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Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the ATSB to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation. This statement is published as a report in accordance with section 25 of the TSI Act, capturing information from the investigation up to the time of discontinuance. |
Overview of the investigation
At 0325 Eastern Daylight-savings Time on 6 February 2019, a Pacific National loaded coal train, MR280, travelling from Moolarben to Kooragang Coal Terminal, derailed near Baerami on the Ulan branch line on the Hunter Valley Network. All wheels of the leading bogie of the 88th wagon derailed and travelled in a derailed state for approximately 1.83 km. As the derailed train reached the points of the Baerami crossing loop, another five wagons derailed and three wagons rolled on their side, narrowly missing a stationary empty coal train UL369.
The Australian Rail Track Corporation was the rail infrastructure manager for the Ulan branch line.
ATSB’s preliminary evidence collection revealed:
- There were known track defects constituting a complete track formation failure in the section of track at the point of mount and in the region approaching the derailment site. Post derailment track measurements confirmed there was a failure of the track formation at the site of the derailment.
- These defects were not treated in accordance with the ARTC’s code of practice, and they deteriorated more rapidly than expected and consequently contributed to the derailment.
- The multiple defects acted in a compounding manner but were treated in isolation. ARTC’s code of practice allowed for consideration of multiple defects and the compounding effect and required more stringent action to be taken accordingly.
- It is likely ineffective track drainage in the area of the derailment contributed to the loss of track formation.
- Prior to the derailment, track workers that inspected the section of track where the derailment occurred had identified a defect that they did not report into the asset management system, contrary to the requirements of the system.
- The last train to successfully traverse the section of track was WG949, and the train crew identified rough riding. However, an inconsistent application of the read-back element of network rule ANGE 204 (Reporting and Responding to Conditions Affecting the Network) likely resulted in the rough riding report not being acted upon.
- Train management of MR280 was consistent with operating procedures and the condition of the rolling stock did not contribute to this derailment.
Reasons for the discontinuation
The ATSB considered the contributing factors to the derailment were a result of individual actions, where personnel had not executed the intent of the ARTC code of practice and/or had not followed procedures as required.
In response to the incident, the ARTC took safety action, including:
- implemented a daily ‘known conditions review’ meeting at all provisioning centres so that call outs, TCR’s and known conditions could be frequently reviewed with other current information and ensure appropriate controls were in place for the management of defects
- issued a communication to key operational staff to reiterate the requirements and their responsibilities under network rule ANGE 206.
Based on this information, the ATSB considered it was very unlikely that further investigation would identify any systemic safety issues or identify opportunity for the enhancement of transport safety. Consequently, the ATSB has discontinued this investigation.