handbrakes, brake cylinders and bearing caps, and the driver advised that 6WM2 would not be able to continue without repair.

The driver of V/Line passenger service 8615 inspected his train and determined that superficial damage had occurred to the locomotive and that there were no passenger injuries. Train 8615 continued its journey to Albury without further incident.

Subsequent inspection of wagon NQJF-21574 was conducted by ARTC in Violet Town, Victoria on 4 April 2018, and by the ATSB at PN’s West Melbourne Yard on 22 May 2018. The inspections, shown in Figure 3, identified:

  • that the rubber mat was dislodged from one face of the A-end coil cradle
  • witness marks on the exposed metal surface of the A-end cradle
  • a break in the wagon frame under the B-end cradle.

Figure 3: Inspection of wagon NQJF-21574

Figure 3: Inspection of wagon NQJF-21574. Source: ARTC (top and bottom right images) and ATSB (bottom left image), annotated by the ATSB

Source: ARTC (top and bottom right images) and ATSB (bottom left image), annotated by the ATSB

Investigation progress

As part of the investigation, the ATSB has interviewed the crew of train 6WM2, reviewed operational information from both rollingstock operators and the infrastructure manager, and analysed information recorded on the on-board recorders for both trains. Further, the ATSB conducted an inspection of wagon NQJF-21574 at PN Yard, West Melbourne and observed jumbo coil loading at Port Kembla. The investigation is ongoing and further analysis work to be completed includes:

  • examination of the loading, load restraint and examination processes with respect to jumbo coil wagons
  • review of the frequency and mechanisms of historical occurrences of jumbo coil load shift
  • examination of possible dynamic forces acting on the wagon
  • analysis of the effect of wagon condition on the incident
  • analysis of the track conditions, both historical and on the day, present in the vicinity of the incident
  • gather further information from involved parties.  

__________

The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this update. As such, no analysis or findings are included in this update.

 

__________

  1. Eastern Daylight-saving Time (EDT): Coordinated Universal Time (UTC) + 11 hours.
  2. Jumbo coil: Unitised steel sheet or plate that is rolled into cylindrical coils for transport. The centre of the coil (the eye) is hollow. ‘Jumbo’ describes the size of the coil; with a minimum weight of 16 t and diameter less than 2,100 mm. Jumbo coils must be loaded on fixed cradle wagons or wagons with demountable cradles.
  3. Defined Interstate Rail Network (DIRN): The standard gauge interstate rail line linking the mainland capital cities (except Darwin) and the regional centres of Alice Springs, Darwin, Whyalla, Port Kembla and Newcastle. Managed by the Australian Rail Track Corporation (ARTC).
  4. Kilometre marks (km mark): refer to the track distance from a known location. On the Victorian section of the DIRN the 0 km reference mark is Southern Cross Station in Melbourne.
  5. Australian Rail Track Corporation (ARTC): Commonwealth-owned company established to manage and develop the Defined Interstate Rail Network as a single entity.
  6. Brake certificate: Also known as Train Examiners Certificate is issued upon completion of pre-departure brake tests. Details of the testing requirements and certificate for access to the ARTC network can be found in the ARTC Train Operating Conditions Manual – Section 6 Train Inspection
  7. Roll by inspection: A visual inspection of moving rail traffic to identify equipment, loading security, or other defects or failure.
  8. Cross: To go past other rail traffic travelling in the opposite direction.

Safety Issues

Go to RO-2018-008-SI-01 - Go to RO-2018-008-SI-02 - Go to RO-2018-008-SI-03 - Go to RO-2018-008-SI-04 -

Rubber load mats not required in the Freight Loading Manual

Pacific National's Freight Loading Manual, specific to the loading and unitising of jumbo coils, did not require the use of rubber load mat on cradles. Consequently, there was no requirement to consider the condition of load mat during inspection and maintenance. This allowed the continued use of cradles without load mat, which decreased their effectiveness at restraining loads.

Safety issue details
Issue number: RO-2018-008-SI-01
Status: Closed – Adequately addressed

Radial unitising straps contacting the cradle

Pacific National's Freight Loading Manual did not require a combination of radial unitising straps on jumbo coils positioned such that a strap was always free from contact with the cradle. The provision of straps in this configuration would have reduced the risk of the coil telescoping in the event of strap breakage due to contact with the cradle.

Safety issue details
Issue number: RO-2018-008-SI-02
Status: Open – Safety action pending

Load restraint system

Pacific National did not demonstrate that the load restraint system provided by demountable cradles carrying jumbo coils was safe and fit for purpose.

Safety issue details
Issue number: RO-2018-008-SI-03
Status: Open – Safety action pending

Radial unitising straps not required in the Freight Loading Manual

Pacific National's Freight Loading Manual did not require the use of radial unitising straps to prevent telescoping on jumbo coils where the thickness of the steel was greater than 2 mm.

Safety issue details
Issue number: RO-2018-008-SI-04
Status: Closed – Adequately addressed
General details
Date: 30 March 2018   Investigation status: Completed  
Time: 1440 EDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): near Winton   Investigation phase: Final report: Dissemination  
State: Victoria    
Release date: 10 December 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: Minor  

Train 1 details

Train 1 details
Line operator Australian Rail Track Corporation  
Train operator Pacific National  
Train registration 6WM2  
Type of operation Intermodal Freight (Steel)  
Sector Freight  
Damage to train Minor  
Departure point Port Kembla (Wollongong), NSW  
Destination Melbourne, Victoria  

Train 2 details

Train 2 details
Line operator Australian Rail Track Corporation  
Train operator V/Line  
Train registration 8615  
Type of operation Passenger  
Sector Passenger - regional  
Damage to train Nil  
Last update 10 December 2020