An unauthorised repair job and a number of communications issues contributed to a Sydney derailment last year, which drove a loose piece of iron through the floor of a loaded passenger train, the Australian Transport Safety Bureau has found.
Sydney Trains received some unwanted attention on January 15, 2014, after an iron bar burst through the floor of a Tangara passenger train between Edgecliff and Kings Cross during afternoon peak.
Photos of the twisted rod of metal, surrounded by alarmed passengers, went viral on social media.
The dramatic incident was the result of a minor derailment, caused by a broken axle on the leading bogie of the train’s third carriage, the ATSB said in its investigation report, released earlier this month.
The ATSB found an unauthorised, non-standard repair had been carried out on the axle in December 1998 or January 1999.
The axle in question entered into service in July 1998. Later that year it was found to have sustained surface damage that needed either an electro chemical metal deposition (ECMD), or thermal metal spraying, to repair.
While an ECMD repair was approved for the axle, the contractor, A1 Metallising, determined an ECMD technique would not be sufficient, and thermal metal spraying would have to be used.
This change was not clearly recorded in the files studied by the ATSB, however.
“No evidence was available as to how, or if, this change was approved by [UGL Unipart predecessor] Maintrain,” the Bureau said. “The final invoice, issued on 31 January 1999 … [was] non-specific and did not identify the actual process applied.”
According to the ATSB, the apparently unapproved thermal spraying technique “rendered the axle in a state whereby it was more susceptible to the initiation of surface fatigue cracking under operational loads”.
This was identified in the bureau’s report as a contributing factor to the January 2014 incident.
Rail staff failed to properly report burning smell
The bureau also found questionable communications were at fault in the lead-up to the incident.
From roughly half an hour before the derailment, on the train’s prior leg, a burning smell was apparent emanating from the train at Central station and at all subsequent stations to Bondi Junction, the ATSB reported.
“A number of station and train crewing staff were aware of this but the condition was not reported to the appropriate network control officer as required under Sydney Trains’ Network Rules and Procedures,” the bureau said.
“A number of organisational factors contributed to the incident with examples of poor communication and lack of adherence to procedures and reporting lines leading to the train continuing in service and subsequently derailing.”
Drivers ‘desensitised’ to wheel slip indicator
A further issue addressed in the report: The train’s data logger reported the wheel slip indicator light had flickered on and off throughout the lead-up to the derailment, due to the failing axle.
None of the drivers involved reported being aware of this prior to the derailment, when interviewed afterwards by the ATSB.
“Drivers are desensitised to the wheel slip protection indicator light activations through its regular activation in response to momentary losses of adhesion,” the bureau argued in its report.
“This, coupled with the inadequate warning provided by the Train Management System (TMS), may result in delayed reaction in response to activations that need driver intervention.”
Angle iron came from track infrastructure
The bureau’s report also determined where the metal rod, which penetrated the passenger space, had come from.
Immediately after the derailment, “the right hand wheel (in the direction of travel) of the leading axle of the first bogie had slipped into the space between the two rails,” the ATSB explained.
“The wheel continued in a derailed state for 17 metres where it collided with a concrete slab used to allow road/rail maintenance vehicles to be put on or taken off track.”
Lengths of ‘angle iron’ were fitted between the slab and the rail to protect the edge of the slab. One of these lengths was dislodged, and “picked up” by the train.
“One end of the piece of angle iron, that had been removed from the concrete pad and caught under the train, fouled on a piece of infrastructure causing the other end to wrap around the second axle on the bogie,” the ATSB found.
“The angle iron continued upwards, missing passengers in the area, before marking the carriage’s ceiling.” According to the bureau, one woman was standing within roughly half a metre of where the piece of metal penetrated the train floor.
What has been done
The ATSB says Sydney Trains and its maintenance contractors have undertaken an archival document search and determined that seven axles, including the failed axle, had been repaired in the same way as described in report.
All were immediately removed from service.
“Sydney Trains, after conducting its own investigation into the circumstances surrounding the incident, produced a number of safety recommendations which the organisation is considering through its own Safety Action Management procedures,” the bureau added.
“Rail operators should ensure that maintenance procedures are followed and that non-standard repairs comply strictly with an approved variation and do not introduce new risks to operations.
“Also, rail operators should review their internal training and communication pathways both within and between business units/operational areas to ensure that critical communication can occur in line with best current Rail Resource Management principle.”
Greens call on state to do more
Greens transport spokesperson Dr Mehreen Faruqi responded to the ATSB report, calling on the NSW Government to do more to prioritise passenger safety.
“The derailment report clearly shows that the Edgecliff incident occurred because of serious dysfunction and a lack of coordination between the people responsible for keeping train passengers safe,” Faruqi said.
“Multiple opportunities to stop the clearly defective train were not taken up and the vehicle was allowed to continue on until its damaging and potentially lethal derailment.
“The system can and should be run efficiently, but with passenger safety being the top priority, including through giving staff the appropriate training and ensuring that they feel comfortable to stop a train if a potential situation is emerging.
“Over the last few years, we’ve sadly seen the NSW government do all they can to project a new, shiny image for our rebranded rail network, but this may have been at the expense of passenger safety,” she continued.
Sydney Trains’ 2014/15 report showed the move of network maintenance staff from 127 bases into 12 purpose-built depots, “achieved an efficiency of 450 positions,” (i.e. reduced the workforce by 450).
“Sydney Trains might claim that they are making our train network more efficient, but in reality, they are expanding corporate and senior staff while getting rid of the people who make our system run safely and effectively,” Faruqi said.
“A good train system prioritises quality of service over a top-heavy, corporatised approach. Sadly, the government has opted for the latter.”