The driver of a train that derailed in Goulburn last year, toppling five wagons, was not aware that a broken track lay ahead.
An Australian Transport Safety Bureau (ATSB) report has found that the Specialised Container Transport (SCT) freight train derailed on March 31, 2019 due to a broken rail.
The derailment, which occurred at about 4am, woke neighbours and sparked a major salvage and clean-up operation in the Sloane Street rail yard, known as the refuge. It also interrupted train movements and prompted months of track repairs.
The recently released ATSB investigation found that a crack "likely generated from a lack of weld fusion" occurred at the foot of the rail.
"This defect occurred in a portion of the rail not easily detectable through continuous ultrasonic testing, and was not detected during routine maintenance," the report stated.
"Following the derailment, a number of other factors were identified that increased the risk of a derailment in the refuge and on the main line."
The ATSB noted there were no concrete sleepers in that section, the timber ones exhibited "some decay" and that ballast "fouled with mud and dirt" could have made the track unstable. Goulburn had received about 34mm of rain in the previous two days and the ballast was not "free-draining," as it was required to be.
Investigators said the section of track, which showed signs of oxidation, likely broke after another freight train passed through at 11pm the night before. This went undetected before the derailment.
SCT was hauling 43 wagons, carrying mainly dry food goods, through to Brisbane.
A network controller, based at Junee, was alerted to the track circuit fault after the first freight train passed through at 11pm. Although 115 points had failed on the track, the controller and a signal electrician concluded that as this train had not parted, they could work around the fault until the site was inspected during daylight. This was within the rules.
The SCT driver was advised of the circuit fault and that he could divert via a refuge loop before returning to the northbound track. Investigators said the controller told him the points were set for this to occur and he could pass a signal point at 'stop.'
ALSO READ: Hazard on Hume Highway near Hume Street
"On arriving at the signal, the driver did not stop before passing, as required by (the rules)" the report stated.
"The driver was not advised that the condition of the track was unknown and had not been inspected prior to the train passing (two points where the train derailed)."
While the driver was travelling at the mandated 17km/h, investigators said if he had stopped first, the train would have been going slower.
"Had the (controller) advised the driver that the condition of the track was unknown, (he) may have operated the train at a slower speed through the turnout, which may have reduced the consequences of this occurrence," the report stated.
The loco and two wagons passed over before the broken rail "skewed to the left" and uncoupled two wagons, which were pushed over. A total five wagons derailed.
The ATSB said the section of track was inspected weekly before the derailment but was limited to detection of "large or obvious faults." Ultrasonic testing in November, 2018 and didn't detect any faults. However the Bureau said while it gave some assurance, it could not pick up all defects. As such, welds should be tested when they were undertaken.
Investigators concluded that ARTC's rules did not provide "suitable guidance to assess continued safe operation when responding to track circuit faults."
"Additionally, the network rules permitting signals to be passed at 'stop' did not require a reduction in speed when the condition of the track was unknown."
They said post-inspection had identified several contributing factors to the derailment and ARTC had identified some but not all of these before it occurred.
An ARTC spokesman said the organisation was "committed to operating a safe railway network."
We have noted the findings of the ATSB investigation and will continue to manage the track in accordance with a robust set of standards and maintenance codes of practice that are in place alongside a comprehensive safety management system," he said.
"These standards are supported by regular visual and technological track inspections along the entire length of the network as part of ARTC's monitoring procedures.
"As noted in the report, ARTC repaired the section of track at Goulburn damaged by the derailment immediately following the incident. Additionally, a process is currently in place, which is being continually reviewed, to provide assistance to network controllers when responding to track circuit failures and broken rails."
We care about what you think. Have your say in the form below and if you love local news don't forget to subscribe.