Derailment of freight 6MB2 - Tottenham, train of freight Derailment 2009 , 30 January ATSB TRANSPORT SAFETY REPORT Rail Occurrence Investigation RO-2009-004 Final

Derailment of freight train 6MB2 Tottenham, Victoria

30 January 2009

ATSB TRANSPORT SAFETY REPORT

Rail Occurrence Investigation RO-2009-004 Final

Derailment of freight train 6MB2 – Tottenham, Victoria 30 January 2009

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: 62 Northbourne Ave, Canberra City, Australian Capital Territory, 2601 Telephone: 1800 020 616, from overseas +61 2 6257 4150 Accident and incident notification: 1800 011 034 (24 hours) Facsimile: 02 6247 3117, from overseas +61 2 6247 3117 Email: [email protected] Internet: www.atsb.gov.au

© Commonwealth of Australia 2010. This work is copyright. In the interests of enhancing the value of the information contained in this publication you m ay copy, download , display , print, reproduce and distribu te this material in unaltered form (ret aining this notice). However, copyright in t he material obtained fro m other agencies, private individ uals or org anisations, belongs to t hose agencies, individu als or organisations. Where you want to use their material you will need to contact them directly. Subject to t he provisions of the Copyright Act 1968, you m ust not m ake any other use of the material in this publication unless you have the permission of the Australi an 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 iv

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CONTENTS

THE AUSTRALIAN TRANSPORT SAFETY BUREAU ...... v

TERMINOLOGY USED IN THIS REPORT ...... vi

EXECUTIVE SUMMARY ...... vii

1 FACTUAL INFORMATION ...... 1 1.1 Overview ...... 1 1.1.1 Location ...... 1 1.1.2 information ...... 2 1.1.3 Train information ...... 2 1.2 Occurrence ...... 3 1.2.1 Post occurrence ...... 4

2 ANALYSIS ...... 5 2.1 Sequence of events analysis ...... 5 2.1.1 Rolling stock examination ...... 5 2.1.2 Track examination ...... 7 2.2 Track misalignment ...... 9 2.3 Track inspection and maintenance...... 13 2.3.1 Rail creep and measurement ...... 14 2.3.2 Recent track irregularities ...... 16

3 FINDINGS ...... 18 3.1 Context ...... 18 3.2 Contributing safety factors ...... 18 3.3 Other safety factors ...... 18 3.4 Other key findings ...... 19

4 SAFETY ACTION ...... 21 4.1 The Australian Rail Track Corporation ...... 21 4.1.1 Stress testing of rail following track disturbances ...... 21 4.1.2 Measurement of rail creep ...... 21 4.1.3 Referenced rail creep punch marks ...... 22 4.1.4 Documenting of welds on continuous welded rail ...... 22

APPENDIX A : SOURCES AND SUBMISSIONS ...... 23

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DOCUMENT RETRIEVAL INFORMATION

Report No. Publication date No. of pages ISBN RO-2009-004 December 2010 24 978-1-74251-127-6

Publication title Derailment of freight train 6MB2 – Tottenham, Victoria 30 January 2009

Prepared By Reference Number Australian Transport Safety Bureau ATSB-Dec10/ATSB159 PO Box 967, Civic Square ACT 2608 Australia www.atsb.gov.au Acknowledgements Figure 1. Copyright NATMAP - Geoscience Australia.

Abstract At about 1515 on 30 January 2009, 8 wagons on freight train 6MB2 derailed on a left-hand curve located near the 8.915 track km point in Tottenham, Victoria. There were no injuries. The investigation found that the train derailed as it passed over a section of track that contained a build up of longitudinal stress in the rails after three consecutive days of very high ambient temperatures. Safety issues identified during the investigation relate to the stress testing of track after slewing and welding, regular monitoring and accurate measurement of rail creep and the installation of additional creep monuments in accordance with Civil Engineering Circulars developed by the Victorian Government Public Transport Corporation.

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THE AUSTRALIAN TRANSPORT SAFETY BUREAU

The Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory agency. The Bureau is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in: independent investigation of transport accidents and other safety occurrences; safety data recording, analysis and research; fostering safety awareness, knowledge and action. The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia that fall within Commonwealth jurisdiction, as well as participating in overseas investigations involving Australian registered aircraft and ships. A primary concern is the safety of commercial transport, with particular regard to fare-paying passenger operations. The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 and Regulations and, where applicable, relevant international agreements. Purpose of safety investigations The object of a safety investigation is to identify and reduce safety-related risk. ATSB investigations determine and communicate the safety factors related to the transport safety matter being investigated. The terms the ATSB uses to refer to key safety and risk concepts are set out in the next section: Terminology Used in this Report. It is not a function of the ATSB to apportion blame or determine liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. Developing safety action Central to the ATSB’s investigation of transport safety matters is the early identification of safety issues in the transport environment. The ATSB prefers to encourage the relevant organisation(s) to initiate proactive safety action that addresses safety issues. Nevertheless, the ATSB may use its power to make a formal safety recommendation either during or at the end of an investigation, depending on the level of risk associated with a safety issue and the extent of corrective action undertaken by the relevant organisation. When safety recommendations are issued, they focus on clearly describing the safety issue of concern, rather than providing instructions or opinions on a preferred method of corrective action. As with equivalent overseas organisations, the ATSB has no power to enforce the implementation of its recommendations. It is a matter for the body to which an ATSB recommendation is directed to assess the costs and benefits of any particular means of addressing a safety issue. When the ATSB issues a safety recommendation to a person, organisation or agency, they must provide a written response within 90 days. That response must indicate whether they accept the recommendation, any reasons for not accepting part or all of the recommendation, and details of any proposed safety action to give effect to the recommendation. The ATSB can also issue safety advisory notices suggesting that an organisation or an industry sector consider a safety issue and take action where it believes it appropriate. There is no requirement for a formal response to an advisory notice, although the ATSB will publish any response it receives.

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TERMINOLOGY USED IN THIS REPORT

Occurrence: accident or incident. Safety factor: an event or condition that increases safety risk. In other words, it is something that, if it occurred in the future, would increase the likelihood of an occurrence, and/or the severity of the adverse consequences associated with an occurrence. Safety factors include the occurrence events (e.g. engine failure, , grounding), individual actions (e.g. errors and violations), local conditions, current risk controls and organisational influences. Contributing safety factor: a safety factor that, had it not occurred or existed at the time of an occurrence, then either: (a) the occurrence would probably not have occurred; or (b) the adverse consequences associated with the occurrence would probably not have occurred or have been as serious, or (c) another contributing safety factor would probably not have occurred or existed. Other safety factor: a safety factor identified during an occurrence investigation which did not meet the definition of contributing safety factor but was still considered to be important to communicate in an investigation report in the interests of improved transport safety. Other key finding: any finding, other than that associated with safety factors, considered important to include in an investigation report. Such findings may resolve ambiguity or controversy, describe possible scenarios or safety factors when firm safety factor findings were not able to be made, or note events or conditions which ‘saved the day’ or played an important role in reducing the risk associated with an occurrence. Safety issue: a safety factor that (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time. Risk level: The ATSB’s assessment of the risk level associated with a safety issue is noted in the Findings section of the investigation report. It reflects the risk level as it existed at the time of the occurrence. That risk level may subsequently have been reduced as a result of safety actions taken by individuals or organisations during the course of an investigation. Safety issues are broadly classified in terms of their level of risk as follows: • Critical safety issue: associated with an intolerable level of risk and generally leading to the immediate issue of a safety recommendation unless corrective safety action has already been taken. • Significant safety issue: associated with a risk level regarded as acceptable only if it is kept as low as reasonably practicable. The ATSB may issue a safety recommendation or a safety advisory notice if it assesses that further safety action may be practicable. • Minor safety issue: associated with a broadly acceptable level of risk, although the ATSB may sometimes issue a safety advisory notice. Safety action: the steps taken or proposed to be taken by a person, organisation or agency in response to a safety issue.

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EXECUTIVE SUMMARY

At about 1515 on 30 January 2009, northbound freight train 6MB2, owned and operated by , derailed near the beginning of a left-hand curve located near the 8.915 track km point in Tottenham, Victoria. In total, 8 wagons derailed and about 400 m of timber sleepered track was damaged. Damage to rolling stock was minimal and there were no injuries as a result of the occurrence. At the time of the derailment, major works between and were being carried out to improve the general track condition and operating efficiency on the standard gauge rail corridor. Train 6MB2 derailed as it passed over a section of mainline track in the Tottenham Yard precinct that contained a build up of longitudinal rail stress after three consecutive days of very high ambient temperatures. Due to the extreme weather conditions, the Australian Rail Track Corporation had implemented heat speed restrictions for train operators between Tottenham and Albury, restricting to speeds not greater than 60 km/h. When train 6MB2 approached the left-hand curve near the Ashley Street Bridge, the train crew observed that a small lateral misalignment had developed in the track. During the passage of the train the dynamic movement of the rail vehicles added sufficient force to increase the size of the misalignment as the train passed over it. A container flat wagon (NQKY 34695L), 31st in the consist, was the first vehicle to and it was positioned near the rear of the train. No evidence was found that defective rolling stock components had contributed to the derailment and minor damage to the rolling stock was sustained during the derailment sequence. The investigation found that as part of the project works, the Tottenham standard gauge passing loop was converted for mainline operation on 28 July 2008. A safety issue was identified where this section of track was not tested after the conversion to mainline to determine if any residual stress was present in the rails and if any treatments were necessary to reduce the likelihood of track misalignments. Other safety issues identified that creep monuments had not been installed at the east end of the curve near where train 6MB2 derailed and the rails had not been punch marked to allow track inspectors to detect rail creep. In addition, a record of two rail welds carried out at the 8.351 km point on the 30 January 2009 had not been documented for future reference. Attention to both of these items were specific requirements of the V/Line Infrastructure Civil Engineering Circular 3/87. Following the derailment, the Australian Rail Track Corporation reconstructed this section of track and replaced the timber sleepers with concrete sleepers as part of the Tottenham to Dynon infrastructure track upgrade.

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1 FACTUAL INFORMATION

1.1 Overview

At about 15151 on 30 January 2009, 8 wagons on freight train 6MB2 derailed on a left-hand curve located near the 8.915 track km point2 in Tottenham, Victoria. About 400 m metres of track was damaged during the derailment. There were no injuries and damage to rolling stock was minor.

1.1.1 Location

The suburb of Tottenham is located about 9 km west of the Melbourne central business district. The derailment site was located on the northern most standard gauge track, near the beginning of a 500 m radius left-hand curve immediately west of the Ashley Street rail overpass (Figure 1). The track was elevated on a raised earth embankment about 5 m above natural ground level. The derailment occurred as train 6MB2 traversed the timber sleepered track near the South Improvement Alliance (SIA) railway construction compound that was located at the base of an earth embankment adjacent to the Ashley Street Bridge.

Figure 1: Track layout near location of derailment and map showing proximity to Melbourne.

1 The 24-hour clock is used in this report to describe to local time of day; Eastern Daylight Time (EDT) was Coordinated Universal Time (UTC) + 11 hours. Unless shown otherwise, all times are EDT.

2 Railway track zero km reference point is located near Southern Cross Station, Melbourne Victoria.

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1.1.2 Track information

The track between Tottenham and Sunshine was constructed with 47 kg/m continuous welded rail3 (CWR) fastened to sections of concrete and timber sleepers on a bed of ballast with an average depth of 300 mm. The rail through the derailment site was mounted on base plates and fastened to timber sleepers using dog spikes. In January 2007 major works were started to improve the general track condition and the operating efficiency on the standard gauge rail corridor between Melbourne and Sydney. The Australian Rail Track Corporation (ARTC) contracted the SIA to carry out the track upgrade through the Tottenham Yard as part of the Tottenham to Dynon Stage 4 Infrastructure Upgrade. The SIA is a railway infrastructure alliance and the parties consisted of the Australian Rail Track Corporation, John Holland Rail Pty Ltd, MVM Rail Pty Ltd and O'Donnell Griffin Pty Ltd. A separate contract between the ARTC and Downer EDI Works Infrastructure (DEDI) was previously established for ongoing infrastructure maintenance. On 3 February 2007, civil works in the Tottenham Yard commenced and staging plans show works included drainage, earthwork, the rearrangement of signalling and track duplication to ease the rail traffic bottleneck through this location. Other phases of work show that some sections of timber sleepered track were to be replaced with concrete sleepers. In addition, signal trunk cabling was relocated and new signal gantries were installed for TOT4 / TOT16 and TOT6 / TOT18 signals. These signal gantries were located east and west of the derailment location. On 27 July 2008, the track section previously utilised as the Tottenham standard gauge passing loop was slewed at the east and west ends and connected to the existing parallel mainline. The track previously designated as the passing loop was then opened for mainline traffic with the previous mainline parallel running track immediately south, changing use to become the passing loop track. (Figure 1) The Stage 4 commissioning of civil works for duplication of standard gauge track through the Tottenham Yard precinct was completed in August 2008.

1.1.3 Train information

Train 6MB2 was operated by Pacific National and consisted of three , (NR27 leading, NR45 and NR34 trailing. NR34 was not under power) hauling 40 wagons (6 of which were multiple unit wagons). The train was 1299 m long and weighed a total of 2831 t. The train manifest showed eight wagons were transporting dangerous goods. No dangerous goods were damaged by the derailment and all wagons containing these goods remained railed and coupled to the front portion of the train. The crew of train 6MB2 consisted of two drivers and a driver trainer. The driver at the time of the derailment had more than 14 years driving experience. Both drivers were appropriately qualified and assessed medically fit for duty. The driver trainer

3 Track where the rail is joined by welding (and other non-moveable joints such as glued insulated joints) in lengths greater than 300 metres.

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was carrying out a routine qualification reassessment of the driver as part of the operator’s staff training and re-assessment program.

1.2 Occurrence

For 2 days before the derailment on 30 January 2009, afternoon temperatures in the Melbourne CBD reached maximums of 43.4 degrees and 44.3 degrees Celsius4 respectively. The minimum temperature was 25.7 degrees for each of the two nights preceding the derailment. The weather forecast issued by the Australian Government Bureau of Meteorology on the morning of the derailment showed very hot and dry weather conditions were to continue throughout Victoria. As a result, WOLO5 working was implemented from Tottenham to Albury restricting freight trains to speeds no greater than 60 km/h. Normal track speed through the Tottenham precinct is posted at 80 km/h. Over a period of 9 days before the derailment, track maintenance inspectors carried out three walking visual inspections on the standard gauge track through the Tottenham Yard and no defects were found. On the afternoon of 29 January 2009, a heat buckle developed on the mainline track through Tottenham Yard and this was reported to train control by the crew of Melbourne bound train 5WX2. The buckle was located about 550 m east of the Ashley Street Bridge rail overpass and the track was closed until an SIA crew repaired the defect on the morning of 30 January 2009. Another buckle located about 7.7 km west of the Ashley Street Bridge was reported to train control by a train crew at 1850 on 29 January and by a second train crew at 0318 on 30 January. Track maintenance staff assessed the buckle and advised train control that a 15 km/h temporary speed restriction had been placed through the affected location. The buckle was removed by a track gang in the morning of 30 January 2009. At 1400 on the afternoon of the derailment the drivers of train 6MB2 signed on for duty at the Melbourne Drivers’ Depot. At 1502 the train departed the Melbourne Freight Terminal bound for Junee (NSW) and was routed via the mainline through the Bunbury Street tunnel, West Footscray and Tottenham. On approach to the Ashley Street Bridge rail overpass the driver and co-driver stated that they noticed ‘a bit of a kink’ in the track. The kink (lateral misalignment) was located immediately after the overpass at the beginning of the left-hand curve. The locomotives passed over the misalignment without incident, but about 900 m later the drivers felt the train shudder a couple of times and suspected something was wrong (the time was about 1510). The co-driver looked in the mirror and saw dust near the rear of the train. At the same time the driver looked at the brake pipe air flow meter and noticed an increase in the air flow volume and immediately suspected that the train had parted. The driver eased the throttle back to bring the train to a stop. The front of the train stopped about 1400 m beyond the Ashley Street Bridge.

4 Weather observations were extracted from the BoM Melbourne weather station website and all temperatures shown are degrees Celsius.

5 WOLO is the term used for ‘speed restrictions applied during hot weather’ and is derived from a telegraph code to mean 'Welded track - restrictions on speed of Operation of LOcomotives' ( Telegraph Code Book).

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1.2.1 Post occurrence

The co-driver alighted from the and walked back along the train to find out why the train had lost air. He found that wagon NQKY 34695L, the 31st in the consist, had derailed. This wagon remained coupled to the 32nd wagon (RQWW22009R) before a gap of about 300 m to the beginning of the rear portion of the train where he found six of the remaining eight wagons had also derailed. The co-driver then told the driver who reported to train control that train 6MB2 had separated into two sections. Approximately 400 m of track was damaged in the derailment. The drivers were tested at 1650 for the presence of alcohol by the Victoria Police from Sunshine and both returned negative results. The track was closed for about 55 hours to enable the re-railing of wagons and repair of track which was reopened for traffic at about 2225 on 1 February 2009.

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2 ANALYSIS

On 31 January 2009 investigators from the Australian Transport Safety Bureau arrived at the derailment site. Evidence was sourced by investigators from the ARTC, Pacific National, Downer EDI Works Infrastructure and the Bureau of Meteorology. The evidence included train control graphs, locomotive data logs, train consist and inspection information, maintenance records, track diagrams, train driver, co-driver and driver trainer statements, medical fitness, fatigue and training records and weather observations. Investigators measured and photographed the derailment site. The following analysis examines track structure design, inspection and maintenance, train handling and operating instructions, condition of rolling stock and weather.

2.1 Sequence of events analysis

Data extracted from lead locomotive NR 27 indicated that train speed, about 1 minute before passing over the Ashley St Bridge, was 48 km/h. The train had been slowly increasing in speed and when the first wagon derailed it was travelling at 54 km/h. On seeing an increase in brake pipe air flow on the driver’s panel and being told of dust at the rear of the train by the co-driver, the driver progressively reduced the throttle from notch 8 (full power) through to notch 2 over a period of 21 seconds. The driver then moved the throttle from notches 2 and 1 to idle during the next 27 seconds. The lead locomotive came to a stop about 350 m after the activation of the automatic train brake6.

2.1.1 Rolling stock examination

The first wagon to derail in the derailment sequence was NQKY 34695L located 31st in the train consist. Both wheel sets on the trailing had derailed to the north side of the track while the leading bogie remained on track. The gross mass of wagon NQKY 34695L was 67.8 t and it was transporting a mixed load of steel bar and one container. The total mass of the steel bar located on the trailing end was 27.58 t and the containerised load on the leading end was 19.2 t. The distribution of loading side to side was even and the differential of loading between leading and trailing was less than the limit of 20 t specified in the Pacific National Freight Loading Manual FLM 01-10_06. The outer helical coil spring on the south side of the leading bogie showed signs of light compression contact between the coil layers through ‘bottoming out’. The contact marks on the weathered surfaces appeared new and were probably caused by a combination of the springs being partially compressed due to loading and rough riding after the derailment of the trailing bogie. The brake connecting rod, that had become disconnected from the live lever on the leading end of the trailing bogie, dropped and caught in the track then rotated about

6 A braking system where the loss or failure of the control medium automatically results in an emergency brake application. Code of Practice for the Defined Interstate Rail Network Volume 5 Rolling stock – RCP-1-11 Standard terminology - 4.4 Air Brake Systems.

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180 degrees (Figure 2). The brake connecting rod had pivoted around the dead lever connecting pin, was bent in an arc and came to rest under the trailing axle of the same derailed bogie. Ballast impact marks were observed on the connecting rod with the clevis ends remaining parallel and lightly abraded. The connecting rod had also come into contact with the trailing axle after disconnection when it was frequently kicked up through impact with sleepers and ballast. Figure 2: Damaged brake connecting rod on wagon NQKY 34695L

The clevis pin and retaining clip, connecting the brake connecting rod to the live lever, was not located at the derailment site. There was no physical evidence near the point of derailment (POD) to indicate that the brake connecting rod had fallen and made contact with sleepers or ballast. Safety loops designed to prevent the brake connecting rod from falling to the track were not in place on the bogie. Eye bolts designed to retain the safety loops remained attached to the bogie frames and these items showed some ballast impact damage. In the vicinity of the POD, there was no evidence of disturbance to ballast or marks found on sleepers to indicate the brake connecting rod had impacted track components and it is considered that the disconnection of the brake connecting rod from the live lever occurred later in the derailment sequence. The next wagon to derail was RQWW 22009R and it was coupled immediately behind NQKY 34695L. The trailing bogie of wagon RQWW 22009R had also derailed to the north side of the track. Examination of the first two derailed wagons showed ballast impact damage on the tread of the derailed wheels and that all wheel flanges were within required wear limits. Workshop records showed that regular maintenance had been carried out on both these wagons. Work orders for NQKY 34695L showed wheel maintenance was carried out in December 2008 and a wheel repair had been carried out on RQWW 22009R in October 2008. No recurring bogie related faults were identified for these wagons.

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Of the remaining eight trailing wagons that had separated from the front portion of the train, wagons 33 to 37 had derailed all bogies. Wagon 38 stopped over the POD with its trailing bogie remaining railed on undamaged track. The last two wagons, 39 and 40, remained on track. The investigation concluded that the condition of the rolling stock was unlikely to have contributed to the derailment. The damage sustained by the derailed wagons was the result of the post derailment sequence of events.

2.1.2 Track examination

The POD was located near the 8.915 track km point, about 55 m west of the Ashley Street Bridge, adjacent to a 500 m radius curve. Examination of the track near the POD showed significant horizontal sleeper displacement within the ballast bed, the sleepers having shifted about 400 mm to the right in the direction of train travel (Figure 3).

Figure 3: Approximate start point of sleeper displacement near the Ashley Street Bridge.

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There was evidence of lateral sleeper displacement on the outer radius of the curve. The track displacement was easily distinguishable by the change in ballast colour in line with each sleeper end where the disturbed ballast was dusty and whiter in appearance. This characteristic was visible over about 15 sleepers (Figure 4)

Figure 4: Ballast displacement at sleeper ends on outer radius of curve.

There was also evidence of marks on the rail head and damage to sleepers where the wheel(s) made initial contact with these components after derailing towards the north side (outer) rail. The spreading of track and damage to the sleepers occurred after the point where the wheel(s) first mounted the rail. There was no evidence of broken or fractured rail immediately at or before the POD. Undamaged sections of track were examined for gauge variances, loose fasteners, worn rail and the quantity of ballast packed around sleepers. Some sleepers contained minor defects but overall track condition appeared normal and in good condition. Investigators’ observations of the track near the POD combined with observations made by the train crew immediately before the derailment, show it is likely the size of the track misalignment increased during the passage of train 6MB2. The likelihood that the track misalignment progressively grew under the train is corroborated by the rear portion of the train derailing and separating only after about 900 m of the train had passed over the destabilised track.

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2.2 Track misalignment

A combination of consecutive high daytime and overnight temperatures acting on continuous welded rail and timber sleepered track can have an adverse affect on the stability of the whole track structure. Continuous welded rail provides significant advantages over the traditional rail jointing method of fish-plated rail. However, after initial construction, the effects of temperature induced rail stresses, and live load stresses, can result in: • track buckling during extreme heat; and • rail weld breaks during extreme cold. The main factors that influence track buckling are: • longitudinal rail forces; • lateral track resistance; and • dynamic rail forces.

Longitudinal rail forces

Longitudinal rail forces that act along the length of the track can be considerable and are particularly sensitive to rail temperature. The neutral temperature, or stress free temperature for rail, is a theoretical temperature at which the rail is neither in tension or compression. If the rail temperature is greater than the neutral temperature the rail will be in compression with an increased likelihood of the track buckling. Conversely, if the rail temperature is less than the neutral temperature, the rail will be in tension with an increased likelihood of the rail breaking. The longitudinal rail force due to temperature is directly proportional to the difference between the rail neutral temperature and actual rail temperature. Experience has shown that where rail is subject to full sunlight, the rail temperature may be 15 to 20 degrees Celsius higher than the corresponding ambient air temperature. The rail temperature at the time of derailment was therefore likely to have been between 57 to 62 degrees Celsius, and well above the design neutral temperature of 38 degrees specified in V/Line Infrastructure Civil Engineering Circular7 CEC 3/87. Consequently, the compressive forces in the rails were likely to have been high, increasing the risk of track misalignment. Longitudinal rail forces can be substantially influenced by track construction techniques and it is important to ensure that the correct amount of rail (length) is inserted in track at the specified rail neutral temperature when laying and repairing track. If there is too much rail in the track it is equivalent to lowering the rail neutral temperature and this increases the longitudinal compressive forces, particularly on days of extreme heat. In addition, CEC 3/38 specifies that stress adjustments should be made over 330 m lengths but this may be reduced to 82 m to suit local requirements, for example tangent track leading into curves. This measure is intended to minimise localised stresses in the sections of rail which are most prone to track buckles on hot days. Track leading into and through the derailment site

7 The Civil Engineering Circulars were developed by the Victorian Government Public Transport Corporation and contain standards, defect response levels and track maintenance and monitoring requirements.

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used foot mounted rail anchors8 to transfer the longitudinal forces to the sleepers and track structure. Generally, the anchors were fastened to each rail on both sides of every fifth sleeper, to provide longitudinal resistance to rail creep9. The Ashley St Bridge is an open deck design made of reinforced concrete and is the nearest structure to the POD. Open deck rail bridges have the track laid on a bed of ballast over the bridge top deck. In most instances the track structure is not fastened to the bridge structure. This method of track construction does not restrain the track structure as it passes over the bridge deck which allows the track to behave in a similar manner to track laid on a compacted ballast and earth formation. Where the track passed over the Ashley St Bridge it was not restricted in free movement so longitudinal track stresses are not considered to have accumulated at this location. Curves tend to be more vulnerable to buckling than tangent track. This is due to rail stress in curved track resulting in both longitudinal and lateral components of rail force. For example, high track temperature is not only likely to cause increased longitudinal compressive force, but also increased lateral force pushing rail towards the outside of the curve’s radius. This behaviour was evident in this case, as the POD was on curved track (near the transition point from tangent track) and the track had displaced towards the outside of the curve’s radius.

Lateral track resistance

Track buckling is heavily influenced by the condition of ballast, the amount of ballast in between the sleepers (crib) and shoulder, and the resultant frictional relationship between the ballast and the sleepers. Where the ballast quality, crib and shoulder fullness is less than optimal, the track is more susceptible to buckling. Over time, the quality of ballast deteriorates, as does lateral track stability, because of the reduction in lateral resistance. Track constructed using timber sleepers typically has less lateral resistance to track buckles when compared with track constructed with concrete sleepers. The total weight of a timber sleeper is about 20 percent of one made of steel reinforced concrete and a consequence, the timber sleeper has a reduced ability to bind to the ballast packed around it. For comparison, a typical air dried hardwood sleeper (usually red gum) weighs about 55 kg whereas a weighs about 275 kg. In addition, concrete sleepers use resilient fasteners that firmly clamp the rail to the sleeper. This method of fastening provides greater rigidity to the overall track structure and a vast improvement in resistance to track buckles when compared with timber sleepered track. Where a curve is constructed at a radius less than 800 m, as in this case, CEC 3/38 specifies that the outer rail (high leg) requires an increase of 50 mm in ballast shoulder width to 450 mm, heaped 150 mm above the sleeper end, then a slope down to the formation at an angle of about 35 degrees (Figure 5). The additional

8 A fastening which is attached to the foot of the rail and against the sleeper to transfer longitudinal forces to the sleepers and in turn to the track structure. Rail anchors are used to resist rail creep.

9 The permanent or progressive longitudinal movement of rails in track caused by expansion or contraction of the rail or the action of traffic. (ARA Glossary for National Code of Practice and Dictionary of Railway Terminology).

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ballast mass packed around the ends of sleepers through a curve assists in reducing the risk of lateral sleeper movement and the likelihood of a track misalignment.

Figure 5: Typical ballast profile for tangent track

An examination of ballast material leading into and through the derailment site showed it was made from crushed quarry stone, it was clean and of irregular shape, sharp edged and in the correct size range that would be compliant with Australian Standard AS 2758.7 Aggregates and rock for engineering purposes Part 7: Railway ballast. The inspection of the ballast profile before and after the derailment site established that ballast was packed firmly between and around the ends of the sleepers and was well drained. Although the track structure had been disturbed by derailed vehicles through the derailment site, there was sufficient evidence to show the ballast was a compliant with AS 2758.7 before the derailment. The ballast shoulder width through the outer side of the curve was broad. It extended about 300 mm past the sleeper end and was steeped up about 50 mm above the top of the sleeper before tapering off on the ballast slope. The disturbance of track through maintenance activities, like sleeper replacement and tamping, temporarily reduces the frictional relationship between the ballast and the sleepers. Until the track has completely stabilised through the passage of trains at reduced speeds, there is a period of instability in the track structure and a resultant increase in the risk of lateral misalignments. During the mainline realignment of the Tottenham Yard, the SIA replaced some timber sleepered track with concrete sleepers and installed temporary curves to accommodate future project duplication works. This work was completed on 3 February 2008 and the next day a lateral track misalignment occurred. The misalignment was corrected without further incident and earthworks were commenced for the duplication of track in March 2008. SIA records show that the existing curve rails were tamped10 at the 9.150 km and 8.820 km points when the track was slewed and welded in preparation for further duplication works. If the stress level in CWR is altered due to track work, good engineering practice dictates that the track should be stress tested to see that the rail is still within the correct stress free temperature. If it is not, the rail should be restressed and adjusted.

10 Tamping – The process by which ballast is packed around the sleepers to ensure the correct position for the location, speed and curvature of the line. (ARA Glossary for National Code of Practice and Dictionary of Railway Terminology).

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There were no records to show the Tottenham Yard to Dock Link Road track section had been destressed11 at the time of track slewing or prior to completion of duplication and project commissioning on 28 August 2008. Track inspection and maintenance records show that there were no reported defects or subsequent maintenance works carried out where they could have significantly destabilised the track structure after the track duplication. In addition, no speed restrictions were recorded through the derailment location by the ARTC for any track instability following routine maintenance inspections leading up to the day of the derailment on 30 January 2009. The section of track leading into and through the curve near the derailment location was not tested to determine if there was any residual stress in the rails following the conversion of track previously designated as the Tottenham standard gauge passing loop to mainline operation. If this section of track had been tested for residual stress, it is likely that any concentration of stress near the 8.900 km point would have been discovered. Preventative maintenance action to relieve any stress would have assisted in maintaining track stability and reduced the likelihood of the horizontal misalignment that occurred on 30 January 2009.

Dynamic rail forces

The long term effect of trains moving along a section of track can cause rail creep and an associated redistribution of longitudinal rail forces. Characteristically a train driven on a falling grade and/or into a curve while braking encourages bunching of the track, thereby effectively lowering the localised neutral temperature. For trains departing Melbourne, the posted maximum curve speed through each of five curves from the 8.350 km to the 9.955 km points were set at 80 km/h. The derailment of train 6MB2 occurred at the beginning of the second curve near the 8.915 km point. The maximum posted speed of 80 km/h for all these curves over the total distance of 1.6 km also dictates the overall maximum speed of trains travelling over this section. As the posted speed for trains through the Tottenham Loop precinct does not vary on the straight and curved track sections, it is improbable that a bunching of track near the derailment location has occurred as result of locomotive or train braking forces. On curved track, the lateral and vertical forces during the passage of a train exert heavy forces on the outside rail through the curve. These forces are compensated for in the track design by elevating the outside rail (cant12) to maintain the rail vehicles’ equilibrium and prevent the outside wheels from riding up and over the rail and derailing at normal speeds. When a horizontal rail buckle occurs, the curve radius is reduced in a localised area thereby providing a sharper curve. As there has been no change in the amount of applied to the outside rail to compensate for

11 The procedure used to ensure that there is no longitudinal stress in rail when it is at a nominated stress free temperature. (ARA Glossary for National Code of Practice and Dictionary of Railway Terminology) 12 The difference in level between the two rails of the track at right angles to the centreline of the track. This allows for higher speeds than if the two rails were level. Cant counteracts for the centrifugal force from a train going over a curve Source: PTC Infrastructure Standard (NG- TESTD-2101 Ver 1.0)

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the sharper curve, the lateral and vertical forces on the outside rail at normal train speeds are substantially increased. As lateral forces increase, a point is reached where the vertical force and wheel flange contact on the rail cannot prevent the outside wheel riding up over the rail, causing the wheel set to drop off the rail and derail. It is probable that when train 6MB2 passed over the section of stressed rail near the curve, the dynamic forces imparted by the train exacerbated the condition of the developing track buckle, leading to a lateral misalignment in the direction of the outside rail. The misalignment probably caused severe lateral movement of the rail vehicles which further increased the misalignment until wagons ultimately derailed.

Summary

Precursors to the derailment were set in place by the build-up of longitudinal stress near a curve and a bunching of the track structure due to three consecutive days and two nights of very high ambient temperatures that did not allow the rail to disperse the retained thermal load. It is likely that high rail stresses, in addition to dynamic forces exerted by train operations, were sufficient to overcome the track structure’s resistance to lateral misalignment. It was evident that a small lateral misalignment had developed before the passage of train 6MB2. As the train traversed the misalignment, lateral movement of the rail vehicles added sufficient force to increase the misalignment until wagons ultimately derailed. The 31st wagon (NQKY 34695L) of train 6MB2 was the first of eight wagons to derail.

2.3 Track inspection and maintenance

While the South Improvement Alliance (SIA) carried out upgrade works through the Tottenham Yard, Downer EDI Works Infrastructure (DEDI) continued to carry out inspections and routine maintenance work on track not occupied by the SIA. The work carried out by the SIA for the Tottenham to Dynon upgrade (up to the 10.590 km point) was constructed to CEC standards and upgrade works north of Dynon were built and later maintained in accordance with the Track & Civil Construction Standards. To detect track defects and items requiring maintenance, all freight lines, crossing loops and major sidings must be visually inspected at least weekly by foot patrols in suburban areas or by road/rail vehicle in country areas. All curves must be inspected in detail annually as part of the walking inspections that check gauge and cant13. Where extreme weather conditions are experienced, additional patrols and inspections must be arranged to confirm the integrity of the track structure for safe train operations. Track inspectors complete a weekly report of defects for the sections of track patrolled. These reports are forwarded to the Road Foreman for checking. Track inspection records show that over the 9 days preceding the derailment on 30 January 2009, three walking inspections were carried out with no defects found. No temporary speed restrictions were implemented within 500 m of the derailment site as a result of these inspections.

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Two minor defects were reported during a road/rail inspection at the 8.300 km and 8.875 km points on 13 April 2008 and these related to a surface or vertical defect on the right rail and a horizontal alignment on the left rail respectively. Both defects were allocated with a P2 response code that requires inspection by exception on regular patrols. A P2 defect is classified as minor and must be reinspected within14 days. If a subsequent inspection detects deterioration in condition, it may then be necessary to revise the maintenance action priority. At the time of the derailment, both defects were shown as ‘reported’ and the status report had not been revised to ‘repaired’. The ‘reported’ notation indicates that both defects were still present in the track and were continuing to be inspected by regular patrols. The P2 defect at the 8.300 km point was located within a curve east of the POD. It is unlikely that this defect would have contributed to the derailment as it was about 550 m away from the POD and confined to a localised area. The defect recorded at the 8.875 km point was situated about 40 m from the POD. Inspection records show that the priority rating for this defect had not been escalated as a result of any observed deterioration in track condition in the 9 months before the derailment. As this minor defect was on the left rail only and there was no evidence of further distortion in the track after the derailment, it is unlikely that this defect contributed to the track buckle near the 8.915 km point and POD. In addition to visual inspections carried out by track inspectors, mechanised inspection vehicles are used to evaluate track geometry. The most recent test carried out using a mechanised track geometry car in the vicinity of the derailment was on 3 December 2008, about 2 months before the derailment. A review of the records that were created by the geometry car and other manual walking inspections did not reveal any anomalies requiring maintenance action near the derailment location.

2.3.1 Rail creep and measurement

Rail creep is the longitudinal movement of rail along the length of the track due to thermal forces and the action of traffic on the line. Rail creep is most likely occur at the bottom of grades, at places where trains brake, and in the direction of traffic on double lines or the direction of predominant traffic tonnage on single lines. To enable the accurate monitoring and measurement of rail creep, trackside monuments14 are placed for the following purposes:- • To monitor the track positions where its stability, both laterally and longitudinally, may be at risk15. • To enable track to be located and maintained in its design position. • To monitor the track position at restricted clearance locations. For the Dynon to Tottenham section track upgrade, ending at the 10.590 km point, the applicable engineering standard was CEC 3/87. This document provides specific information for the erection of monuments and the monitoring of rail creep.

14 Creep monument: A permanent monument on each side of the track to facilitate the accurate measurement of creep. The monuments are installed in the cess, at least 3.5 m clear of the track centreline. Rails are punch marked on the field side of the head on the up side of each monument. Source: ARA Glossary for the National Codes of Practice and Dictionary of Railway Terminology

15 ARTC Track and Civil Engineering Specification, ETD-11-01

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70.2 Erection of Monuments: To facilitate the accurate measurement of creep, monuments are to be utilised. Where necessary, new m onuments of a pe rmanent nature are to be place d at 1km i ntervals. To perm it closer m onitoring o n cu rves of radi us 8 00 m and under, additional m onuments are to be placed at each e nd of the c urve and around it so t hat there is no more than 5 00 m bet ween t hem. (C EC 3/ 87 - 70.2)

70.3 Monitoring of creep All welded track is t o be closely monitored for creep. Close monitoring and corrective action on all cu rves below 800 m radius is essen tial. (CEC 3/87 - 70.3)

70.4 Frequency of Creep Checks Track is t o be checked against the creep markers at six monthly intervals or more regul arly as requi red. One set of m easurements i s to be t aken i n t he September – October period, the other set in the March – April period. (CEC 3/87 - 70.4) The left-hand curve through the location of the derailment had a radius of about 500 m. This curve commenced at the 8.870 km and transitioned into a right-hand curve at the 9.040 km over a total track distance of 170 m. A creep monument existed near the 9 km point (Figure 1) at the west end of the left-hand curve before the track realignment works started. This monument was left undisturbed and was intended to be used as the west end reference point for creep monitoring of the newly designated mainline track. A similar monument was not installed at the east end of the curve (near the Ashley Street Bridge) for use in the same manner as that proposed for the west end. The nearest creep monument on the original mainline alignment was located at the 6.8 km point, about 2.1 km east of the POD and would have been ineffective in monitoring rail creep near the POD close to the Ashley Street Bridge. At the completion of track work, no new creep monuments were installed to ensure accurate measurement of rail creep near the east end of the curve (which was close to the POD). Consequently, the installation did not comply with the requirements documented in CEC 3/87 because creep monuments had not been placed at each end of the 500 m radius curve. CEC 3/87 does not specify how long after the track has been laid, realigned or tamped, that track monuments should be installed and referenced to record rail creep. Previous practice has shown that where monuments have been installed they have been re-referenced very soon after track disturbances. The installation of new, reinstatement of existing and the referencing of monuments affected by the upgrade works through the Tottenham Yard was the responsibility of the SIA under the alliance contract. When Downer EDI Works Infrastructure (DEDI) maintenance staff carried out an inspection of track in October 2008, they found that no punch marks had been made on the rail in July 2008 that would have provided an accurate reference to the 9 km monuments. On discovery of this omission, DEDI punched the rail and documented the relevant reference details for future monitoring of rail creep at this location. If the rail had been marked and reference details documented by the SIA when the track was slewed on 28 July 2008, any rail creep would have been visible in the

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October 2008 maintenance inspection thereby provide advance warning of the build up of any longitudinal rail stress at the west end of the curve. The failure to reinstate and re-reference the monuments and measure rail creep at the 9 km point on the west end of the 500 m radius curve would not have contributed to the derailment at the east end of the curve near the Ashley Street Bridge. However, had creep monuments been installed on the curve in accordance with the CEC’s and combined with regular maintenance inspections, it is likely that any rail creep would have been detected and rectified before the derailment of train 6MB2 on 30 January 2009.

2.3.2 Recent track irregularities

On the 29 January 2009, the day before the derailment at Tottenham, the crew of Melbourne bound train 5WX2 reported to train control that the mainline track at Tottenham had developed a large buckle. The buckle was about 550 m east of the Ashley Street Bridge, near a curve tangent point immediately after the change from concrete to timber sleepered track (Figure 1). Train Control advised the train crew that they were aware of the buckle and that the track had been closed until a track gang could repair it the next morning. On the morning of 30 January 2009, a track gang cut and removed 60 mm from each rail before re-aligning, welding and grinding the rail. The CEC’s state that repairs to the track must be carried out in an unstressed condition at an equivalent neutral temperature of 38 degrees Celsius16. A penned notation on the rail web confirms the welds were made at the 8.351 km point when the rail neutral temperature was recorded as 38 degrees Celsius. In this instance the repair work was carried out by SIA and a Weekly Return - Aluminothermic Welding/Adjustment (Form SIA-FRM-GL-CON-009) or Weld Repair Permission Form (CEC 3/87 Appendix G) was not completed to confirm notations made on the rail web at this location. The process for carrying out the weld is specified in CEC 3/87 Appendix G – Checklist for Stress Adjustment Closure. The checklist also requires the welder to document details of each weld that in effect certifies conformance with the manufacturer’s or network owner’s specification. This buckle and corrective works to realign the track were about 550 m from the POD, and are not considered to have contributed to the track misalignment and subsequent derailment that occurred later that day. Another track buckle was reported in the Tottenham Loop to McIntyre track section on 29 January 2009 by train 5MB7 at 1850 and by train 4BM4 at 0318 on 30 January 2009. In each case the buckle occurred on a curve at the 16.610 km point, located about 7.7 km west of the Ashley St Bridge. A 15 km/h temporary speed restriction was imposed through the affected location until a track gang rectified the fault later that morning. The number of reported heat induced misalignments through the Tottenham Loop to McIntyre track section was an indication of the susceptibility of this section of timbered sleepered track to buckles under high temperature weather conditions.

16 CEC 3/87 – Stress Control Measures for Continuously Welded Rail.

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The ARTC imposed WOLO working on the Dynon to Albury track section that restricted freight train speeds to less than 60 km/h during this period of extremely hot weather. The application of WOLO working and the management train operations following reports of the track misalignments through the Tottenham precinct were carried out in accordance established network operating practices and organisational procedures.

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3 FINDINGS

3.1 Context

At approximately 1515 on 30 January 2009, freight train 6MB2 derailed about 9 km west of Melbourne in Victoria. Eight wagons derailed sustaining minor damage and about 400 m of track was destroyed. There were no injuries. From the evidence available, the following findings are made with respect to the derailment of train 6MB2 near Tottenham (Victoria) and should not be read as apportioning blame or liability to any particular organisation or individual.

3.2 Contributing safety factors • Very high rail temperatures as a consequence of extremely hot weather over a period of 3 days and 2 nights resulted in elevated levels of longitudinal stress building up in the track near the point of derailment. • The passage of train 6MB2 exacerbated a small track buckle near the 8.915 km point which became progressively worse as the train passed over it. • As the track buckle grew near the 8.915 km point, it provided a sharper curve in a concentrated location thereby allowing the outside wheel of wagon NQKY 34695L to ride up over and drop off the outer rail. • The section of track where train 6MB2 derailed, was previously utilised as the Tottenham standard gauge passing loop. It was not stress tested after slewing and welding when it was converted to mainline operation on 28 July 2008, 5 months before the derailment. [Minor safety issue] • Regular monitoring and accurate measurement of rail creep was not carried out at the east end of the curve where train 6MB2 derailed in accordance with Civil Engineering Circular 3/87 - 70.2 and 70.3. Creep monuments were not installed on the east end of the curve following the work to convert the passing loop track to mainline operation in July 2008. [Minor safety issue]

3.3 Other safety factors • Punch marks were not made on the rail and documented with references to monuments at the 9 km point following the realignment of track west of the Ashley Street Bridge. This omission precluded the detection of rail creep that may have been present during the October 2008 maintenance inspection. [Minor safety issue] • A record of the welds carried out at the 8.351 km point at Tottenham on the 30 January 2009 was not documented in accordance with the requirements of Civil Engineering Circular 3/87. [Minor safety issue]

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3.4 Other key findings • At the time of the derailment, heat related speed restrictions were in place between Tottenham and Albury restricting trains to speeds not greater than 60 km/h. • Curves with a radius of less than 800 m, in this case 500 m, require close monitoring for rail creep. • The timber sleepered mainline track was more prone to rail creep and bunching near the 500 m radius curve than the concrete sleepered track laid either side of the derailment location. • Train 6MB2 was being operated in accordance with the relevant rules and procedures and actions by the train driver did not contribute to the derailment. • No rolling stock components contributed to the derailment and the damage sustained by the wagons occurred during the derailment.

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4 SAFETY ACTION

The safety issues identified during this investigation are listed in the Findings and Safety Actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices. Depending on the level of risk of the safety issue, the extent of corrective action taken by the relevant organisation, or the desirability of directing a broad safety message to the rail industry, the ATSB may issue safety recommendations or safety advisory notices as part of the final report.

4.1 The Australian Rail Track Corporation

4.1.1 Stress testing of rail following track disturbances

Minor safety issue

The section of track where train 6MB2 derailed, was previously utilised as the Tottenham standard gauge passing loop. It was not stress tested after slewing and welding when it was converted to mainline operation on 28 July 2008, 5 months before the derailment.

ATSB safety advisory notice RO-2009-004 SAN-030

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

4.1.2 Measurement of rail creep

Minor safety issue

Regular monitoring and accurate measurement of rail creep was not carried out at the east end of the curve where train 6MB2 derailed in accordance with Civil Engineering Circular 3/87 - 70.2 and 70.3. Creep monuments were not installed on the east end of the curve following the work to convert the passing loop track to mainline operation in July 2008.

ATSB safety advisory notice RO-2009-004 SAN-032

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

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4.1.3 Referenced rail creep punch marks

Minor safety issue

Punch marks were not made on the rail and documented with references to monuments at the 9 km mark following the realignment of track west of the Ashley Street rail bridge. This omission precluded the detection of rail creep that may have been present during the October 2008 maintenance inspection.

ATSB safety advisory notice RO-2009-004 SAN-033

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

4.1.4 Documenting of welds on continuous welded rail

Minor safety issue

A record of the welds carried out at the 8.351 km point at Tottenham on the 30 January 2009 was not documented in accordance with the requirements of Civil Engineering Circular 3/87.

ATSB safety advisory notice RO-2009-004 SAN-031

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

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APPENDIX A : SOURCES AND SUBMISSIONS

Sources of Information Downer EDI Works Infrastructure Pacific National Pty Ltd The Australian Rail Track Corporation The drivers of train 6MB2.

References

ARA Glossary for the National Codes of Practice and Dictionary of Railway Terminology. ARTC Track and Civil Engineering Specification, ETD-11-01. ARTC Track and Civil Code of Practice Infrastructure Guidelines - Section 4 - Ballast. Australian Standard AS 2758.7 Aggregates and rock for engineering purposes – Part 7: Railway ballast. Code of Practice for the Defined Interstate Rail Network Volume 5 Rolling stock. Pacific National Freight Loading Manual FLM 01-10_06 Public Transport Corporation Infrastructure Standard (NG-TESTD-2101 Ver 1.0) Public Transport Corporation (V/Line Infrastructure) Civil Engineering Circulars. South Improvement Alliance Contract extracts. Victorian Railways Telegraph Code Book.

Submissions

Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report. A draft of this report was provided to: • Downer EDI Works Infrastructure • Pacific National Pty Ltd • The Australian Rail Track Corporation • The drivers of train 6MB2. • Transport Safety Victoria

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Responses to the draft report were received from: • Pacific National Pty Ltd • The Australian Rail Track Corporation • Transport Safety Victoria The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.

- 24 - Derailment of freight train 6MB2 - Tottenham, train of freight Derailment 2009 Victoria, 30 January ATSB TRANSPORT SAFETY REPORT Rail Occurrence Investigation RO-2009-004 Final

Derailment of freight train 6MB2 Tottenham, Victoria

30 January 2009