Derailment : Epala – Ambrose Central Queensland Ray Holsheimer Principal Adviser Rail Safety (Derailment Prevention) Aurizon 30th April, 2014 Sydney Harbour Marriot

Introduction •  At 12:11, 8th February 2013, a fully

loaded coal train (9F24) derails on the Epala – Ambrose section of the North Coast Line (NCL)/ Blackwater System

•  9F24 – 10,359t, 1,685m, TDO

•  36 Wagons and 2 Locomotives derailed •  1.2km track and overhead damage •  150 services delayed or cancelled

2 + 2 DP 4000/4100 49 x 106t “VC/VS” Wagon Pairs

Introduction (cont.)

•  Investigators POV

•  What happened?

•  Why did it happen?

•  Share learnings •  Derailment Investigation

•  Immediate and Basic Causation

•  Preventing a Recurrence

North Coast Line (NCL) and Blackwater System

(Including Site based Evidence)

Investigation •  Need to solve the right

problem to prevent recurrence

•  Critical to find the POD and what acts or conditions existed

•  Use facts based systems approach to discover basic causation

•  Learning – Having available networked capability is important

RISSB COP and Guideline outline “Best Practice”

approach

Systems Approach

What Happened •  Blackwater system is affected

by heavy rain (ex Tropical Cyclone Oswald)

•  825mm rain, 24th _ 27th January •  NCL closed 24th at 20:10 •  9F24 stowed at Rangal

•  Learning – Investigation boundaries need to be broad enough to “discover” causation

Flood Damage •  Blackwater system and NCL

is shut down for 13 days •  153 sites suffer flood damage •  Client Requirement Brief

(CRB) process invoked to manage recovery operations

Learning – Helicopter flyovers invaluable to determine scope of works on this scale

NCL – 4 View looking South

Recovery and Resumption of Operation •  Track restoration begins on 30th

January •  Track is ballasted, resurfaced and

stress tested (multiple workgroups) •  Track inspected and handed back at

normal operational speed – 15:10, 5th February

•  42 services (32 loaded UP direction totalling 174,000 tonnes)

•  9F24 derails at 12:12, 8th February, UP line, UP direction

The Site and Factual Evidence

Wagon #29 – 720m towards Epala

Lead wheel, lead bogie, first to derail

8mm flat LH Rail - Trapped sideframe and wheel

Increasing intensity – Wagons 18 through 28

Other Impacts/Learnings •  Fire •  Check rails do their job at bridge

Direction of Travel 9F24

Lead Locos + 28 Wagons 572.321 km

Wagon #98 574.206 km

#29

#64

Direction of Travel 9F24

Heat Marks Sideframe Wagon #28

Rolled Rail

All Clips Dislodged

#28

Continuous Flange Mark

Tread Marks

Direction of Travel of 9F24

Failed Knuckle

Ballast Marks

Mark from rail foot

#29 #3629

Direction of Travel

Right hand rail

9F24 Direction of Travel

of

#32 #31

#29 #30

Sleeper impact marks

Direction of Travel

#34

Bogies missing

Continuous Flange Marks

Police Photo

Photographs •  Learning - Aerial

photography invaluable

•  Take “lots” of photos – evidence lost on recovery

•  Safety Advise Travelling in cabs Remote Locomotives

30

36

29

34

Direction of Travel 31

32

35

63

64

4128

4020

Initial position of Wagon 36 following roll

sequence

33

Flange Marks on web RH Rail - Gauge Side

Direction of Travel

Direction of Travel

277 mm

The “C” Shaped Buckle

•  29 metres long •  60 meters from

the end of the pile-up

•  Drivers report seeing a buckle

•  No derailed running evidence

Learning – “Track Survey” is critical in determining immediate causation

Learnings – The “C” Shaped Buckle

573.698 km 573.727 km

573.638 km 573.698 km Misalignment (Buckle)

573.633 km

25mm Design Cant (LH Rail DOT) 0 mm CantCurve - Design Radius 3708 m Straight

670 740680 690 730720710700660650640630

83  Metres  (  4  seconds  at  74  kph) Length  29  Metres  (  277mm  Lateral  -­‐ Static  )

Towards  Epala

No evidence of Derailed Running to this point

There is no loss of detection prior to derailment.Signal detection circuit is active on RH Rail DOT.

Speed of Last Upright Wagon (Position 68) is20.49 kph as it traverses the misalignment.

•  Stay facts focused

•  Open questions

•  Learning - Proving “what is not” can be important to “what is” on the basis of fact

•  Within limits, harmonic roll will not “feed” forward

These witness marks cannot be made by the “C” shaped buckle

29 m 29 m

NUCARS® and Engineering Analysis

Determination of the POD – Facts Based

573.638 km 573.698 km

573.633 km

25mm Design Cant (LH Rail DOT)Curve - Design Radius 3708 m

610 670590 600 680 690660650640630620

POD  :  573.615   (+/-­‐ 0.005)  kmNCL  -­‐ UP  Line

83  Metres  (  4  seconds  at  74  kph)

Wagon 28 (VCAL 55055)

T=0        UTC  12:11:048th February,  2013Speed  =  74  kph

Leading  Wheelset  Derails  to  Right  in  DOT

Most Likely PODError Bar

POD - Event Recorders

NUCARS

POD - Observed On-Site Factual Evidence No evidence of Derailed Running to this point

Legend

: Dragging Equipment Detector

: Mast (OHLE Equipment)

: Flood Recovery Works

: NUCARS - Predicted POD

: Most Likely POD - Consolidated Evidence - Lag Adjusted

Direction  of  Travel  EF24

What was the Immediate Causation •  Most evidence at

the POD is destroyed

•  Based on fact, 9F24 encounters an “S” shaped buckle

•  Drivers confirm the shape

•  There is “too much steel”

NUCARS® Analysis On the basis of fact

The only possible shape

Marks laterally displaced indicating bogie yaw

L/V =1.12 Headstock Strike

Sequence The “Rolled” Rail

Why was there “Too much Steel” •  Need to be mindful of the

environment

•  Standards & Procedures exist, are adequate, have been communicated and understood

•  Independent workgroups carry out tasks within competency

•  CRB process is ineffective in delivering the required interdependent process control

Why was there “Too much Steel” (cont.)

•  Ballasting performed •  Lift and Line (Resurfacing) •  Stress Testing

•  Design Neutral Temperature (DNT) 38ºC (-7/+8) - CETS

•  Tested OK at 34ºC •  Max temp daytime 31.2ºC

•  Further ballasting •  Lift and Line (Resurfacing) •  No TSR – Loaded trains at

operational speed, UP direction

Pro

cess

Ano

mal

y

CETS Mod 2

Stress Testing at NCL - 4

Rail Buckles

•  Most likely, a smaller “S” shaped buckle is left behind the previous train Loaded Coal Train EF32, 11:30

Scope Variation and Stabilisation •  Variation to “Scope of

Work” ineffective with the CRB process (at the time)

•  Learning - Once regulated, it is impossible to tell where ballasting has been performed

•  Learning - Interdependence between resurfacing, stress testing, restressing and stabalisation

Authority Gradient and Norms •  No speed restriction (TSR)

applied on resumption of operation

•  Driver Interviews •  track rough - not reported •  “no worse than usual”

•  Learning – Forward facing camera provides valuable information

Basic Causation •  Adequate Standards and Procedures exist to

complete the work •  Independent workgroups perform competently

•  Insufficient control over process at NCL – 4 •  independent work groups require

interdependence for successful delivery

•  Change management of the CRB process

•  Communications and authority gradient – seeking a “Zero Harm” outcome

Discovery of Basic Causation is the key to preventing a

recurrence

Other Organisational Responses •  Blanket speed restriction was applied to the

Blackwater network

•  Safety Advice communicated regarding appropriate responses to infrastructure defects

•  Rail Stress Management review

•  Change management of CRB process to prepare for potential future scenarios

•  Continuing journey to “Zero Harm” by sharing and leading cultural change

Final Thoughts •  Have team presence during recovery to

quarantine evidence

•  Investigation team “war room” near site

•  Importance of these forums to share, learn and grow as industry

•  Ensure you have access to appropriate capability to get a quality investigation

•  Quality investigations take time and resources

Questions

Thank You