April 2015
This is a collation of some of the world’s railway formal inquiry reports. It includes a brief incident
synopsis, along with the main causes and recommendations from each investigation.
Readers may find some of the actions and recommendations useful to their own operations.
Co-ordinated by Greg Morse, Operational Feedback Specialist, RSSB
Contents: (Click to navigate)
Australia: Empty coaching stock derailment at
Teepookana, Tasmania, 9 December 2014
UK: Freight train derailment at Stoke Lane level
crossing, 27 August 2013
Croatia: Freight train derailment at Mađarevo, 11
July 2014
Australia: Freight train derailment at Whyalla, SA, 7
July 2014
UK: Freight train derailment
November 2014 – BULLETIN
at
Ashburys,
Whyalla
13
UK: Empty coaching stock train derailment at Paddington, 25 May 2014
Some of the key issues raised and/or suggested by the stories in this edition:
Locomotive inspection and maintenance
Risk assessment
Asset protection
Under-track crossings
Construction
Wagon maintenance
Track maintenance (fishplates, non-compliance with standards)
Rolling stock maintenance (including, procedures, training and guidance)
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
8 April
Australia: Empty coaching stock derailment at Teepookana, Tasmania, 9
December 2014
For the full report, click here: LINK
At around 12:15 (local time) on 9 December 2014, a
train consisting of an 0-6-0 diesel shunter and an empty
carriage derailed near Teepookana.
The three-person crew sustained minor injuries.
The operator, West Coast Wilderness, investigated and
found that the track condition and geometry were not
contributing factors.
An examination of the locomotive found that the front right-hand axlebox horn guide had jammed,
due to a lack of lubrication. The jammed horn guide had restricted axle articulation while the
locomotive was negotiating a slight left-hand curve, causing the leading wheel on the right side to
climb the rail head and derail.
A blanket speed restriction of 10 km/h existed for diesel locomotives travelling the section between
Regatta Point and Dubbil Barril. Although the locomotive did not have a mechanism to display or
record speed, individual crew member interviews and the damage sustained by the track
infrastructure and rolling stock suggested that speed was not a factor in the derailment.
West Coast Wilderness Railway operates three diesel locomotives of this type – primarily for
shunting and the occasional freight service. They are not normally used for passenger services.
Although the locomotives receive regular inspections, they can spend long periods idle, are often
housed in the open and are subject to the harsh environment of Tasmania’s west coast.
A pre-departure inspection was conducted on the locomotive before operation, but the lack of
adequate horn guide lubrication was not noted. The investigation found that the inspection did not
specify a requirement to check the axle box horn guide oil reservoir to ensure lubrication was being
applied.
Action taken
West Coast Wilderness Railway has advised the Australian Transportation Safety Bureau (ATSB) that,
in order to reduce its safety risk, it is:

Reviewing its locomotive examination recording sheet, making changes where needed and
ensuring maintainers are advised of any changes made.

Reviewing the daily locomotive to include the need for ensuring the oil reservoir above the
axle box horn guide is clear, horn cheeks are showing signs of lubrication and checked for
visual signs of binding, and that locomotive crews are advised of the change.

Investigating the possibility of improving the lubrication delivery method.

Revisiting and amending the risk register for rolling stock inspections.

Undertaking a review of its rolling stock maintenance procedures manual.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
Safety message
The ATSB notes that this incident highlights to operators and maintainers, the importance of
continually monitoring and reassessing risks to the safe operation of rolling stock – particularly with
respect to low utilisation operating scenarios.
Back to top
12 April
UK: Freight train derailment at Stoke Lane level crossing, 27 August 2013
For the full report, click here: LINK
At around 04:27 on 27 August 2013, a freight train
comprising a Class 66 and 30 tank wagons carrying diesel
fuel derailed by two axles as it traversed Stoke Lane level
crossing on the Newark to Nottingham line.
The train was travelling at 53 mph when the trailing
wheelsets of the 26th and 28th wagons derailed.
Consequential damage to the rear of the train resulted in
an air leak and the automatic application of the brakes.
The train came to a stop after around 1.3 kilometres, at Carlton station. The wagons remained
upright and in line, and did not foul the adjacent running line. There was no leakage of diesel fuel
from any of the tank wagons. The track was damaged by the derailed wheelsets for a distance of
around 800 metres. The driver was not injured. The railway remained closed for repairs until 15:30
on 8 September 2013.
RAIB found that the immediate cause of the derailment was a severe dip in the track which
developed rapidly under the leading portion of the train. After the derailment, severe dips of about
100 mm were found in both rails of the affected line, where the rails had deformed over a large void
in the ground which had left the track unsupported over a length of around 3 metres.
The void under the railway and other voids found later under the adjacent road surface were caused
by excessive ground loss during the recent construction of a ‘microtunnel’ along the road centre line.
Although some alternative explanations cannot be completely discounted, RAIB considers that the
most likely explanation is that the voids resulted from of over-mining of the ground during the
construction of this under-track crossing (UTX).
An underlying factor to the incident was that Network Rail’s asset protection standards and guidance
were not fully complied with, which introduced risks to the UTX project. Furthermore, the risks posed
by the UTX at Stoke Lane level crossing were not adequately assessed.
Network Rail’s procedures for UTXs, and the way they were used, did not provide adequate guidance
for those involved in the design, scrutiny and construction of the UTX.
Similarly, the criteria used for monitoring settlement were not appropriate for a UTX under a level
crossing and did not adequately alert the asset protection team to the severity of the developing
problem.
Normal train services had been allowed to resume following the tunnelling work, despite evidence of
abnormal ground behaviour.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
Although not linked to the cause of the derailment, RAIB observed that changes to the design of the
UTX as it evolved were not formally notified to Network Rail and were not captured in the design
drawings.
Action taken
On 3 March 2014, Network Rail’s LNE&EM route issued a document, Guidance for the installation of
undertrack crossings using horizontal directional drilling (HDD) and other micro tunnelling/thrust
boring techniques. This is an enhanced version of the document that existed prior to the derailment.
It stresses certain key points such as the need to avoid UTXs under level crossings as far as possible,
ensuring adequate communication between all parties, demonstrating competency of the designer
and tunnelling contractor, the need for a designer’s risk assessment and analysis of possible failure
modes.
Network Rail reports that it is in the process of delivering training for its LNE&EM route asset
protection teams to bring them up to date with the latest microtunnelling techniques in relation to
UTXs.
Learning points
RAIB has identified the following learning points for the construction industry:

A detailed risk assessment should be carried out which includes careful consideration of the
prevailing ground conditions and the consequences of excessive ground loss or heave, and
appropriate control measures should be implemented during the works.

UTXs should not be routed under level crossings unless absolutely necessary, due to the
difficulties of reliably monitoring both the road and railway for settlement and the potential
risk from settlement.

Bentonite or other appropriate additives should be used in the slurry where ground conditions
require it, or best practice suggests it should be used.

The volume of spoil excavated from a tunnel or microtunnel under construction should be
carefully monitored, to a level of accuracy that is achievable for the method of tunnelling being
used, and compared to the expected volumes. Records of the spoil volumes extracted should
be retained.

The method and frequency of measurement for monitoring ground settlement during and
after tunnel construction should take cognisance of any nearby civil engineering structures
such as level crossings, bridges, stations (which may mask the severity of any subsequent
voiding or settlement) and any temporary changes to traffic conditions. For the specific case of
UTXs at level crossings, consideration should be given to monitoring subsurface movements
because surface measurements alone can be unreliable and give optimistic results.

Where there is an unexpected event such as the appearance of a surface hole in the vicinity of
a tunnel, this should be investigated immediately and thoroughly, to identify the cause and
any associated risks.
Recommendations

The Health and Safety Executive (HSE) should:
o
Disseminate the key lessons from this accident, to UK organisations representing
tunnelling companies (eg The Pipejacking Association, British Tunnelling Society, UK
Society for Trenchless Tunnelling), and request them to further disseminate the
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
learning points to their members, so that individual companies can review and
improve their working practices as necessary.
o

Assess the need to carry out monitoring checks at UTX construction sites, as part of
its audit programmes, to verify that the procedures being followed on site are in line
with industry good practice and lessons learned from this investigation.
Network Rail should review how its current processes related to the construction and approval
of UTX works are being applied, and consider the most effective way of merging its national
standard and local route guidance documents into a unified set of requirements for UTXs.
These requirements should:
o
Include improvements to cover lessons learned from this accident and be included in
a process of periodic review to check that they remain up to date;
o
List the main sources of risk to its infrastructure from the construction of UTXs (eg
ground settlement, heave or voiding) and how it expects those risks to be mitigated;
o
Provide clarity on roles and responsibilities within Network Rail, and its expectations
of outside parties, particularly with respect to assessing and managing risk and
communication for matters affecting safety of the railway; and
o
Seek to use a risk based approach which leads users to additional control measures
for higher risk UTXs, such as those at level crossings.
Once developed, the requirements should be the subject of appropriate briefing and training
to relevant Network Rail staff and made available to outside parties installing UTXs.
Compliance with the requirements should also be subject to a system of periodic internal
audit.


Network Rail should:
o
Review the working knowledge of its asset protection engineers with respect to UTXs
and where necessary provide appropriate training, which should include information
on types of UTX, methods of construction, best practice, failure modes, seeking
specialist assistance; and
o
Review the resourcing in its asset protection teams to check that engineers have
sufficient time allocated to carry out their duties and access to specialist technical
assistance when required, and where necessary, make any appropriate changes.
Network Rail should:
o
Review the suitability and action limits of its standard for the monitoring of track
movement over or adjacent to civil engineering works, including UTXs. This should
take into account calculated predictions of settlement, rates of movement and the
potential for the movements to be masked by existing structures, and not rely upon
inappropriate track maintenance standards; and
o
Make any necessary changes to its procedures and brief these out to relevant staff.
Back to top
20 April
Croatia: Freight train derailment at Mađarevo, 11 July 2014
For the full report, click here: LINK (includes summary in English)
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
At around 18:00 (local time), on 11 July 2014, one wagon in a
freight train derailed at Mađarevo station. There were no
reported injuries, however minor damage to the track and
wagon were sustained. The recovery operations also delayed
traffic by almost 13 hours.
The investigation determined that the incident was caused by
a technical fault on the wagon, specifically the rupture of the
leaf springs on the left-hand wheel of the second axle.
Recommendations

The Ministry of Maritime Affairs, Transport and Infrastructure should expand the definition of
a Railway Undertaking in the Act on Safety and Interoperability of the Rail System in
accordance with Railway Safety Directive 2004/49 /EC to ensure that the safety of the
complete railway system respects every organization that uses the rail infrastructure
regardless of whether the transport is the primary business of the organization or not.
Back to top
28 April
Australia: Freight train derailment at Whyalla, SA, 7 July 2014
For the full report, click here: LINK
On 7 July 2014, an ore train operated by Genesee & Wyoming Australia (GWA) departed from Iron
Duke for the port of Whyalla, South Australia.
Shortly after the train entered the Iron Baron–21km Junction section, the driver felt a slight ‘bump’
and noticed a loss in brake pipe pressure, before observing a large cloud of dust towards the rear of
the train. Once it had come to a stand, he walked back and saw that several wagons had derailed,
resulting in significant damage to the track.
The ATSB found that two mechanical fishplate joints had failed under the passage of the train. The
joints failed due to a combination of pre-existing fatigue cracks in the fishplates, and at least one
joint being in a condition of weakened structural integrity due to inadequate fastening.
As the wagons passed over the incomplete and ineffective rail joints, joint instability and movement
produced increasing impact forces, lateral pressure and subsequent joint separation. This was
followed by the progressive failure and misalignment of the track until the wagons inevitably
derailed.
Action taken
Shortly after the derailment, GWA, through a welding programme, removed all the mechanical joints
within the Whyalla Narrow Gauge mainline network.
In addition, GWA and Transfield Services Australia completed an audit of maintenance standards and
processes – focused on improving instructions relating to joint inspection, maintenance and risk
reporting. In November 2014, Transfield Services Australia, in cooperation with GWA, disseminated
the document Mechanical Joint Rectification to all track maintenance staff.
Following an internal investigation and an incident cause analysis study into the derailment, GWA
identified corrective actions associated with installation, inspection and maintenance of mechanical
rail joints. GWA has made significant progress in implementing those recommendations.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
Safety message
The ATSB notes that, to ensure fishplate joints are correctly installed and joints are not compromised
during operation, track infrastructure owners and operators should ensure that track maintenance
staff are provided with sufficient guidance and instruction for all works requested.
Track managers should also ensure the effective application of policy and procedures relating to the
assurance of the structural integrity of track joints – before returning the joints to service.
Back to top
28 April
UK: Freight train derailment at Ashburys, 13 November 2014 – BULLETIN
For the full bulletin, click here: LINK
At around 19:35 on 13 November 2014, the seventeenth of
eighteen empty bogie box wagons on the 19:37 freight from
Ashburys, Manchester, to Brigg’s Sidings (near Buxton)
derailed. The train was departing from the yard and travelling
at about 6 mph. The driver was alerted to the derailment by
the loss of brake pipe pressure causing the brakes to apply.
RAIB found that the derailment had been caused by the
fracturing (through to the axle) of the right- hand leading
wheel of the trailing bogie. This resulted in the loss of the
interference fit between the wheel and the axle and permitted the wheel to move inwards on the
axle. The derailment of this wheel then pulled all the wheels of the trailing bogie off the rails.
RAIB has identified the following Learning point:

Staff who examine freight trains should check for signs of overheated wheels, such as rust and
flaking paint, and take appropriate action, such as arranging for a more detailed inspection or
withdrawing the vehicle from traffic. It also confirms the need for yard management
arrangements to include regular checks on the efficacy of train preparation and inspection
procedures.
Since the incident, the operator has issued a safety alert notice to its staff reminding them of the
need to check for overheated wheels as indicated by signs of excessive heat or burnt paint.
Back to top
30 April
UK: Empty coaching stock train derailment at Paddington, 25 May 2014
For the full bulletin, click here: LINK
At around 05:20 on Sunday 25 May 2014, the third vehicle of
an empty five-car Class unit manufactured by Siemens and
operated by Heathrow Express derailed while it was running
along Platform 3 at Paddington. All four wheels on the leading
bogie of the third vehicle became derailed on a track defect
which, according to Network Rail’s standards, required a
repair within 36 hours. There were no reported injuries.
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk
RAIB found that the derailment occurred because the bogies of the third vehicle had been set up
incorrectly. This resulted in the left-hand wheels of the leading bogie being partially unloaded even
when stationary. The track defect along Platform 3 exacerbated this unloading and contributed to
the derailment.
RAIB also found that the incorrect set-up was the result of the repeated implementation by Siemens
technicians of a procedure aimed at setting the vehicle ride heights following tyre turning or bogie
replacement. This procedure did not clearly instruct the technicians on how to adjust one of the
bogie components (the anti-roll bar) which resulted in the technicians setting it in such a way as to
create the wheel load imbalance. None of the checks in the procedure identified the incorrect setup
because these checks were not monitoring parameters likely to provide a clear indication of a wheel
load imbalance. An underlying factor was the lack of effective transfer of design information about
the role and importance of the anti-roll bars between the vehicle designers (Siemens Germany) and
the vehicle maintainers (Siemens UK).
Recommendations

Siemens’ procedure for setting the vehicle ride heights after tyre turning or bogie replacement
should be revised to reflect the original design intent, including the function of the anti-roll
bars and the risks associated with incorrectly setting the anti-roll bar links. The revised
procedure should also include checks of the bogie setup post-intervention to ensure that the
wheel load distribution is maintained within Siemens’ acceptable limit.

Siemens’ training materials and competence assessments for technicians and supervisors
should be revised to capture the function of anti-roll bars, their method of adjustment and the
risks associated with incorrectly setting the anti-roll bar links. Siemens should also make this
information available to maintenance and overhaul contractors working on its behalf.

Siemens should complete its review of the safety critical procedures used to maintain its
vehicles operating in the UK to confirm that they meet the original design intent and are
capable of being implemented by competent staff. Based on the findings of this review,
Siemens should make any necessary changes to the procedures and re-brief its maintenance
staff.

Siemens should review the effectiveness of its recently developed processes for ensuring that
all necessary information from the design process is correctly incorporated in maintenance
procedures and training materials. If found necessary, Siemens should update its processes
and continue to monitor their effectiveness.
This recommendation may also apply to other suppliers and manufacturers of rolling stock.

Network Rail should review the supervision and self-assurance arrangements in place at West
Ealing depot to identify any shortcomings which led to the non-compliances with mandated
standards going unnoticed. Network Rail should then include any lessons learnt into its revised
assurance framework.
Back to top
Produced by RSSB
Author: Dr Greg Morse
Email address: Greg.Morse@rssb.co.uk