RAIL SAFETY INVESTIGATION REPORT

2004/006

Derailment of Coal Train DS212

Departing Bloomfield Colliery Loop

Thornton, New South Wales

Released in accordance with section 25 of the Transport Safety Investigation Act 2003

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Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office location: 15 Mort Street, Canberra City, Australian Capital Territory Telephone: 1800 621 372; from overseas + 61 2 6274 6590 Accident and serious incident notification: 1800 011 034 (24 hours) Facsimile: 02 6274 6474; from overseas + 61 2 6274 6474 E-mail: atsbinfo@atsb.gov.au Internet: www.atsb.gov.au

© Commonwealth of Australia 2006.

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Subject to the provisions of the Copyright Act 1968, you must not make any other use of the material in this publication unless you have the permission of the Australian Transport Safety Bureau.

Please direct requests for further information or authorisation to: Commonwealth Copyright Administration, Copyright Law Branch Attorney-General’s Department, Robert Garran Offices, National Circuit, BARTON ACT 2600 www.ag.gov.au/cca

ISBN and formal report title: see ‘Document retrieval information’ on page v.

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CONTENTS

DOCUMENT RETRIEVAL INFORMATION ................................................... v

PREFACE ............................................................................................................. vii

EXECUTIVE SUMMARY ................................................................................... ix

INTRODUCTION .................................................................................................. 1

1 OVERVIEW.................................................................................................... 3 1.1 Location ................................................................................................ 3 1.2 The Occurrence..................................................................................... 3 1.3 Injuries .................................................................................................. 5 1.4 Damage................................................................................................. 5

1.4.1 Track Infrastructure ............................................................ 5 1.4.2 Pacific National Train DS212............................................. 7

1.5 Personnel Involved ............................................................................... 7 1.5.1 Pacific National Train DS212............................................. 7 1.5.2 Maitland Signal Box ........................................................... 8 1.5.3 ARTC Broadmeadow Train Control Centre ....................... 8 1.5.4 Track Details....................................................................... 9 1.5.5 Accreditation and Audit.................................................... 14

1.6 Train Details ....................................................................................... 14 1.6.1 Wagon NHRH 50245C..................................................... 15 1.6.2 Monitoring and Maintenance............................................ 17 1.6.3 Accreditation and Audit.................................................... 18

1.7 Environmental Conditions .................................................................. 18

2 KEY ISSUES ................................................................................................. 19 2.1 Track Condition .................................................................................. 19 2.2 Monitoring and Maintenance.............................................................. 21 2.3 Train DS212 ....................................................................................... 21 2.4 VAMPIRE Modelling......................................................................... 21 2.5 Train Handling.................................................................................... 23 2.6 Mechanism of Derailment .................................................................. 24 2.7 Site Protection..................................................................................... 26

2.7.1 Pacific National Train DS212 Crew Actions.................... 27 2.7.2 ARTC Signallers’ Actions - Maitland Signal Box ........... 29

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2.7.3 ARTC Train Controller’s Actions – Broadmeadow Train Control Centre......................................................... 30

3 CONCLUSIONS ........................................................................................... 31 3.1 Findings .............................................................................................. 31 3.2 Contributing Factors in the Incident ................................................... 32

4 SAFETY ACTIONS ..................................................................................... 33 4.1 Recommended Safety Actions............................................................ 33

4.1.1 Australian Rail Track Corporation Ltd (ARTC)............... 33 4.1.2 Pacific National................................................................. 33 4.1.3 Independent Transport Safety And Reliability

Regulator (New South Wales) .......................................... 34 4.2 Safety Actions already initiated.......................................................... 34

4.2.1 Independent Transport Safety and Reliability Regulator (New South Wales) .......................................... 34

5 SUBMISSIONS ............................................................................................. 35 5.1 Australian Rail Track Corporation Ltd............................................... 35 5.2 Pacific National .................................................................................. 35 5.3 New South Wales Office of Transport Safety Investigation

(OTSI)................................................................................................. 35 5.4 Independent Transport Safety and Reliability Regulator (New

South Wales) ...................................................................................... 36

6 APPENDICES............................................................................................... 37 6.1 Area Map ............................................................................................ 37 6.2 RailCorp SAFE Telegram 081-2002 .................................................. 38 6.3 Schematic of Bradken AR-1 Bogie .................................................... 39 6.4 VAMPIRE Results ............................................................................. 40

6.4.1 Plot of Site Curvature ....................................................... 40 6.4.2 Wheelset lateral displacement relative to track – all

new wheels........................................................................ 41 6.4.3 Wheelset lateral displacement relative to track –

Wheelset no.3 as measured, other wheelsets new............. 41 6.4.4 Wheelset lateral forces – all new wheels .......................... 42 6.4.5 Wheelset lateral forces – Wheelset no.3 as measured,

other wheelsets new.......................................................... 42 6.5 Timeline Diagram............................................................................... 43

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DOCUMENT RETRIEVAL INFORMATION

Report No. 2004/006

Publication date January 2006

No. of pages 55

ISBN 1 921092 30 0

ISSN

Publication title Derailment of coal train DS212

Prepared by Australian Transport Safety Bureau PO Box 967, Civic Square ACT 2608 Australia www.atsb.gov.au

Acknowledgements The map section identified in this publication is reproduced by permission of Geoscience Australia, Canberra. Crown Copyright ©. All rights reserved. www.ga.gov.au

Other than for the purposes of copying this publication for public use, the map information from the map section may not be extracted, translated, or reduced to any electronic medium or machine readable form for incorporation into a derived product, in whole or part, without prior written consent of Geoscience Australia, Canberra.

The aerial photograph identified in this publication is reproduced by permission of Geo-Spectrum (Australia) Pty Limited, Parramatta. Copyright ©. All rights reserved. geospectrum@exemail.com.au

Other than for the purposes of copying this publication for public use, the aerial photograph may not be extracted, translated, or reduced to any electronic medium or machine readable form for incorporation into a derived product, in whole or part, without prior written consent of Geo-Spectrum (Australia) Pty Limited, Parramatta.

Abstract

At about 1345 on Monday 11 October 2004, freight train DS212, hauling 54 fully loaded coal wagons from the Bloomfield Colliery balloon loop, became derailed approximately 300 metres north of Thornton station platform. The majority of the train passed through the crossing before seven wagons derailed over 103 and 104 points at the main rail corridor junction. Three of the derailed wagons tipped over fouling the Up and Down Coal Roads as well as the Down Main Line.

The investigation concluded that the derailment occurred as a result of gauge widening at about 182.527 km due to poor rail fastener condition, in between 104A points and 104B catch points which allowed the right wheel, in direction of travel, of the third axle on the trailing bogie of wagon NHRH 50245C to drop into the four foot. The adjacent right wheel on axle number three rolled the high rail outwards.

Given the lack of awareness of the poor and deteriorating condition of the high rail stability, a derailment at this location was inevitable without remedial action.

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PREFACE

This report is the result of an independent investigation carried out by the Australian Transport Safety Bureau (ATSB). The ATSB is an operationally independent multi-modal Bureau with the Australian Government Department of Transport and Regional Services. The ATSB’s objective is safe transport. It seeks to achieve this through: independent investigation of transport accidents and other safety occurrences; safety data research and analysis; and safety communication and education.

The ATSB operates within a defined legal framework and undertakes investigations and analysis of safety data without fear or favour. Investigations, including the publication of reports as a result of investigations, are authorised by the Executive Director of the ATSB in accordance with the Transport Safety Investigation Act 2003 (TSI Act).

Readers are advised that ATSB investigations are for the sole purpose of enhancing transport safety. Consequently, Bureau reports are confined to matters of safety significance and may be misleading if used for other purposes. Reports released under the TSI Act are not admissible in any civil or criminal proceedings.

As the ATSB believes that safety information is of greatest value if it is passed on for the use of others, readers are encouraged to copy or reprint this report for further distribution, acknowledging the ATSB as the source.

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EXECUTIVE SUMMARY

At about 1345 on Monday 11 October 2004 freight train DS212, hauling 54 fully loaded coal wagons from the Bloomfield Colliery balloon loop, derailed approximately 300 metres north of Thornton station platform. The majority of the train passed through the crossing before seven wagons derailed over 103 and 104 points at the main rail corridor junction. Three of the derailed wagons tipped over fouling the Up1 and Down2 Coal Roads as well as the Down Main Line.

Thornton is located on the main northern railway corridor between Sydney and Brisbane, 182.2 kilometres from Central Railway Station, Sydney. Thornton is on the railway section3 between Broadmeadow and Maitland, prescribed as part of the Defined Interstate Rail Network (DIRN). The railway corridor contains four standard gauge lines, an Up and Down Coal Road, and an Up and Down Main Line.

The train crew tried contacting Broadmeadow Train Control Centre but were referred to Maitland signal box. The signaller at Maitland noticed the transit lights for the points flashing, indicating that the ‘points detection’ had been lost. The signaller immediately placed all signals in that location at stop and applied blocking facilities. An approaching passenger train 747 on the Down Main Line at Beresfield was stopped by signals before the section of fouled track. The track circuiting4 over the Down Main Line was not affected by the derailment.

To assist the investigation an independent railway engineering organisation, Interfleet Technology Pty Ltd, was engaged to inspect the track and train to determine what factors contributed to the derailment.

Other freight train traffic had traversed the line earlier in the day without incident. The first half of train DS212 passed safely over the site before wagon NHRH 50245C derailed. This indicated that although the track-based elements were significant causal factors, it was a combination of the vehicle-based and track-based factors that led to the derailment.

The investigation concluded that the derailment occurred as a result of gauge widening at about 182.527 km due to poor rail fastener condition, in between 104A points and 104B catch points which allowed the right wheel, in direction of travel, of the third axle on the trailing bogie of wagon NHRH 50245C to drop into the four foot5. The adjacent right wheel on axle number three rolled the high rail6 outwards.

Given the lack of awareness of the poor and deteriorating condition of the high rail stability, a derailment at this location was inevitable without remedial action.

1 An Up line or train is a line or train heading towards Sydney.

2 A Down line or train is a line or train heading away from Sydney.

3 See appendix 6.1 for an area map.

4 An electric circuit that uses the rails of a railway track as conductors such that a train electrically connects them via its axles. The absence or presence of this rail-to-rail connection indicates the absence or presence of a train or item of rollingstock.

5 A colloquial term used to describe the gap between the rails (laid at standard gauge of 1435mm)

6 The high rail is the outer rail of railway track in a curve

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A number of safety actions have been taken, or are underway, through the New South Wales Independent Transport Safety and Reliability Regulator, Pacific National, and the Australian Rail Track Corporation. These safety actions included: the inspection of all branch line turnouts/junctions used by Hunter Valley coal traffic; the implementation of a plan to remediate infrastructure identified as deficient and/or non-compliant; and the inspection of rollingstock for asymmetric wheel profiles. Of the eleven branch line turnout/junction sites inspected, one site was found to be deficient and/or non-compliant. Pacific National found one bogie with significant asymmetric wheel wear and four bogies in the early stages of asymmetric wheel wear, all were at the end of effective service life.

The report makes a number of recommendations on pages 33 and 34 relating to: track monitoring and maintenance; reviewing the effects of asymmetric wheel wear on lateral track forces and rail safety; and reinforcement of network rules and procedures regarding the protection of trains.

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INTRODUCTION

On Monday 11 October 2004 train DS212 departed the Bloomfield Colliery balloon loop hauling 54 fully loaded coal wagons. The train stopped at the staff hut to perform safeworking duties, then continued towards the crossing onto the Up Coal Road. The majority of the train passed through the crossing before seven wagons became derailed at the Coal Road/Main Line junction about 300 metres northwest of Thornton station platform. Three of the derailed wagons tipped over fouling the Up and Down Coal Roads as well as the Down Main Line. Train DS212 separated between the 43rd and 44th wagons causing brake pipe air to escape, resulting in the application of the train brakes, bringing the train to a stop.

The train crew tried contacting Broadmeadow Train Control Centre but were referred to Maitland signal box. The signaller at Maitland had already noticed the transit lights for the points flashing, indicating that the ‘points detection’ had been lost. The signaller immediately placed all signals in that location at stop and applied blocking facilities. An approaching passenger train, number 747, on the Down Main Line at Beresfield was stopped by signals before the section of track fouled by the derailment. The track circuiting7 (rail vehicle detection) over the Down Main Line was not affected by the derailment.

To assist the investigation an independent railway engineering organisation, Interfleet Technology Pty Ltd, was engaged to inspect the track and train to determine what factors contributed to the derailment. The independent organisation’s findings have been incorporated into this report.

Figure 1 – Aerial photograph of the accident site

(Geo-Spectrum (Australia) Pty Limited Copyright ©)

7 An electric circuit that uses the rails of a railway track as conductors such that a train electrically connects them via its axles. The absence or presence of this rail-to-rail connection indicates the absence or presence of a train or item of rollingstock.

Main rail corridor

Bloomfield Colliery Loop

line

Approximate POD

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1 OVERVIEW

1.1 Location Thornton is located on the main northern railway corridor between Sydney and Brisbane, 182.2 kilometres from Central Railway Station Sydney, between Broadmeadow and Maitland8. The railway corridor is part of the Defined Interstate Rail Network (DIRN) and consists of four standard gauge lines, an Up9 and Down10 Coal Road, and an Up and Down Main Line. Bloomfield Colliery Balloon Loop is a single line branch line from the main rail corridor to service Bloomfield Colliery.

The Coal Roads predominately carry freight trains. The Main Lines predominately carry passenger trains. Traffic, however, can be crossed between the various lines at points along the line.

Train movements in the Thornton area are controlled by a signaller located at Maitland signal box, 10.3 kilometres southeast from Thornton station. A train controller located at Broadmeadow Train Control Centre oversees all train movements in that area.

1.2 The Occurrence11 Train DS211 (down journey) departed Port Waratah at 0855 as an empty coal train en route to Bloomfield Colliery. Train DS211 arrived at the Thornton staff hut at 0930 to perform safeworking duties, departing at 0935. Train DS211 arrived at the coal loader at 1015. Loading was finished at 1245 and the train identification changed to DS212.

Train DS212 departed the balloon loop at 1300 (with the same drivers on board) arriving at the Thornton staff hut at 1330 and departing at 1341:0412 after performing safeworking duties. Due to the prevailing down grade the train proceeded under full dynamic brake reaching a maximum speed of 21 km/h. The train speed gradually decreased under dynamic braking. The brake pipe air pressure rapidly decreased and the brakes applied due to what transpired to be a derailment and breakaway. The train came to a stop at 1344:51. The driver of train DS212 reported that the train stopped smoothly without significant longitudinal train forces.

8 See appendix 6.1 for an area map.

9 An Up line or train is a line or train heading towards Sydney.

10 A Down line or train is a line or train heading away from Sydney.

11 See appendix 6.5 for a timeline diagram.

12 Times shown have been adjusted to compensate for a -5 minute error with the locomotive data loggers.

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At 1345:05 the driver of DS212 called the Broadmeadow Train Control Centre by the train radio reaching an area controller. The area controller advised the driver to re-direct his call to Maitland signal box.

The driver of DS212 called the signaller at Maitland signal box at 1345:22 and advised him that the train had ‘lost the air’ and gave him the location. The signaller at Maitland had already noticed that the transit light for points 103 and 104 were flashing ‘in transit’ on the signalling panel. The signaller told the driver about the transit lights. The second driver of train DS212 started to walk back to the rear of the train, towards 103 and 104 points. The signaller at Maitland placed all controlled signals in the area at stop and applied blocking facilities. The signaller then advised the train controller at Broadmeadow and the signaller at Hanbury Junction signal box at 1346:26.

A short time later, at 1350:21, the train controller received a call from the Pacific National Shift Operations Support Officer (SOSO)13 advising that an off duty train driver had seen the derailment site. The off duty driver described the site near the points (103 and 104) and said that some wagons were on their side blocking adjacent lines (shown in figure 3). The train controller contacted the signaller at Maitland signal box at 1352:06 and advised him to stop a down passenger train 747 (1330 train from Newcastle all stations to Telarah) on the Down Main Line. The signaller had already placed all signals at stop and applied blocking facilities. At this time train 747 was near Tarro platform, 4.016 km southeast of Thornton platform.

The train controller at Broadmeadow also called the signaller at Hanbury Junction signal box and advised him to apply blocking facilities. The signaller at Hanbury Junction had already been advised of the derailment by the signaller at Maitland.

The second driver from train DS212 had walked far enough back to be able to see that several wagons had tipped over onto adjacent lines and advised the driver of DS212. A short time later, about 1357, the second driver reached the derailment site. The second driver called the signaller at Maitland and passed on information about wagon position, damage, and lines affected. The second driver advised the signaller at Maitland that all adjacent lines were blocked except the Up Main Line. Train DS212 was then secured by the second driver.

13 Operational help desk for train drivers.

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Figure 2 – Picture showing wagon NHRH50869E fouling the Down Main Line (facing Maitland)

Passenger train 747 departed Beresfield station on time at about 1355. The driver remembered that the automatic signal on departure from Beresfield platform was displaying a caution indication. The following signal TN3 (Maitland Accepting signal) was at stop. Train 747 came to a stop at signal TN3 at about 1357 and waited until verification that the Down Main Line was clear into Thornton station platform. Train 747 proceeded into Thornton station platform, with authority from the signaller, at about 1402 where passengers were detrained.

The train controller at Broadmeadow verified the condition of the line and train with the signaller at Maitland and driver of DS212. Arrangements were made to deploy a recovery work group to the site.

1.3 Injuries No injuries were reported.

1.4 Damage

1.4.1 Track Infrastructure

The track from Bloomfield Colliery entering the main rail corridor was extensively damaged. Point assemblies 104 and 103 were destroyed by the derailment. Sections of track on the Up and Down Coal Roads were skewed out of alignment. Concrete and timber sleepers were fractured by wheel impacts.

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Figure 3 – Site recovery operations on the following day

Figure 4 – Damaged rail infrastructure

– 7 –

1.4.2 Pacific National Train DS212

Seven wagons of Pacific National train DS212 derailed. In direction of travel, the first wagon derailed was the 42nd, it remained upright with its trailing bogie derailed, dropped in the four-foot14. The following three wagons (43rd, 44th, and 45th) all derailed and tipped towards the adjacent lines. The automatic coupler between the 43rd and 44th position wagons disconnected causing a separation and a break in the train brake pipe. The leading edge of wagon 44 fouled the Down Main Line. All wheels derailed on the 46th wagon which remained upright. Wagon 47 derailed the leading bogie and one wheel on the trailing bogie. Wagon 48 derailed one wheel on the leading bogie.

1.5 Personnel Involved

1.5.1 Pacific National Train DS212

The Pacific National driver who was driving the train at the time of the incident had extensive experience with 26 years of train driving. The other driver was sitting in the observer’s position at the time of the incident. He had 10 years of train driving experience. Both drivers are based in the Newcastle region.

Table 1 - Train DS212 driver details DS212 1st Driver 2nd Driver

Gender Male Male

Classification Driver Driver

Medical Status Medically fit Medically fit

Training Current Current

Time On Duty 6 hours 24 minutes 6 hours 24 minutes

The two drivers of Pacific National train DS212 signed on ‘fit for duty’ in accordance with the rules and procedures of their employer. The train crew were breath tested and both returned a zero reading.

The train crew were up to date with their medical examinations and assessed as medically fit for duty by Pacific National. The train crew working roster was examined to consider roster-induced fatigue.

The medical condition, training status, toxicology, and fatigue levels of the crew of Pacific National train DS212 are not considered to be contributing factors to the incident.

14 A colloquial term used to describe the gap between the rails (laid at standard gauge of 1435mm).

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1.5.2 Maitland Signal Box

Both signallers at Maitland were experienced. Signaller 1, employed by the Australian Rail Track Corporation Ltd (ARTC), had worked at Maitland fulltime for the past three years. Signaller 2, employed by the ARTC, had worked at Maitland as a relief signaller for the past 4 years.

Table 2 – Maitland signal box staff details

Maitland Box Signaller 1 Signaller 2

Gender Male Male

Classification Signaller Signaller

Medical Status Medically fit Medically fit

Training Current Current

Time On Duty 7 hours 45 minutes Sign on 1400 (15 minutes early)

The two signallers signed on ‘fit for duty’ in accordance with the rules and procedures of their employer. Both signallers were up to date with their medical examinations and assessed as medically fit for duty. The working shift roster was also examined to consider roster-induced fatigue. Neither signaller was breath tested.

The medical condition, training status, toxicology, and fatigue levels of the ARTC signallers at Maitland signal box are not considered to be contributing factors to the incident.

1.5.3 ARTC Broadmeadow Train Control Centre

The train controller, employed by the ARTC, had 4 years experience as a train controller at the Broadmeadow Train Control Centre managed by ARTC.

Table 3 – Train controller details

Broadmeadow Train Control

Train Controller

Gender Male

Classification Train Controller

Medical Status Medically fit

Training Current

Time On Duty 2 hours 30 minutes

The train controller signed on ‘fit for duty’ in accordance with the rules and procedures of his employer. The train controller was up to date with his medical examinations and assessed as medically fit for duty. The working shift roster was also examined to consider roster-induced fatigue. The train controller was not breath tested.

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The medical condition, training status, toxicology, and fatigue levels of the ARTC train controller are not considered to be contributing factors to the incident.

1.5.4 Track Details

The rail corridor at Thornton is managed by the ARTC, including a length of track on the Bloomfield Colliery Loop line up to and including 104B catch points.

The ARTC was created after the Commonwealth and State Governments agreed in 1997 to the formation of a 'one stop' shop for all operators seeking access to the national interstate rail network.

The ARTC is responsible for the management of 5861 route kilometres of standard gauge interstate track, in South Australia, Victoria, Western Australia, and New South Wales (NSW). The ARTC also manages the Hunter Valley Coal Rail network in New South Wales (311 km) and other regional rail links in New South Wales (651 km).

RailCorp, formed in 2004 from State Rail Authority of NSW (StateRail) and Rail Infrastructure Corporation (RIC), entered into a 60-year lease with ARTC over the Interstate and Hunter Valley Rail Network (Leased Network). ARTC took over responsibility for the track on 4 September 2004. Under the lease, ARTC has full responsibility for all land and infrastructure vested in RIC and StateRail (subject to certain specified exclusions) within the rail corridors: Albury to Macarthur, Cootamundra to Parkes (via Stockinbingal), Parkes to Werris Creek (via Narromine, Dubbo, Merrygoen, Binnaway and Gap), Werris Creek to Maitland, Merrygoen to Muswellbrook (via Gulgong), Parkes to Broken Hill, Moss Vale to Unanderra and Maitland to Border Tunnel. The remainder of the country network, known as the Country Regional Network (CRN) continues to be the responsibility of Country Rail Infrastructure Corporation. The ARTC will operate the CRN under a management agreement.

Within the main railway corridor between Hanbury Junction signal box and Maitland there are four railway tracks. They are the Up and Down Coal Roads, and the Up and Down Main Lines. There is no overhead wiring on any line. The Up and Down Coal Roads are 60 kg/m head-hardened rail-anchored on concrete sleepers by elastic fasteners in a track bed of ballast. Through crossover 104A into Bloomfield Colliery Loop the rail is 60kg/m anchored on timber sleepers transitioning into 53 kg/m rail, then into 47kg/m rail anchored onto timber sleepers through to 104B catch points (diagram in Figure 6).

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Figure 5 – Schematic diagram of site area

Although the designed curvature radius is 180m, a varying curvature radius ranging between 107m to 200m was measured onsite.

Train movements are controlled on all lines by fixed signals, both automatic (permissive15) and controlled (absolute16), using Rail Vehicle Detection (RVD)17. Train movements into and out of Bloomfield Colliery Loop are controlled by a Staff and Ticket (white triangle) system.

Track measurements taken from the site after the derailment are shown in Table 4 below.

15 A fixed signal designated as a permissive signal, normally controlled by the passage of trains. Its

normal indication is a Proceed Authority.

16 A fixed signal designated as an absolute signal, normally controlled by a person usually from a signal box or control office. Its normal indication is at stop.

17 The portions of line where the system of Safeworking relies on track-circuiting or axle counters.

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Table 4 - Table of measurements taken after derailment

StationGauge Gauge Versine Radius Super Depression Test Effective

m Deviation Dn rail Up rail m Up rail Dn rail Super-40 1442 7 -5 -5

-38 1447 12 -10 -10

-36 1447 12 40 50 200 -15 -15

-34 1445 10 45 45 178 -20 -20

-32 1445 10 54 47 148 -22 -22

-30 1442 7 56 56 143 -25 -25

-28 1444 9 57 57 140 -25 -25

-26 1449 14 50 60 160 -19 -19

-24 1450 15 55 60 145 -11 -11

-22 1445 10 58 138 -9 -9

-20 1453 18 40 52 200 -8 -8

-18 1445 10 49 38 163 -2 5 15 8

-16 1442 7 55 52 145 -4 4 2 -6

-14 1444 9 60 59 133 -5 12 14 -3

-12 1452 17 58 60 138 -7 11 9 -9

-10 1455 20 60 60 133 -7 10 8 -9

-8 1461 26 67 69 119 -7 15 4 -18

-6 1465 30 74 80 108 -10 3 4 -9

-4 1465 30 75 72 107 -1 10 13 2

-2 1470 35 64 52 125 -12 13 16 -9

0 1493 58 52 65 154 -20 10 13 -17

POD 1503 68 -20 13 15 -18

2 1507 72 50 74 160 -15 -15

4 1495 60 38 45 211 0 0

6 1495 60 20 52 400 -10 -10

8 1498 63 5 32 1600 -5 -5

10 1452 17 3 0 2667 10 10

12 1435 0 17 -16 471 20 20

14 1434 -1 16 16

16 1434 -1 16 16

Bold Measurements may be affected by derailment

Measurements in millimetres unless otherwise shown

Category 5 compliance - action during planned maintenance

Category 2 compliance - action within 28 days

Category 1 compliance - action within 7 days

Outside specified limits – immediate action, no rail traffic

Track measurements were recorded at two-metre stations from the Point of Derailment (POD) starting from the closest sleeper. Negative stations values are on the approach and positive stations are on the departure side of the POD.

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Measurements recorded past the POD may have been affected by the derailment. The graph in Figure 6 below demonstrates the track gauge deviation.

Figure 6 – Graph showing gauge deviation

1430

1440

1450

1460

1470

1480

1490

1500

1510

1520

1530

1540

1550

1560

1570

-40

-38

-36

-34

-32

-30

-28

-26

-24

-22

-20

-18

-16

-14

-12

-10 -8 -6 -4 -2 0

POD 2 4 6 8 10 12 14 16

Station

mm

Actual gauge

Nominal gauge

The measurements recorded also included a depression test conducted between stations -20 and +2. The results were compared with the original super elevation and adjusted producing the effective super elevation figure. The graph in Figure 7 below indicates the difference between dynamic (under load) and static super elevation of the track.

Figure 7 – Graph showing effective track super elevation after dynamic compression tests

-30

-25

-20

-15

-10

-5

0

5

10

15

20

25

-40

-38

-36

-34

-32

-30

-28

-26

-24

-22

-20

-18

-16

-14

-12

-10 -8 -6 -4 -2 0

POD 2 4 6 8 10 12 14 16

Station

mm

Super Elevation

Effective Super Elevation

After the derailment the track infrastructure was examined by the investigation team. Walking in the direction of travel from the ARTC control boundary point (six sleepers on the approach side of catch points 104B) the sleepers transition from concrete to timber. Once entering the curve, the four-foot was fouled with coal product. The fouling product was deep enough to obscure plain view of the track fastenings. A closer examination was made of the track fastenings by removing the

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coal product build up. On the high rail a number of sleeper plates were found to have lifted from the timber sleeper and back canted18.

Figure 8 – High rail with displaced fasteners

The majority of Pandrol clips on the high rail were still in position. Numerous lock spikes were found missing, broken, and/or bent. Closer examination of these lock spikes revealed that the fracture face was dull and corroded indicating that they had been broken for some time.

Figure 9 is a schematic diagram representing the third wheelset of wagon NHRH 50245C at the point of derailment. It shows the measured geometric contributions of the track gauge widening, wheel width, wheel back-to-back dimension and wheel flange thickness. At the point of derailment, allowing for the maximum measured dynamic gauge of the track and no rail roll, there was only 19 mm of the inner wheel overlapping the head of the low rail.

18 Rail cant is the inclination of the base of the rail relative to the sleeper base.

Pandrol clip Lock spike

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Figure 9 – Diagram of wheelset 3 on track at point of derailment

The condition of track will be discussed further in Section 2.

1.5.5 Accreditation and Audit

The ARTC is an accredited organisation. Accreditations are managed in NSW by the State regulatory body, the NSW Independent Transport Safety and Reliability Regulator (ITSRR).

Audit reports prior to the incident were reviewed by the investigation team. No adverse comments about the ARTC track infrastructure, in relation to the accident, were noted by the ITSRR audit team during the accreditation process in August 2004.

1.6 Train Details Train DS212 is operated and managed by Pacific National Pty Ltd. DS212 travels between Bloomfield Colliery and Kooragang/Port Waratah. On 11 October the train consisted of three diesel electric locomotives (9009, 8212, 8223) hauling 54

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loaded PH and NH type hopper wagons containing coal. The total maximum train weight was 6480 tonnes with a total length of 932.4 metres. The maximum permissible line speed of train DS212 was 60 km/h limited by rollingstock type. The rollingstock type is known as a unit train consisting of ‘packs’ of four, seven, or eight (depending on type) wagons permanently attached together by a drawbar. The ‘packs’ are attached to each other by an automatic coupler arrangement forming a unit train. Unit 15 was allocated to train DS212.

Locomotive data logs indicated that train DS212 was travelling at a maximum speed of 21km/h through crossovers 103 and 104 from Bloomfield Colliery Loop. The maximum designated speed for those crossovers is 25 km/h.

The condition/handling of train DS212 will be discussed further in section 2.

1.6.1 Wagon NHRH 50245C

Wagon NHRH50245C was the 42nd wagon in the consist of train DS212. The wagon is a bulk coal hopper type with a maximum gross tonnage of 120 tonnes, net tonnage of 96.8 tonnes, and length of 16.2 metres. The wagon was weighed as it passed the weighbridge at Hexham after recovery. The recorded weight of the wagon was 113.75 tonnes. The wagon is constructed of welded stainless steel with mechanical discharge doors underneath. The bogies are Bradken AR-1 cross-braced three-piece bogies19 numbered EAT204 and EAT143.

An examination of the wagon and bogies was conducted at the Pacific National maintenance facility at Tighes Hill (Port Waratah, Newcastle) on 14 October 2004. Representatives from ATSB, Interfleet Technology, Pacific National, Bradken, and ARTC attended. The bogies had been removed and stored separately from the wagon. The independent report from Interfleet Technology found pronounced asymmetrical wear apparent on wheelset no.3 (the leading axle of the trailing bogie EAT143 at the time of derailment, and the first wheelset to drop between the rails). The left hand wheel, in direction of travel, of wheelset no.3 showed heavy wear to the flange with an arris20 at the flange tip. The tread showed a shiny band close to the flange root area of the wheel profile indicating the wheel had been running in an offset position on the rails. This was confirmed by the shiny surface of the outer edge of the tread on the right hand wheel, in direction of travel, on wheelset no.3 (shown in Figure 10).

19 See Appendix 6.3.

20 An arris is a sharp metal flow formed on the flange tip of the wheel.

22 Track patrols conducted on the main railway corridor encompassed 104A and 104B points.

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Figure 10 – Wheel tread profile of wheelset (in direction of travel)

Measurements were made of the left hand wheel, in direction of travel, of wheelset no.3 using ‘go / no-go’ gauges and these confirmed the following:

• The flange thickness was within allowable limits. A further measurement of actual flange thickness showed the flange was just over 22mm thick, 3mm greater than the minimum of 19mm allowed.

• The flange height was within allowable limits.

• The flange angle was within allowable limits.

• The tread hollow wear was within allowable limits.

• Measurement was made of the wheelset back-to-back dimension of wheelset no.3 and this was within allowable limits.

• The arris to the left hand wheel, in direction of travel, was within permissible limits. The arris height was not in excess of 1mm and not curved towards the flange-back. Therefore, the arris was categorised as Class 2, for which no action is required.

The other wheelset on bogie no. EAT143, wheelset no.4, showed no signs of asymmetric wear or off-centre running. The shiny surface of the treads of each wheel on wheelset no.4 were in the same position on each tread.

Wheelset no.3 of bogie EAT143 had been running with the left hand wheel, in direction of travel, towards flange contact. Despite this, wheelset no.4 on this bogie had been running in a more normal centre position. A visual examination was conducted on the remainder of this bogie (bogie no. EAT143) and nothing untoward was observed on the bogie that could explain how the asymmetric wear on wheelset no.3 could have arisen.

A visual examination was also made of the leading bogie (no. EAT204) of the wagon. The wheelsets on this bogie both showed indications of normal centre running. Both wheelsets were clearly within acceptable limits and nothing problematic was observed on the bogie.

An examination was made of the wagon body of NHRH 50245C by a member of Interfleet Technology. The couplers were examined for any indications of lack of freedom of movement. The couplers were found to be acceptable. The centre pivot and sidebearer structures on the body were also examined and found to be in acceptable condition.

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On 18 October 2004 bogie EAT143 was dismantled for further examination, witnessed by a representative from ITSRR. Bogie EAT204 was also examined further, but not dismantled. The dismantling report provided did not indicate any faults that were likely to have contributed to the derailment. There are two points worthy of note:

• One inner spring on bogie EAT143 was reported as broken. There are 18 outer springs and 10 inner springs on each bogie. The spring identified as broken was measured as having a free length of 270mm, compared with 271-275mm for the other inner springs and a minimum allowable free length of 255mm. Therefore, given the small change in free length and the large number of springs, this spring would cause negligible difference to wheel loads.

• The diameters of the wheels of no.3 wheelset were measured at the datum point of 70mm from the flange-back and found to be of equal diameter. This is coincidental. For these wheels standing on a rail head, the wheelset needs to be offset by about 12.5mm from centre running in order to achieve equal rolling radii. See Figure 11 below.

Figure 11 – Wheelset 3 wheel profiles datum point

Wheelset 3 Wheel Profiles

-70-60-50-40-30-20-10

010

0 50 100 150

mm

mm Left

Right70mm line

1.6.2 Monitoring and Maintenance

Maintenance records were inspected for wagon NHRH 50245C from the installation date of the bogies on the wagon in February 2002. A summary of the maintenance history is listed below:

• The bogies EAT204 and EAT143 were fitted to wagon NHRH 50245C on 25 February 2002.

• The 7-pack wagon set to which 50245C belongs is noted to have swapped between train units at frequent intervals.

• All maintenance was done on time, and mostly well within the 112-day period required. There is one exception where the 112-day unit train maintenance was

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at 114 days (on 26 November 2003), but a tolerance of +7days is permitted on the 112 days.

• An arris on no.3 wheelset of 50245C was identified on 22 December 2003 and ground off.

• The last examination of 50245C prior to the derailment on 11 October 2004 took place on 30 September 2004, just 11 days earlier. At this examination, arrises were identified and repaired on wheelsets on other vehicles in the unit.

In summary, examination of the Pacific National maintenance and inspection records of wagon NHRH 50245C and its bogies showed that it was inspected and maintained at the required intervals. There were no issues arising from inspection and rectification records that give any cause for concern. The fact that minor arrises were ground off wheels on other vehicles within the same unit on various occasions indicates that the presence of arrises was not uncommon and no cause for concern.

1.6.3 Accreditation and Audit

Pacific National is an accredited operator. Accreditations are managed in NSW by the State regulatory body, the NSW Independent Transport Safety and Reliability Regulator (ITSRR).

A review of audit reports was conducted by the investigation team. No adverse comments about Pacific National rollingstock, in relation to the accident, were noted by the ITSRR audit team during an audit in May 2004. However, ITSRR had issued a safety concern notice to Pacific National regarding off-centre running of the Bradken AR-1 bogie.

1.7 Environmental Conditions At the time of the derailment the weather was clear and fine.

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2 KEY ISSUES Two possible contributory issues relate to the condition of the track and condition of the train. Other potentially significant issues include the actions of the personnel immediately involved in ensuring the safety of other trains and other rail workers.

An independent consultant from Interfleet Technology Pty Ltd was engaged to inspect the track and train to assist the investigation team in determining what factors contributed to the derailment. The following scope of work was outlined for Interfleet:

• provide suitably qualified and independent persons to examine the vehicle and bogies of wagon NHRH 50245C;

• review the rolling stock maintenance and inspection records since 1 October 2003;

• visit the derailment site for details of the wheel/rail interface information;

• provide advice and assistance to the ATSB; and,

• provide a report of the findings on points 1 to 4 above with appropriate analysis, conclusions and recommendations. The report will be used in part or in full in the final published ATSB investigation report.

2.1 Track Condition Evidence found onsite suggests that the track was in a less than optimal condition and that the condition contributed to the derailment.

Loose, missing, and/or ineffective fasteners were found on consecutive sleepers on the high rail side at, and on approach to, the POD. Based on ARTC track standards for this portion of track, there is a zero tolerance for ineffective and/or missing track fasteners. Evidence found on the gauge face of the low rail indicated an outer wheel face falling into the four foot, consistent with a wide gauge derailment. No evidence was found that wheels had climbed the high rail head and derailed onto the outside of the high rail.

The track between 104A and 104B points had a large amount of coal product (material) lying on and around the track fastenings. The area forming 104A and B points were clear of fouling material. Under normal atmospheric exposure, iron and steel alloys rely on the formation of a stable and resilient surface oxide layer for protection against ongoing rapid oxidation / corrosion. Burying or covering the steel with earth or other loose material interferes with the formation of that layer and allows oxidation / corrosion to continue. Chemicals in the soil such as chlorides can exacerbate the corrosion, leading to localised attack (pitting) or accelerated rates of general metal loss. Moisture retained in the soil also contributes to accelerating this process.

A 15cm sample was cut from the high and low rails at the POD. From these samples a profile was created for each rail. The low rail profile exhibited an unusual wear pattern or contact mark on the inner gauge face of the rail head. The

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high rail was noted to have side wear of the gauge face, consistent with flange contact of small radii curves.

Figure 12 – Actual wheel/rail interface at the POD.

Low Rail/Wheel Interface - Actual

-20

0

20

40

60

80

-880 -860 -840 -820 -800 -780 -760 -740 -720 -700 -680 -660

Right Wheel Low Rail

High Rail/Wheel Interface - Actual

-20

0

20

40

60

80

660 680 700 720 740 760 780 800 820 840 860 880

Left Wheel High Rail

The pronounced contact mark on the low rail head, shown in Figure 12, indicates that a large proportion of wear has occurred due to repeated wheel tracking over the inner gauge side of the rail head for a significant time period. The outer side of the rail head was shiny across its width indicating that wheel / rail contact had occurred.

Broken track fastenings were examined to determine if the fastener had been broken as a result of the derailment. All of the broken track fastenings found on the approach to the POD on the high rail had oxidised fracture faces indicating that they had been broken for a period of time before the derailment.

Figure 13 – Broken and oxidised lock spikes

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2.2 Monitoring and Maintenance Based on the track standards used by ARTC at the time of the incident, a track patrol22 should be conducted to inspect sleepers and fastenings at intervals not exceeding seven days on main lines and 28 days on crossing loops. This is based on the adopted standard from RailCorp. ARTC reports provided to the investigation team indicate that the track had been regularly inspected but the inspection was focused on the point mechanisms. The area in-between the points was overlooked which allowed build-up of foreign material to occur. This build up of foreign material prevented effective visual inspection of the sleepers and track fastenings. Fouling material on track, in itself, is an actionable defect under the ARTC Civil Engineering Standards.

In this case the track inspections had not followed established standards identifying the fouling material and / or responding, allowing the ineffective track fastenings to go undetected. Given the variable curvature radii of between 107m to 200m, and 30-tonne axle loads, this site was susceptible to gauge growth. There were a number of opportunities to detect the gauge growth and take remedial action.

Given the lack of awareness of the poor and deteriorating condition of the high rail stability, a derailment at this location was inevitable without remedial action.

2.3 Train DS212 The consist of train DS212 was inspected both onsite and at the Pacific National depot at Tighes Hill. No monitoring or maintenance exceedences were found on the train, in particular wagon NHRH 50245C. The only noteworthy observations were the arrissed outer wheel on number three wheelset and pronounced asymmetrical wear (off centre wheel tracking) of number three wheelset on the trailing bogie of wagon NHRH 50245C. This third wheelset, leading in the trailing bogie EAT143, of wagon NHRH 50245C has been identified as the first to derail, and as such, testing/modelling has been focused on this equipment.

2.4 VAMPIRE Modelling Independent consultant, Interfleet Technology, was engaged to use VAMPIRE23 to model data provided to determine if wagon NHRH 50245C dynamics had contributed to the derailment. A ‘quick-look’ assessment was made in order to give an indication of the effect of the wheel profile at the derailment site. Aspects of track geometry such as super elevation, cant and twist have not been considered in this ‘quick-look’ assessment because evidence indicated a wide gauge derailment, not a conventional flange climb derailment.

The derailment took place on a small radius curve, so the curving forces would be expected to be high and the dominant effects are the curve radius, wheel profile and axle load. The suspension characteristics of the vehicle have not been considered in

23 VAMPIRE is a railway vehicle dynamics software program.

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this ‘quick-look’ assessment, since these are regarded as secondary effects on such a small curve radius. This includes the fact that that AR-1 bogie is a steering bogie24, since the benefits of steering are neutralised on such a small radius curve. In any case, the simplified vehicle model used does not possess the correct suspension characteristics to respond to track based inputs. Therefore, this is a simplified assessment, but one that serves to indicate the sort of lateral forces that may have existed.

A generic four-axle VAMPIRE vehicle model was used with 30t axle load. This was modelled over a piece of track corresponding to the curve radii measured at the site (see Appendix 6.4.1). The vehicle was run twice, once with all four wheel profiles with a representative new profile, and next with the profiles of the third wheelset only changed to the actual profiles measured on wheelset no.3. The results are shown in Appendices 6.4.2 – 6.4.3.

Appendix 6.4.2 shows the lateral displacement of the four wheelsets of the vehicle relative to the track as they negotiate the curvature measured at the site, with representative new profiles. This shows the wheelsets run centrally between the rails, but once on the curve the leading wheelsets of the leading and trailing bogies are seen to move towards the high rail and flange contact occurs where indicated on Appendix 6.4.2. As the curve radius reduces further, the lateral displacement of the leading wheelsets of each bogie increases further as the lateral forces deflect the high rail outwards. The trailing wheelsets of each bogie are also shown to move towards the high rail, but not as far as outer flange contact.

Appendix 6.4.3 is the same as Appendix 6.4.2, but for the case of wheelset no.3 profiles changed to those measured. This shows wheelset no.3 to be offset towards the outside rail by about 12.5mm even on the straight section of track. This causes the trailing wheelset, wheelset no.4, to be offset by about 7mm to follow it. Once on the curve, the leading wheelsets of the leading and trailing bogies move into flange contact with the high rail.

Appendices 6.4.4 and 6.4.5 correspond to Appendices 6.4.2 and 6.4.3 respectively, but show wheel lateral forces.

Appendix 6.4.4 shows the wheel lateral forces at each wheel for the same case of all new wheel profiles. On the straight section of the track file (0-20m) the left and right hand wheels each produce a small lateral force due to the cone angle on the wheels. This is about 1.5kN per wheel in a direction so as to spread the track gauge. Thus, a small gauge-spreading force of about 3kN per wheelset is produced by new wheels on straight track. This is indicative of normal gauge-spreading force.

Appendix 6.4.5 shows that on the straight track section of the track file (0-20m) the wheel lateral forces on wheelset no.3 with the as-measured profiles produce a lateral force of about 25kN at the right wheel, in direction of travel, and 10kN at the left wheel, in direction of travel. Again, these act to spread the rail gauge, hence giving a gauge-spreading force of about 35kN.

Once on the curve, Appendix 6.4.4 shows the inner and outer wheel forces increase, each acting to spread the track gauge. The maximum gauge spreading force seen

24 A steering bogie turns into corners to minimise wheel flange contact with the high rail on medium

and large radius curves.

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with new wheel profiles is about 140kN, made up of a force of 90kN on the high rail and 50kN on the low rail.

Appendix 6.4.5 shows that, with asymmetric wheelset no.3, the maximum gauge spreading force is increased slightly on the curve at about 155kN, made up of a force of 90kN on the high rail (unchanged from Appendix 6.4.4) and 65kN on the low rail.

Therefore, this simplified study indicates the following:

• The worn profile of wheelset no.3 generates a gauge-spreading force of about 35kN on straight track, compared to about 3kN for a representative new profile.

• The worn profile of wheelset no.3 generates a gauge-spreading force of about 155kN on curved track representative of the derailment site, compared with about 140kN for a representative new profile.

• The lateral force on the high rail on curved track representative of the derailment site is about 90kN for a representative new profile and the same value for the worn profile on wheelset no.3.

However, given the simplifications of the study, the magnitudes of the above forces are indicative only, but the following trends were found:

• On small-radius curved track, as found at the derailment site, the effect of the worn profile of wheelset no.3 on gauge-spreading force is to increase the gauge-spreading force, but only by a very small amount (about 11%).

• On straight track a new wheel profile generates a very small gauge spreading force, but the effect of the worn profile of wheelset no.3 is to cause a large increase (about 12 times greater) in the gauge spreading force. (Note that no assessment has been made of the effect of this force on straight track, and this is not relevant at the derailment site).

In order to check whether these results were likely to be valid for a steering bogie, a simple modification was made to the VAMPIRE model used in order to introduce a representation of a steering mechanism between the wheelsets. Again, for this ‘quick look’ assessment, the VAMPIRE model used was purely representative and did not use the actual parameters for the AR-1 steering bogie. However, changing the bogie type from non-steering to steering did not change the above results, as is to be expected for such a small radius (tight) curve.

2.5 Train Handling Both drivers of train DS212 were interviewed by the investigation team. In addition, Pacific National conducted separate interviews. In all instances both drivers recalled consistent and collaborative evidence. Locomotive data log information from all three locomotives support the information provided by the train crew. Train DS212 did not exceed 21 km/h while between the Thornton Staff Hut and the point of stopping. The dynamic brake was operational and in full use on all three locomotives during this time. The train brakes were not used until the reduction of air in the brake pipe as a result of the train separation. The locomotive data logs, as well as the crew recall, indicate that the train gradually gained speed on the down hill grade to the main line crossing at 104A points. During this time

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the train would have been in compression experiencing buff forces up to the locomotives.

Based on evidence collected from the train crew and locomotive data loggers, train handling is not considered to be a contributing factor.

2.6 Mechanism of Derailment Standard gauge track in Australia is nominally set to 1435mm. On tight curves (i.e. < 300m) the gauge may be widened to ease the passage of multi-axle locomotive bogies to more easily negotiate the curve. As wheelsets negotiate a curve the wheels on both the high and low rails produce a lateral gauge spreading force. Based on indicative results from the Interfleet report the wheelsets involved (number 3) exerted about 90kN on the high rail and 65kN on the low rail, a total gauge spreading force of 155kN. An extract from a paper25 ‘Effects of Wide Gauge on Derailment Potential’ shown below describes how lateral wheel forces affect the track structure.

Track with timber ties and cut spike fasteners is fairly elastic under lateral forces of approximately 20,000 pounds [89kN] or less. That is, the gauge might spread slightly, but after the train passes, the gauge snaps back to its original dimension. However, when lateral, gauge-spreading forces exceed 20,000 pounds [89kN], permanent deformation of the ties and fastening system can occur. That is, the gauge no longer snaps back to its original dimension, but stays in a wider position than originally set.

On a microscopic basis, wood fibres around the spike are compressed and deformed slightly. The spike itself might bend. In total, the gauge is incrementally and permanently widened from its initial position by the repetitive application of lateral wheel loads. And those few wheelsets producing the highest lateral loads have the potential to do the most and permanent damage. Eventually, the spike holes become elongated to the point where the spikes are loose, and often work themselves up out of the spike hole. In addition to elongation of the spike holes, the roll moment on the rail produced by the combination of lateral and vertical wheel forces causes the wood fibres under the outer edge of the tie plate to become permanently compressed, resulting in the rail canting outward. As the rail cants outward, the gauge is opened up at the gauge corner of the rail head.

The derailment occurred as a result of gauge widening at about 182.527 km, between 104A points and 104B catch points which allowed the right wheel, , in direction of travel, of the third axle on the trailing bogie of wagon NHRH 50245C to drop into the four-foot. The adjacent right wheel on axle number three rolled the high rail outwards.

The factors contributing to the spreading of the track gauge include the following:

• Poor track fastening condition allowed a static gauge of 1503 mm at the POD, 68 mm wide (see Figure 9); and

25 Wolf, G P (2005) ‘Effects of Wide Gauge on Derailment Potential’, Interface Rail Journal.

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• forces on the rails from the wagon spread the gauge a further 19 mm to allow the right wheel of the third axle of wagon NHRH 50245C to drop into the four foot.

Figure 14 – Low rail wheel tracking, high rail roll out

The factors contributing to the spreading forces on the rail include the following:

• The sharp and varying curvature radii of the track; and

• additional gauge spreading force of up to about 11% exerted by wheelset three at and/or near the point of derailment.

Figure 15 below demonstrates the lateral and longitudinal displacement of an un-anchored sleeper plate on the high rail near the point of derailment. No evidence of back cant wear could be found on the timber sleepers due to the sleeper plates ‘floating’ free above the sleeper.

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Figure 15 – Displaced track fastenings

2.7 Site Protection Part of an effective response to an incident is to protect the site, particularly on adjacent lines in multiple line areas, from approaching rail traffic.

On 12 July 2002, at about 0614, an empty coal train derailed near Hexham (NSW), fouling two out of the three adjacent railway lines. A short time later a passenger train collided with the fouling wreckage. The line that the passenger train was travelling on was track circuited (Rail Vehicle Detection) but the track remained unbroken, preventing the automatic signals returning to stop. The crew from the coal train tried to contact the local signal box with no success. They also provided trackside protection for two adjacent lines, not for the line that the passenger train was travelling on. The occurrence was investigated and a report was published by Transport NSW26. The report into the collision highlighted a number of deficiencies and as a result a number of recommendations were made. As a result, Pacific National placed three additional track circuit shorting clips27 in each locomotive cab. Additionally, a ‘Safe Telegram’28 was issued by Rail Infrastructure

26 Investigation panel chaired by Transport NSW, with representatives from Pacific National, State

Rail Authority of NSW, Rail Infrastructure Corporation, and the Australian Transport Safety Bureau.

27 A track-circuit shorting clip is a flexible insulated wire with a clamp at each end which may be used to activate a track circuit and so place the signals protecting that track section at stop.

28 Shown in appendix 6.2.

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Corporation (RIC) to reinforce an appropriate response to a train that has derailed and/or has potentially fouled the adjacent line(s).

2.7.1 Pacific National Train DS212 Crew Actions

The train crew of Pacific National train DS212 advised the signaller at Maitland signal box in a timely manner that their train had stopped unexpectedly. At this stage the crew did not know what caused the sudden loss of air. Only when the signaller at Maitland signal box mentioned to the driver that there was a problem with the ‘points in transit’ was the seriousness of the situation apparent. The signaller at Maitland signal box reacted to the incident promptly by placing all signals in the area at stop and applying blocking facilities. The message was promptly relayed to the ARTC train controller and adjacent signal box at Hanbury Junction. Although the train crew performed their duties, no protection29 had been placed on the adjacent lines to protect the site. Protection was placed some time later after the incident.

In cases such as this (loss of train brake pipe air) the train is deemed to be ‘disabled’ as defined by the ARTC Glossary AGL1. If a train is deemed disabled, network rule ANTR 416 Disabled Trains states that ‘the train crew must tell the Network Control Officer about the failure; and follow the requirements of rule ANTR400 Protecting Trains; and determine the nature of the failure’. In this case the train crew:

• told a Network Control Officer about the failure;

• determined the nature of the failure after walking back; but

• did not follow the requirements of rule ANTR400 by protecting the site in accordance with network procedure ANPR720.

ARTC network rule ANTR400 states that ‘trains require protection in all circumstances if: they need assistance; or they obstruct, or might obstruct, adjacent lines; or the line is obstructed’. The rule makes reference to the ARTC Network Procedures including ANPR720 Protecting Trains. An extract of network rule ANTR400 for adjacent lines is below.

29 Explosive, visual, or mechanical/electrical warning devices.

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Figure 16 – Extract from network rule ANTR400

In this incident the driver was assured by the signaller at Maitland signal box that all adjacent signals had been placed at stop with blocking facilities applied. At the time of the loss of air, the driver was not sure if his train was foul or might be foul of adjacent running lines.

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Figure 17 – Extract from network procedure ANPR 720

The train crew of train DS212 did not apply track circuit shorting clips to the adjacent lines as stated in network procedure ANPR720. It is not clear why this action did not occur.

2.7.2 ARTC Signallers’ Actions - Maitland Signal Box

While conducting a handover, the signallers at Maitland signal box noticed that the track diagram board was indicating ‘track splatter30’ over the area of 104 and 103 points. Shortly after, the driver of train DS212 contacted the signal box. The signallers advised the driver that there must be a problem in that area and placed all signals at stop, and applied blocking facilities. Both the ARTC train control and the adjacent signaller at Hanbury Junction were advised. Both signallers at Maitland signal box commented that their actions on this day were guided by lessons learnt from the Hexham incident.

The ARTC signallers’ actions effectively protected the derailment site from the approaching CityRail passenger train 747.

30 Track splatter colloquially refers to all lights in a track circuit segment illuminated.

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2.7.3 ARTC Train Controller’s Actions – Broadmeadow Train Control Centre

After receiving advice from the signaller at Maitland signal box, the ARTC train controller immediately arranged to protect the derailment site by ensuring all signals had been placed at stop and that no trains were being advanced into the affected section. At this time the train crew from train DS212 had not confirmed that the train had in fact derailed. The train controller indicated that his actions on the day were also guided by lessons learnt from the Hexham incident.

The ARTC train controller’s actions reinforced those of both the signallers at Maitland and requirements of the network rules and procedures.

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3 CONCLUSIONS

3.1 Findings • Train DS212 derailed due to gauge widening.

• No injuries were reported.

• Seven wagons of Pacific National train DS212 derailed.

• No adverse comments about the ARTC track infrastructure, in relation to the accident, were noted by the ITSRR audit team during the accreditation process in August 2004.

• Examination of the Pacific National maintenance and inspection records of wagon NHRH 50245C and its bogies showed that it was inspected and maintained at the required intervals. There were no issues arising from inspection and rectification records that give any cause for concern. The fact that minor arrises were ground off wheels on other vehicles within the same unit on various occasions indicates that the presence of arrises was not uncommon and no cause for concern.

• No adverse comments about Pacific National rollingstock, in relation to the accident, were noted by the ITSRR audit team in May 2004. However, ITSRR had issued a safety concern notice to Pacific National in regard to the off-centre running of the Bradken AR-1 bogie.

• Based on evidence collected from the train crew and locomotive data loggers, Pacific National train DS212 did not exceed 21 km/h while between the Thornton Staff Hut and the point of rest. The speed limit for that area is 25km/h.

• Based on evidence collected from the train crew and locomotive data loggers, train handling is not considered to be a contributing factor.

• The medical condition, training status, toxicology, and fatigue levels of all the personnel involved are not considered to be contributing factors to the incident.

• All parameters measured on the Bradken AR-1 bogie EAT143 were within limits. One broken inner spring was found on this bogie, but would have negligible impact on wheel loading/handling.

• Indicative VAMPIRE calculations suggest that on straight track a new wheel profile generates a very small gauge spreading force, but the worn profile of wheelset no.3 caused a large increase (about 12 times greater) in the gauge spreading force.

• The Pacific National train crew of Train DS212 did not follow the requirements of rule ANTR400 to protect the adjacent lines from approaching rail traffic.

• The Pacific National train crew of train DS212 did not apply track circuit shorting clips to the adjacent lines as stated in network procedure ANPR720.

• The ARTC signallers’ actions effectively protected the derailment site from the approaching CityRail passenger train 747.

• The ARTC train controller’s actions reinforced those of both the signallers at Maitland and requirements of the network rules and procedures.

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3.2 Contributing Factors in the Incident • Poor track fastening condition allowed a static gauge of 1503 mm at the POD,

68 mm wide. Forces on the rails from wagon NHRH 50245C spread the gauge a further 19 mm to allow the right wheel, in direction of travel, of the third axle of wagon NHRH 50245C to drop into the four-foot.

• ARTC reports provided to the investigation team indicate that the track had been regularly inspected, but the inspection was focused on the point mechanisms. The area in-between the points were overlooked which allowed build-up of foreign material to occur over time. This build up of foreign material prevented effective visual inspection of the sleepers and track fastenings.

• The sharp and varying curvature of the track contributed to additional gauge spreading at and/or near the point of derailment.

• Given the lack of awareness of the poor and deteriorating condition of the high rail stability, a derailment at this location was inevitable without remedial action.

• Due to asymmetric tread wear on wheelset three, indicative VAMPIRE calculations suggests an additional 11% gauge spreading force at the derailment site (on curved track). This is only considered to be a contributing factor due to the less than optimal condition of the track.

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4 SAFETY ACTIONS

4.1 Recommended Safety Actions As a result of its investigation, the ATSB makes the following recommendations with the intention of improving railway operational safety. Rather than provide prescriptive solutions, these recommendations are designed to guide interested parties on the issues that need to be considered. Recommendations are directed to those agencies that should be best placed to action the safety enhancements intended by the recommendations, and are not necessarily reflective of deficiencies within those agencies.

4.1.1 Australian Rail Track Corporation Ltd (ARTC)

RR20050058

The Australian Transport Safety Bureau recommends that the ARTC review the maintenance standards for track inspections and observations, including reporting and remedial actions, to ensure that physical track is consistent with track standards in NSW.

RR20050059

The Australian Transport Safety Bureau recommends that the ARTC identify high risk areas of wide gauge and implement an effective monitoring and remedial regime.

4.1.2 Pacific National

RR20050060

The Australian Transport Safety Bureau recommends that Pacific National review the implications of asymmetric wheel tracking and wear on rail vehicle safety.

RR20050061

The Australian Transport Safety Bureau recommends that Pacific National review the effect of lateral wheel load forces in relation to asymmetric wheel tracking and wear on rail vehicle safety.

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RR20050062

The Australian Transport Safety Bureau recommends that Pacific National reinforce the requirements of the ARTC network rules and procedures regarding the protection of trains.

4.1.3 Independent Transport Safety And Reliability Regulator (New South Wales)

RR20050063

The Australian Transport Safety Bureau recommends that ITSRR, during routine audits, ensure that ARTC track in NSW complies with accredited ARTC track standards.

4.2 Safety Actions already initiated.

4.2.1 Independent Transport Safety and Reliability Regulator (New South Wales)

The Independent Transport Safety and Reliability Regulator had initiated a number of safety actions as a result of the incident. They are:

ITSRR issued a Notice of Emerging Safety Concern requiring ARTC to a) report to ITSRR the extent of the condition of all ARTC branchline junctions/turnouts (currently in use in the Hunter Valley coal traffic) with mainline track and to b) provide to ITSRR an implementation plan to rectify any identified infrastructure deficiencies and/or non-compliances with specified inspection and maintenance standards. As a result of this notice, ARTC responded by identifying and inspecting eleven other sites, one of which was in a similar condition to that of the Bloomfield turnout.

ITSRR issued a Notice of Emerging Safety Concern requiring Pacific National (PN) to look for non-typical wheel profiles. PN identified 1 significant and 4 minor bogies in early stages (but all at end of life). No further action.

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5 SUBMISSIONS Section 26, Division 2, and Part 4 of the Transport Safety Investigation Act 2003, requires that the Executive Director may provide a draft report, on a confidential basis, to any person whom the Executive Director considers appropriate, for the purposes of:

• Allowing the person to make submissions to the Executive Director about the draft; or,

• Giving the person advance notice of the likely form of the published report.

The final draft of this report was provided for comment to the following directly involved parties:

• Australian Rail Track Corporation;

• Pacific National;

• New South Wales Office of Transport Safety Investigation;

• Independent Transport Safety and Reliability Regulator (New South Wales); and,

• Directly involved individuals.

5.1 Australian Rail Track Corporation Ltd Australian Rail Track Corporation made several comments and observations on the draft report issued to directly involved parties. The comments and observations have been incorporated into the body of the report.

5.2 Pacific National Pacific National made several comments and observations on the draft report issued to directly involved parties. The comments and observations have been incorporated into the body of the report.

5.3 New South Wales Office of Transport Safety Investigation (OTSI) The Office of Transport Safety Investigation made a comment and observation on the draft report issued to directly involved parties. The comment and observation have been noted.

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5.4 Independent Transport Safety and Reliability Regulator (New South Wales) The Independent Transport Safety and Reliability Regulator made a number of comments and observations on the draft report issued to directly involved parties. The comments and observations have largely been incorporated into the body of the report. In addition the Independent Transport Safety and Reliability Regulator noted that:

The pre-accreditation audit of ARTC carried out by ITSRR was a systems audit the scope of which would not normally cover specific track locations such as Bloomfield turnout.

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6 APPENDICES

6.1 Area Map

(Crown Copyright ©)

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6.2 RailCorp SAFE Telegram 081-2002

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6.3 Schematic of Bradken AR-1 Bogie

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6.4 VAMPIRE Results

6.4.1 Plot of Site Curvature

A = Straight track for 20m as ‘lead in’ for vehicle model.

B = Transition from straight track to first point of measured curvature.

C = Measured curvature using ‘down rail’ versine and radius details between points 36 & -12. Point of derailment at point 0 which corresponds to 100m position on above track input.

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6.4.2 Wheelset lateral displacement relative to track – all new wheels

6.4.3 Wheelset lateral displacement relative to track – Wheelset no.3 as measured, other wheelsets new

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6.4.4 Wheelset lateral forces – all new wheels

6.4.5 Wheelset lateral forces – Wheelset no.3 as measured, other wheelsets new

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6.5 Timeline Diagram