Rail safety investigations & reports

Derailment of freight train 7MB9, Goulburn, NSW on 31 March 2019

Investigation number:
RO-2019-010
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 4.04MB]
 

What happened

On 31 March 2019, freight train 7MB9, operated by Specialised Container Transport (SCT), derailed while exiting the refuge at Goulburn, New South Wales. A total of five wagons derailed, with wagons coming to a rest foul of both the Up and Down main lines. Prior to the derailment, the driver of train 7MB9 was authorised to pass signal G38 at Stop. This signal could not be cleared due to a track circuit fault. The track circuit fault occurred the evening before, after train 2343 passed through the refuge. At that time, the network controller contacted the on-call signal electrician and it was agreed that trains could continue by passing the signal at Stop.

What the ATSB found

The ATSB found that train 7MB9 derailed due to a broken rail. A crack likely initiated from a lack of weld fusion at the foot of the rail in an aluminothermic junction weld. This defect area was located in a portion of rail not easily detectible through continuous ultrasonic testing, and was not detected during routine maintenance. Train 7MB9 was authorised to pass signal G38 at Stop as the signal could not be cleared. The signal was likely at Stop as a result of the Up rail breaking under the previous train, 2343, that passed through the section. The track failure went undetected.

Following the derailment, a number of other factors were identified that increased the risk of a derailment in the refuge and on the main line. These were communicated with the rail infrastructure manager while the ATSB was on site.

What's been done as a result

The Australian Rail Track Corporation repaired the section of track at Goulburn damaged by the derailment immediately following the occurrence. Additionally, a process is currently being trialled to provide assistance to network controllers when responding to track circuit faults.

Safety message

Network rules that permit degraded operations must be assessed to ensure that the application of these rules do not increase risk to an unacceptable level. Personnel responsible for implementing these rules should have sufficient guidance to assess when it is safe to continue operating trains, or under what conditions operations can continue.

It is critical that areas of the rail that cannot be easily tested during scheduled continuous ultrasonic testing are tested thoroughly at the time of welding to ensure that the weld is free from defects.

Download final report
[Download  PDF: 4.04MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issues

Go to RO-2019-010-SI-03 - Go to RO-2019-010-SI-02 -

ARTC Network rules and procedures

ARTC's network rules did not provide suitable guidance to assess continued safe operation when responding to track circuit faults. Additionally, the network rules permitting signals to be passed at Stop did not require a reduction in speed when the condition of the track was unknown.

Safety issue details
Issue number: RO-2019-010-SI-03
Who it affects: All owners and operators of rail networks track circuits
Status: Safety action pending

ARTC Track infrastructure activities

Post-incident inspection of the derailment site identified a number of factors that increased the risk of a derailment in the refuge and main line. ARTC’s maintenance activities had identified some but not all of these factors prior to the derailment.

Safety issue details
Issue number: RO-2019-010-SI-02
Who it affects: All owners and operators of rail networks
Status: Safety action pending
General details
Date: 31 March 2019   Investigation status: Completed  
Time: 0416 EDST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Goulburn   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 07 May 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Australian Rail Track Corporation (ARTC)  
Train operator Specialised Container Transport (SCT Logistics)  
Train registration 7MB9  
Type of operation Freight  
Sector Freight  
Damage to train Substantial  
Departure point Melbourne, Victoria  
Destination Brisbane, Queensland  
Last update 07 May 2020