At about 0914 on Tuesday 18 June 2002 a scheduled suburban
electric passenger train number 1648, on an up journey, collided
with an approaching scheduled suburban electric empty train number
1025, on a down journey, on a section of single line, 772.3 metres
south of Epping Railway station. Passenger train 1648 had a driver
and 16 passengers on board, while the empty train 1025 had a driver
and two other drivers travelling as passengers with the train.
Train 1025 was traversing a single line section and crossing into
Epping Yard at the time of the collision. The leading cab on train
1025 had just traversed a set of points and passed the fouling
point for both the main line and the crossover line into Epping
Yard, moments prior to the collision. Train 1648 had departed
Epping platform and was advanced into the single line section on a
restricted indication, and had subsequently passed signal EPP121
that was indicating stop. Both trains and infrastructure, including
signalling and tracks, were operated by Melbourne Transport
Enterprises, through Connex Trains Melbourne (CTM) and Alstom
Melbourne Transport Limited (AMTL).
Emergency services, including the Police, Fire and Ambulance
services attended the scene. The driver of the passenger train
suffered bruising to his right upper arm, but was discharged from
hospital on the day of the collision. Minor injuries to passengers
were reported. No passengers were hospitalised.
The evidence available, including an expert medical assessment,
suggests that the driver of train 1648's performance was impaired
by his physically 'unwell' condition. He could not recall events
between the departure from Epping station on the up journey and the
point that the train passed signal EPP121 at stop, a period of
about one minute. As a result, signal EPP121 was passed at stop and
a collision occurred. Train 1648 was travelling at about 60 km/h
and train 1025 at about 12 km/h, at the point of initial
impact.
Signal distances at Epping
There are safeguards or defences to protect against such an
accident. 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 train maintenance was not a
factor in the accident. In addition, the signalling system, which
incorporates automatic train stops, operated within its design
criteria. However, the design criteria of the signalling system was
such that it could not maintain a minimum safety margin to prevent
the collision, given the speed of the passenger train involved.
Trains are fitted with pilot valves (including a dead man's
handle), so that in the event that a driver becomes incapacitated
the train should be brought to a halt. On this occasion the driver
of train 1648 had become incapacitated but the pilot valve did not
activate by applying the train's emergency brakes.
The performance of the driver of train 1648 was impaired by
migraine symptoms, and possibly treatment, and the effect of
stressful personal circumstances. The driver's history of migraine
had been declared during regular medical assessments but the
medical guidelines did not address the symptoms or treatment for a
potentially incapacitating illness. The report also addresses
factors that contribute to the driver working when he was
unwell.
The Investigation Team has also reviewed the factors surrounding
the Footscray collision on 5 June 2001 (ATSB rail investigation
report no. 11-01) and considers this event to contain some similar
safety issues.
A number of safety actions have been taken or are underway
through the Victorian Department of Infrastructure.
The report's recommendations on pages 41 and 42 relate to:
- the design of the signalling system;
- the train working procedures for trains operating on single
line sections of track;
- the medical fitness/assessment guidelines;
- the medical conditions that can impair or incapacitate a train
driver;
- driver sign-on procedures;
- sick leave policy;
- emergency procedures; and
- recommendations contained in the ATSB Footscray investigation
report.
Copies of the report are available from the Director Public
Transport Safety, Victorian Department of Infrastructure, Plaza
Level, 80 Collins Street, Melbourne or by telephoning (03) 9655
6402.
