View the Rail Safety Investigation Report
OTSI conducted this investigation in collaboration with the ATSB.
What happened
A southbound Pacific National (PN) freight train derailed in the early hours of 25 February 2021 near Nana Glen, where floodwaters had built up and overtopped the track, washing away ballast.
An XPT passenger service had travelled through the same section of track 27 minutes before the freight train derailed.
One of the two crew on board the PN train sustained minor injuries while rolling stock, freight and a large section of railway were significantly damaged, and the line was closed for nine days.
What we found
Some of the key findings from the investigation include:
- The ARTC process for monitoring and responding to extreme weather events had significant limitations.
- Rail network users were not aware of the extent of the severe weather event and had not been advised of an amber alert issued by the weather prior to the derailment.
- Alerts issued by the weather monitor did not reliably meet the requirements of ARTC’s extreme weather monitoring procedure or the service agreement under which the information was provided.
- ARTC was installing remote weather monitoring stations but had not undertaken formal assessments to determine the need for these stations or their locations.
- ARTC could not reliably determine the risk of flooding along the Telarah to Acacia Ridge corridor or risks associated with inadequate capacity cross drainage systems.
- The culvert located nearest to the derailment did not have sufficient capacity to discharge the runoff from the rain event on the night of 24-25 February 2021.
- Neither the network manager (ARTC) or the operator provided guidance for train crew on how to respond to extreme wet weather events or floodwater in the rail corridor.
What has been done as a result
The following proactive safety actions have been communicated by ARTC as being completed, in progress or planned:
- Installed an additional 20 remote weather stations along the Telarah to Acacia Ridge corridor, with plans to install an additional 50 remote weather stations and 500 stream flow monitors across their network in the next two years.
- Developed and implemented a work instruction for the management of flooding and special locations. Introduced an enterprise-wide special locations register (to capture infrastructure such as non‑standard culverts) which is maintained through their asset management system.
- Release of a safety bulletin which increased the rainfall and flooding alerts by one category (i.e. red alerts treated as black alerts) as a preventative measure based on the cumulated conditions impacting on the network including saturated catchments and the La Niña weather pattern.
- Initially reviewed the contract with the Early Warning Network (EWN) to revise inconsistencies between the contract and extreme weather monitoring procedure (OPE‑PR‑014) and ensured that monitoring for the Hunter Valley commenced.
Safety Message
This investigation highlights the importance of effective risk management by network managers and users in responding to extreme weather events, including flooding, which pose a significant risk to the rail network and are likely to increase in frequency and intensity in the future.
These events can affect the integrity and exceed the design of rail infrastructure so infrastructure managers must ensure they have effective systems in place to identify, assess and manage the risks so that trains are prevented from entering sections where the design of the infrastructure will be exceeded.
Both rail infrastructure managers and rolling stock operators must also ensure that they provide guidance and operational procedures to enable consistent responses to conditions that may affect the integrity of rail infrastructure and operational safety.
While ARTC has taken various actions to improve safety since the incident, recommendations have been made both to ARTC and PN to develop guidance for train crew to respond to and report extreme wet weather events or floodwater in the rail corridor.