Rail safety investigations & reports

Derailment and collision between coal trains Ravenan (25km from Muswellbrook), New South Wales, on 26 September 2018

Investigation number:
RO-2018-017
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

A coal train MR336 departed for Newcastle after being loaded with coal from Moolarben loading terminal. On route the 25th wagon in the train consist derailed at Antiene and then subsequently collided with another coal train WC915 as it passed in the opposing direction at Ravenan. The collision resulted in the locomotives on WC915 being damaged and derailed and several wagons from both trains were also damaged and derailed.

What the ATSB found

A loading sensor malfunctioned during the loading sequence which stopped coal from being loaded into the 25th wagon. The train loading operator (TLO) was pre-occupied when control alarms sounded and missed viewing the wagon pass under the loading bin. The TLO could not confirm if the wagon was loaded or not in the low light conditions, so instigated a verification check. The TLO unknowingly provided misleading information to check the 28th wagon, rather than the 28th vehicle in the sequence. The empty 25th wagon was not detected by the loading terminal before MR336 departed onto the rail network.

An empty wagon positioned between two loaded wagons was allowed onto the rail network and this known risk materialised in a derailment of the empty wagon. The derailed state of the wagon on MR336 caused the collision with WC915.

The controls for managing loading irregularities, were operational in the Moolarben loading system however, it is likely, the reliability of the alarms to indicate a loading irregularity in the loading system contributed to the TLO questioning their accuracy.

What has been done as a result

Moolarben loading terminal corrected the malfunctioning sensor and implemented more detailed verification processes of the train load out summary. They reviewed their risk assessment for train loading and implemented a number of actions resulting from this review process. The details of these actions is presented in this report.

Safety message

Empty or light loaded wagons positioned between loaded wagons running on the rail network is a known risk that can have severe consequences. Coal loading terminals and rolling stock operators should review their processes to prevent this known risk from materialising.

Download final report
[Download  PDF: 1.51MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety action

Additional train details

Sources and submissions

Appendices

General details
Date: 26 September 2018   Investigation status: Completed  
Time: 1224 AEDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Ravenan (approx. 98 km from Newcastle)   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 18 December 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train 1 details

Train 1 details
Line operator Australian Rail Track Corporation (ARTC)  
Train operator Pacific National  
Train registration MR336  
Type of operation Coal freight  
Sector Freight  
Damage to train Substantial  
Departure point Moolarben, New South Wales  
Destination Kooragang Coal Terminal, New South Wales  

Train 2 details

Train 2 details
Line operator Australian Rail Track Corporation (ARTC)  
Train operator Aurizon  
Train registration WC195  
Type of operation Coal Freight (empty)  
Sector Freight  
Damage to train Substantial  
Departure point Kooragang Coal Terminal, New South Wales  
Destination Wilpinjong, New South Wales  
Last update 18 December 2020