Rail safety investigations & reports

Wagon out of gauge on freight train 2BW4, Main North rail line, New South Wales, on 16 June 2020

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

Final report

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[Download  PDF: 1.47MB]

What happened

On 15 June 2020, wagon RKOX4055Y was unloaded at the BlueScope Steel Coopers Plains facility, south of Brisbane, Queensland. The forklift operator experienced difficulty unloading the welded beams and sought assistance from a second forklift operator. Footage from security cameras within the Coopers Plains facility showed the corner of wagon RKOX4055Y lifting during the unloading before dropping back down.

Following unloading, wagon RKOX4055Y was shunted and attached to other wagons to form train 2BW4. This train underwent a full train examination and departed Brisbane bound for Port Kembla, New South Wales.

At around 0430 on 16 June, station staff at Grafton found damage to the platform. Train 2BW4 was identified as passing through Grafton and the train crew were directed to inspect their train at Kempsey. The inspection did not identify any faults with wagon RKOX4055Y and the train continued.

At 1040, workers at Dungog noticed a wagon on train 2BW4 contact the platform. The train was directed to stop at Wallarobba. On inspection, the wagon body on RKOX4055Y was found to have dislodged and was resting on the bogie. Wagon contact damage was also found on, Coffs Harbour, Taree, Wingham and Dungog platforms. There were no injuries as a result of the occurrence.

What the ATSB found

During the unloading of wagon RKOX4055Y the wagon body was likely lifted off the centre pin and dislodged as the load became stuck. The forklift operators did not notice that the wagon body had lifted and continued unloading other wagons. The underframe of train 2BW4 was not inspected as required by Pacific National’s train examination procedure. The likely dislodged wagon body was not identified and train 2BW4 departed with a rolling stock irregularity.

During the journey to Port Kembla, further inspections occurred after reports of platform damage were made by station staff.  The out of gauge wagon was detected when the train crew inspected the train at Wallarobba.

Additionally, the risk of a wagon lift off event had not been identified or controlled by BlueScope Steel or Pacific National.

What has been done as a result

Following the occurrence BlueScope Steel and Pacific National completed the following actions:

  • Communicated the details of the occurrence and contributing factors to the unloading and maintenance personnel.
  • Revised the unloading procedure to include the risk of lift off events and reinforced the requirement to unload welded beams from both sides.
  • Reviewed the safety interface agreement and risk assessments to ensure all risk controls were current and included the risks associated with lift off events.

Safety message

Procedures and practices for loading and unloading rolling stock must ensure risks are identified, controlled and that the practices do not affect the safe operation of rolling stock.

Maintenance inspection regimes must be completed in accordance with engineering practices to identify conditions that might contribute to accidents.

Download final report
[Download  PDF: 1.47MB]

The investigation

General details
Date: 16 June 2020   Investigation status: Completed  
Time: 1050 AEST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Main North rail line   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 20 January 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator Australian Rail Track Corporation (ARTC)  
Train operator Pacific National  
Train registration 2WB4  
Type of operation Freight train  
Sector Freight  
Damage to train Minor  
Departure point Brisbane Freight Terminal, Queensland  
Destination Port Kembla, New South Wales  
Last update 28 January 2021