An empty suburban electric express train collided with the back of a suburban passenger train at number 4 platform Footscray station just after 0828 on 5 June 2001. The passenger train had about 20 people on board.
The emergency services, including the Police, Fire and Ambulance services attended the scene. As both trains and the rail infrastructure were operated by Bayside Trains, a subsidiary of National Express, the National Express emergency plan was implemented.
The driver of the empty train suffered an injury to his left elbow. Two passengers were taken to hospital for observation but were released with no serious injury.
The evidence available to the investigation suggests strongly that the driver's performance was impaired by a medical condition leading to him being unable to recall events for a period of less than two minutes, between the Maribyrnong River bridge and the point of collision. The driver was taking a course of prescribed medication, which combined with the early start to his working day on the morning of the accident and a history of chronically disturbed sleep, may have resulted in a sleep period (apnoeic episode) while he was driving the train.
There are safeguards or defences to protect against such an eventuality. On this occasion the defences in place failed to prevent the accident. A number of defences were identified as being inadequate in terms of design or application.
The investigation established that the maintenance of the trains was not a factor in this accident. The signalling system and automatic train stop operated within their design criteria. The design criteria of the signal and train stop systems, however, were such that the system could not prevent the collision given the speed of the train involved.
Drivers of suburban trains are required to maintain a given pressure on either a hand or foot pedal 'pilot valve', often referred to as a 'dead-man's handle'. In the event of a driver becoming incapacitated for any reason, the relaxing, or increase of pressure on the pilot valve should automatically apply the train brakes. Examination of relevant literature shows that pilot valves can be intentionally or inadvertently circumvented. In certain circumstances, the foot pedal can be maintained at the correct pressure just by the weight of the lower leg, whether or not the driver is incapacitated. Recommendation 7, below, is made in the full understanding that alternative systems, such as vigilance controls, may not be as effective in a metropolitan rail system, given the density of traffic, the time gap between trains and the workload of train drivers.
The alertness and fitness of drivers to perform their duties is also a defence against accident. While the investigation did not identify any significant defect with driver training, it did find serious defects in the monitoring of driver's health and fitness to operate mass public transport vehicles. The report concludes that the driver of the express train, although experienced and skilled, should not, on medical grounds, have been permitted to drive.
The investigation established that there was a lack of communication and coordination between those responsible for driver management and health professionals. The health standards used to assess driver fitness were themselves deficient.
The report's recommendations are:
- Medical standards should be reviewed and amended to:
- better monitor drivers' health and ensure a full past history and current medication regime is recorded, including monitor self medication of over-thecounter and non prescription medication.
- include an appropriate assessment of the current physiological and psychiatric status of all drivers to ensure operators have all relevant information on which to base an informed decision on driver fitness;
- include a system to identify drivers 'at potential risk', with provision for monitoring ongoing fitness;
- ensure that medical examination periods are strictly adhered to and drivers suspended if not holding current medical license;
- require drivers to produce proof of medical fitness at any time;
- create an audit system that will allow confirmation of compliance with such standards.
- The medical examination procedures should be reviewed to manage any perception of a conflict of interest in the future medical fitness system and considers whether such examinations should be conducted by a panel of doctors appointed by, and responsible to, the Accreditation Authority.
- Australian Standard, AS 4292 should be reviewed in respect of the monitoring of the health and fitness of rail safety staff.
- The signalling system and overlap should be reviewed with a view to ensuring, to the extent practicable, that trains passing a signal at danger are stopped within a safe distance. In sections before a station this distance would ensure a train is brought to a halt before a possible collision with another train stopped at the station.
- The anti-collision posts on motor cars on Com Eng trains should be further investigated to identify any deficiency in their design.
- Rail accident response plans should be reviewed to provide procedures to ensure immediate safety of the track infrastructure, training for station staff at manned stations in immediate response procedures and rapid deployment of staff at unmanned stations.
- The use of hand and foot pilot valves should be reviewed, given their limitations, to determine whether the system can be made more effective or whether an alternative, equivalent system might make a better safeguard.
- The train system radio network should be reassessed for radio reliability.
Download complete report (497 Kb PDF)
Copies of the report are available from the Victorian Department of Infrastructures Customer Service Centre, Plaza Level, 80 Collins Street, Melbourne or by telephoning (03) 9655 8830.