Recommendations and Safety Advisory Notices

Minor Safety Issue

The ARTC Code of Practice, with respect to Flooding, 'ETG-10-01', does not specify hydrological design parameters, including height of water ponding against the formation layer for a design precipitation event, and this could lead to under specified track drainage arrangements and an increased risk of track damage arising from flash flood events.

Safety Advisory Notice

The Australian Transport Safety Bureau advises that the Australian Rail Track Corporation should consider the implications of this safety issue and take action where considered appropriate.

Minor Safety Issue
The ARTC had not undertaken an audit of track drainage arrangements for the Trans-Australian Railway to verify that the track complied with the relevant standard and that the standard was appropriate.

Safety advisory notice

The Australian Transport Safety Bureau advises that the Australian Rail Track Corporation should consider the implications of this safety issue and take action where considered appropriate.

Minor Safety Issue

At the time of the derailment the ARTC did not have timely access to reliable weather information and may benefit by building closer relationships with the Bureau of Meteorology and local observers (councils, farmers, etc.) who could pass information to assist them with the identification of localised severe weather events that may potentially affect the safety of their track.

Safety advisory notice

The Australian Transport Safety Bureau advises that the Australian Rail Track Corporation should consider the implications of this safety issue and take action where considered appropriate.

Safety issue
The process for identifying potential rail defects is limited by the ultrasonic test vehicle operator's ability to detect and assess the echo patterns correctly.

Action taken by the ARTC
Rail Technology International (RTI) is actively conducting further development of their ultrasonic testing process. For example, RTI are developing software based on 'Artificial Neural Networks' for recognising ultrasonic reflection patterns that represent potential rail defects such as bolt-hole cracks. RTI have conducted post test re-analysis of ultrasonic test data using the neural network software to identify any defects that may have been missed during the test run. RTI's plan is to run the neural network software in the background and conduct this analysis while ultrasonic testing is being undertaken. RTI have indicated that implementation is planned for early 2010.

ATSB assessment of action
The ATSB acknowledges that the ARTC and RTI are developing processes to reduce the risks associated with operator dependence. While some of those
initiatives have been introduced, especially in relation to bolt-hole cracks, other rail defects are also exposed to the issue of operator dependence. The opportunity exists for continued development and implementation of strategies aimed at reducing operator dependence.

ATSB safety advisory notice RO-2008-005-SAN-035
The Australian Transport Safety Bureau advises that the ARTC should consider the implications of this safety issue and take action where considered appropriate.

Safety Issue
The ARTC Code of Practice does not recognise the relationship between heataffected metal and stress concentration when specifying how far a bolt-hole should be from the rail ends before welding.

ATSB safety advisory notice RO-2008-005-SAN-036
The Australian Transport Safety Bureau advises that the ARTC should consider the implications of this safety issue and take action where considered appropriate.

Safety issue

The ARTC Code of Practice does not clearly address the possibility that a series of track irregularities, even minor ones which do not exceed intervention limits, could cause an undesirable harmonic response in some rail vehicles.

ATSB safety recommendation

The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation takes safety action to address this safety issue.

Australian Rail Track Corporation recognises the issue identified by the Australian Transport Safety Bureau investigation and is undertaking research to identify a sustainable and practical approach to address the issue.

Australian Rail Track Corporation accepts that the track maintenance standard as currently applied treats each identified track geometry deficiency as a separate entity and may not fully recognise that there may be rare but possible combinations of track geometry deficiencies and rail vehicle ride characteristics that can unite to initiate a derailment.

The identified deficiency relates more the spacing of minor track geometry deficiencies in combination with rail vehicle characteristics including bogie spacing and type, wheel profile and load placement than the size of the individual geometry deficiencies.

Australian Rail Track Corporation has a robust electronic track geometry measuring system in place with significant data captured and processed to generate a Track Quality Index (TQI) for any given track section.

Research undertaken to date indicates the problem is not unique to the NCoP applied by Australian Rail Track Corporation, a review indicates that other codes applied within Australia and overseas have yet to define a systemic and sustainable long term solution to the problem.

Australian Rail Track Corporation considers that the issue is worthy of further consideration and has established a project group to review current standards and practices including the concerns raised by Australian Transport Safety Bureau.

The ATSB is satisfied that the intended action by the ARTC would adequately address the safety issue.

Safety Issue

The trailing bogie of wagon RCPF-31882C was found to have loose and broken wedge wear plates. It could not be verified whether the wedge wear plates had broken free before or during the derailment sequence. However, if the condition had existed prior to the derailment, it is likely that body roll induced while traversing a series of track irregularities could result in undamped harmonic oscillations.

ATSB safety recommendation

The Australian Transport Safety Bureau recommends that Pacific National takes safety action to address this safety issue.

PNL has train examination procedures in place for these items. It is also included in the new version of the Pacific National Wagon Pocket Field Manual

The ATSB is satisfied that the intended action by PNL would adequately address the safety issue.

Safety issue

Examination of wagon RCPF-31882C revealed a crack on the tread of a wheel on the second axle of the leading bogie. While not contributing to this derailment, if the crack were to develop to such an extent that the wheel tread completely fractured, the risk of derailment would increase significantly.

Safety recommendation

The Australian Transport Safety Bureau recommends that Pacific National takes safety action to address this safety issue.

PNL has train examination procedures in place for these items. It is also included in the new version of the Pacific National Wagon Pocket Field Manual

The ATSB is satisfied that the intended action by PNL would adequately address the safety issue.

Safety issue

Manual systems of train management, such as Special Proceed Authority working, are used when interlocked/engineered systems are not available. However, manual systems are subject to human error and increase the risk of safeworking irregularities/incidents when compared to interlocked/engineered systems of safeworking.

Response from the ARTC

Special Proceed Authorities (SPAs) are a paper-based safe working system, not unlike Train Orders. Paper-based systems such as Train Orders are used to authorise train movements over a significant part of Australia's national rail network. The incident at Tarana occurred in the execution of the SPA, not as a result of a problem with the safe working system.

ATSB assessment of response

The Australian Transport Safety Bureau notes ARTC's response, however the risk of safeworking irregularities is greater with manual systems of safeworking. The ATSB urges the ARTC to explore further opportunities to mitigate the risks of human error when using a paper-based system in addition to considering alternative risk controls that may reduce or eliminate human error.

Safety recommendation

The Australian Transport Safety Bureau recommends that the ARTC take action to address this safety issue.

Safety Issue

At the time of the collision, the Australian Rail Track Corporation and the Port Adelaide Enfield Council did not have an interface coordination plan to manage the risks associated with the Stirling Street level crossing interface, including the installation and maintenance of pavement marking.

Safety recommendation

The Australian Transport Safety Bureau recommends that the Port Adelaide Enfield City Council takes action to address this safety issue.

Lack of Interface Agreement, Stirling Street Level Crossing
The Port Adelaide Enfield City Council has advised that the recommendation is accepted. The Council is awaiting the drafting of Interface Agreements by the SA State Level Crossing Advisory Committee. Also, the Council has advised that they are currently working with the Department of Transport, Energy and Infrastructure's (DTEI) Level Crossing Unit in relation to DTEI's survey and assessment of level crossings in SA.

Safety issue

At the time of the collision and at times in the past, the required road pavement markings have not been present or appropriately maintained on the sealed surface of Stirling Street.

Safety recommendation

The Australian Transport Safety Bureau recommends that the Port Adelaide Enfield City Council takes action to address this safety issue.

Pavement Markings, Stirling Street Level Crossing
The Port Adelaide Enfield City Council has advised that the recommendation is accepted. The Council has advised that immediately after the Department of Transport, Energy and Infrastructure (DTEI) works associated with the Port River Bridge were completed that the pavement line marking was completed by agencies other then the Port Adelaide Enfield City Council.

Safety Issue

At the time of the collision, the Australian Rail Track Corporation and the Port Adelaide Enfield Council did not have an interface coordination plan to manage the risks associated with the Stirling Street level crossing interface, including the installation and maintenance of pavement marking.

Safety recommendation

The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation takes action to address this safety issue.

The ARTC accepts the above recommendation. The ARTC has been working towards establishing an interface agreement with the SA Department for Transport, Energy and Infrastructure for several years. It is anticipated that once a model agreement is established negotiations  with Local Government agencies will progress at a significantly faster rate.

Negotiations with Local Government organisations if not progressed as a block via the Local Government Association will need to be progressed by individual negotiation with each interfacing Council.

If the latter situation is the case ARTC reserves the right to prioritise negotiations based on a number of interfaces and perceived risk to the safety of rail operations.

Safety Issue

The Australian Rail Track Corporation had not been approached as part of the SA Department for Transport, Energy and Infrastructure's (DTEI) process of issuing Heavy Vehicle Permits for routine 'fixed term' Restricted Access Vehicle operations. Consequently, the process may preclude the opportunity to determine all risks associated with a railway level crossing, or identify changes to a railway level crossing risk profile that may have occurred over a period of time.

Safety recommendation

The Australian Transport Safety Bureau recommends that the Department for Transport, Energy and Infrastructure take further action to address this safety issue.

• Non general access vehicles, such as B-Doubles, can access parts of the road network if provided with an exemption from the mass and / or dimension limits of the Road Traffic Act by a permit or through a general exemption via a government gazette notice.
• Under the Department's Heavy Vehicle Access Framework, which was updated in April 2009 (see www.transport.sa.gov.au), exemptions by permit are now only being provided in limited circumstances, generally on a one off basis.
• DTEI is currently reviewing all routes where permits are being used to provide access over level crossings. The objective of this review is to identify works required to upgrade the route so that there is no longer a need to issue permits for access but to have the route exemption provided by government gazette notice subject to rail authority agreement.
• In addition, DTEI currently undertakes a rolling level crossing survey and assessment program which sees each individual crossing re-assessed approximately once every three years. Any issues that are found during the assessment process is brought to the attention of the relevant infrastructure manager.
• In relation to Stirling Street, DTEI has worked with the ARTC to ensure all issues have been addressed. DTEI is currently in the process of securing ARTC agreement to have route gazetted thereby eliminating the need for permits.

Safety Issue

There was no record to indicate that a worn section of rail, inserted into the track on 25 July 2007, was tested as being suitable for reuse as prescribed in the WestNet Rail Standard Gauge Mainline Code of Practrice. The lack of construction and maintenance documentation compromises the ability to maintain railway infrastructure safely and places greater importance on adhering to mandated test procedures.

Action taken by WestNet Rail

WestNet Rail has advised:

A complete review of WestNet Rail's ultrasonic testing regime is being conducted by Monash University's Institute of Railway Technology to ensure best practice is being followed.

WestNet Rail has also advised that it is establishing an electronic track asset management system.

ATSB assessment of action

The Australian Transport Safety Bureau notes that WestNet Rail has taken action in response to this safety issue. These actions are still in the formative stage. WestNet Rail does not yet have systems in place that address the specific safety issue.

Safety Recommendation

The Australian Transport Safety Bureau recommends that WestNet Rail takes action to address this safety issue.

Safety Issue

There was no clear guidance within the WestNet Rail rules for train crews that defined an allowable speed associated with proceeding 'cautiously'. Had the train been travelling at a slower speed it is probable that the extent of damage caused by the derailment would have been less.

Action taken by WestNet Rail RO-2007-006-NSA-007

WestNet Rail has advised:

Immediately after the derailment WestNet Rail implemented, on the 47 kg/m track equipped with CTC, between Koolyanobbing and West Kalgoorlie, the following instruction - Upon any unexplained illumination of a track or block section in the above section the Train controller must not permit any train to enter the section concerned until the Infrastructure person and the Safeworking Technician on call have both been advised and attended to ascertain the cause and corrective action implemented.

The above instruction applies 24 hours a day until further notice.

ATSB assessment of action

The Australian Transport Safety Bureau notes that WestNet Rail has taken action in response to this safety issue. However, WestNet Rail has not addressed the lack of guidance within their rules for train crews who are requested to proceed 'cautiously'. WestNet Rail's rules in this regard are not best practice when compared to rules in other rail systems.

Safety Recommendation

The Australian Transport Safety Bureau recommends that WestNet Rail undertake further work to address this safety issue.

Safety Issue

A single extra pulse echo was recorded during the last ultrasonic inspection of the rail, nine months before the derailment, in the vicinity of the failure. An examination with handheld ultrasonic testing equipment at the time concluded there was no sizable defect in the rail, even though the evidence suggests that the fatigue cracks existed (to some degree) at the time.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the ARTC take action to address this safety issue.

Safety Issue

Unused bolt-holes in the rail web are sufficient stress concentrators to result in the initiation and propagation of fatigue cracking, ultimately leading to the failure of the rail.

Action taken by the ARTC

The ARTC has introduced a common standard for bolt-hole crack limits across the whole ARTC network. The standard has lower thresholds for intervention.

ATSB assessment of response/action

Although the ARTC has addressed the risk of crack propagation in unused rail bolt-holes, the risk of crack initiation still exists under cyclic loading typical of actual rail traffic.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the ARTC take further action to address this safety issue.

Safety Issue

The railway 'Stop' sign assembly (RX-2 modified) for drivers entering Murrow Farm, was not located on the left side of the road to assist with driver familiarity and standard placement of signs as shown in Australian Standard AS 1742.7-2007.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation take action to address this safety issue.

Safety Issue

The railway 'Stop' sign assembly (RX-2 modified) positioned approximately 4.6 m from the nearest rail instead of nearer to 3.5 m as recommended in Australian Standard AS 1742.7, made it more difficult for the driver to gain a clear view of approaching trains.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation take action to address this safety issue.

Safety Issue

At the time of the accident the Australian Rail Track Corporation and the District Council of Mallala did not have an 'Interface Agreement' defining each organisation's responsibilities with respect to the maintenance of level crossings and land adjoining the rail corridor in the district.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Australian Rail Track Corporation take action to address this safety issue.