XPT Passenger Train ST22 Harden, New South Wales 9 February 2006 ATSB TRANSPORT SAFETY INVESTIGATION REPORT Rail Safety Investigation Report 2006/002 Final
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ATSB TRANSPORT SAFETY INVESTIGATION REPORT Rail Occurrence Investigation Report 2006002 Final Derailment of XPT Passenger Train ST22 Harden, New South Wales 9 February 2006 ATSB TRANSPORT SAFETY INVESTIGATION REPORT Rail Safety Investigation Report 2006/002 Final Derailment of XPT Passenger Train ST22 Harden, New South Wales 9 February 2006 Released in accordance with section 25 of the Transport Safety Investigation Act 2003 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 6440 Accident and incident notification: 1800 011 034 (24 hours) Facsimile: 02 6247 3117; from overseas + 61 2 6247 3117 E-mail: [email protected] Internet: www.atsb.gov.au © Australian Government 2007. This work is copyright. In the interests of enhancing the value of the information contained in this publication you may copy, download, display, print, reproduce and distribute this mate- rial in unaltered form (retaining this notice). However, copyright in the material obtained from non-Commonwealth agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. 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. ii CONTENTS DOCUMENT RETRIEVAL INFORMATION ................................................... v THE AUSTRALIAN TRANSPORT SAFETY BUREAU ................................ vii TERMINOLOGY USED IN ATSB INVESTIGATION REPORTS .............. viii EXECUTIVE SUMMARY ................................................................................... ix 1 FACTUAL INFORMATION ........................................................................ 1 1.1 Introduction .......................................................................................... 1 1.1.1 Location .............................................................................. 1 1.1.2 Train information................................................................ 1 1.1.3 Crew of train (ST22)........................................................... 1 1.1.4 XPT power cars .................................................................. 2 1.1.5 XPT bogies ......................................................................... 2 1.1.6 PLA bogie axles.................................................................. 3 1.1.7 Train crew account.............................................................. 4 1.1.8 Post accident response ........................................................ 5 1.1.9 Loss and damage................................................................. 7 1.2 Safety action following the derailment................................................. 7 2 ANALYSIS ...................................................................................................... 9 2.1 Rollingstock examination ..................................................................... 9 2.2 Track geometry................................................................................... 13 2.3 Wheel Impact Load Detector.............................................................. 13 2.4 Examination of cracked axles............................................................. 14 2.4.1 Design ............................................................................... 14 2.4.2 Manufacture...................................................................... 15 2.4.3 Axle stress analysis........................................................... 17 2.4.4 Axle failure analysis ......................................................... 18 2.4.5 Summary of axle failure analysis...................................... 22 2.5 Maintenance, testing and inspection................................................... 23 2.5.1 Wheelset overhaul............................................................. 23 2.5.2 Axle crack testing ............................................................. 25 2.5.3 Crack growth rate and previous MPIs .............................. 28 2.5.4 Axle painting .................................................................... 30 2.5.5 Summary of maintenance, testing and inspection............. 30 2.6 High Speed Train (United Kingdom) comparison.............................. 31 – iii – 2.6.1 In service testing of HST wheelsets.................................. 31 2.6.2 Overhaul of HST wheelsets .............................................. 31 2.6.3 Defect limits for HST axles .............................................. 31 2.7 History of cracked XPT/HST power car axles ................................... 32 2.7.1 Australia............................................................................ 32 2.7.2 United Kingdom ............................................................... 32 3 FINDINGS..................................................................................................... 35 3.1 Contributing Factors ........................................................................... 35 3.2 Other Safety Factors ........................................................................... 35 3.3 Other Key Findings............................................................................. 36 4 SAFETY ACTIONS ..................................................................................... 37 4.1 Safety actions already taken ............................................................... 37 4.1.1 RailCorp............................................................................ 37 4.1.2 Independent Transport Safety and Reliability Regulator (NSW) .............................................................. 37 4.2 Recommended safety actions ............................................................. 38 4.2.1 Recommendations to RailCorp......................................... 38 4.3 Safety advisory notices....................................................................... 38 4.3.1 Safety advisory notice to all rail vehicle operators in Australia............................................................................ 38 5 APPENDIXES............................................................................................... 39 5.1 Table of axle examination findings .................................................... 39 5.2 ATSB test results ................................................................................ 40 5.2.1 Mechanical property data.................................................. 40 5.2.2 Chemical analysis ............................................................. 40 5.2.3 Crack dimensions.............................................................. 41 5.3 UK and Australian differences ........................................................... 42 5.4 Summary of rejection criteria for HST and XPT axles....................... 44 5.5 Submissions ........................................................................................ 46 5.6 References .......................................................................................... 47 5.7 Media release...................................................................................... 48 – iv – DOCUMENT RETRIEVAL INFORMATION Report No. Publication date No. of pages ISBN 2006/002 June 2007 60 978-1-921165-03-0 Publication title Derailment of XPT Passenger Train ST22, Harden New South Wales, 9 February 2006 Prepared by Reference No. Australian Transport Safety Bureau June2007/DOTARS50299 PO Box 967, Civic Square ACT 2608 Australia www.atsb.gov.au Acknowledgements The identified images used in this report are reproduced with the permission of those organisations and/or individuals. 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 those organisations and/or individuals. Abstract On Thursday 9 February 2006 at about 0351 an XPT passenger train travelling from Melbourne to Sydney derailed near Harden in New South Wales. An inspection by the driver found one wheel on the trailing bogie of the leading power car had derailed. During recovery operations the axle of the derailed wheel was found to have completely sheared with a crack in the radius relief area between the gear and wheel seats. The ATSB’s investigation concluded that impacts from track ballast from unknown location(s) had led to the formation of the cracks in the axles. The investigation also concluded that routine testing of the axles carried out by the operator’s maintenance contractor, using magnetic particle inspection (MPI), was ineffective and resulted in the fatigue cracks going undetected for a considerable period of time. A number of safety actions have been undertaken by RailCorp and the Independent Transport Safety and Reliability Regulator of New South Wales which include measures aimed at the early