The Victorian Minister for Transport, the Hon Peter Batchelor, MP requested the Australian Transport Safety Bureau (ATSB) to undertake an independent investigation into the collision between steam locomotive K183,and its consist, and a loaded 'B-double' truck at the Saleyards Road level crossing, Benalla.
The investigation was conducted in accordance with the provisions of the Transport Act 1983 (Victoria) as amended.
The Terms of Reference for the investigation were:
The Investigation will examine all relevant matters including:
- The immediate events leading to the collision, including determination of the relative contribution of rolling stock, infrastructure and operating procedures.
- Train maintenance systems.
- The track authority.
- Qualification,training and re-training procedures for relevant staff.
- Scheduling of train staff to heritage and special interest.
- Operating procedures and effectiveness of such procedures.
- Medical condition of the rail safety workers involved in the collision.
- Post collision emergency management arrangements and procedures.
- Conspicuity of the engine and tender.
- Any specific issues relating to the Saleyards Road crossing and its approaches.
- Final report format to follow the model Draft AS Guidelines for rail safety investigations.
At about 1250 on Sunday 13 October 2002 an historic steam passenger train, 8382 carrying a wedding party, collided with a fully loaded B-double flour truck on a railway level crossing at Benalla, Victoria.
The B-double truck did not give way and crossed the level crossing in the path of train 8382. The evidence to the investigation was that the B-double driver did not see the train until he was actually crossing the rail track. The train was so close that he did not have time to accelerate his vehicle clear. The probability is that the train crew had no reason to suppose that the B-double would not stop at the crossing and as the B-double started to cross the train crew could do nothing to avoid or mitigate the collision.
The train driver, fireman, and one footplate1 visitor on the locomotive were fatally injured. Another footplate visitor was seriously injured as a result of the collision. No other injuries were reported.
The collision occurred on the Saleyards Road railway level crossing located approximately 1.1 kilometres from Benalla township on the Benalla - Yarrawonga/Oaklands branch line. The level crossing was a passive crossing protected by 'give way' and other warning signs on the road approaches. As a result of the collision, locomotive K183 and tender, carriage DT319 (power supply van) and the leading bogie of carriage BK712 derailed.
The B-double truck was owned and operated by Greenfreight Pty Ltd based in Wodonga. The train was operated by West Coast Railway. The train locomotive was owned by the Victorian Government and managed by Steam Rail Victoria Inc based in Newport. The carriages from the train were owned and maintained by West Coast Railway.
After impact, the train locomotive left the tracks and ploughed into soft earth next to the railway line. The locomotive was tipped onto its side and the tender was pushed into the locomotive cabin. The tender also distorted the crew compartment roof shearing the bolts holding the boiler safety valve assembly. High pressure steam vented into the atmosphere and into the crew compartment.
In accordance with the Terms of Reference, the investigation was limited to factors directly affecting safe rail operation. Other factors directly involving the B-double truck do not form part of this report.
The train and track infrastructure and maintenance systems were found to be in operational condition and conducted in accordance with accepted procedures. The train was running on an appropriate track authority. The qualifications, training and re-training procedures were appropriate and had been followed. The scheduling of train staff was not a factor in the collision, though the report recommends a review of rostering for special trains by the Rail Tram and Bus Union, particularly crews in secondary employment. The medical condition of the rail safety workers involved met the required standard and no medical factors were implicated in the cause of the collision. Post collision emergency management and response procedures were effective and efficient.
The locomotive was displaying its headlight on high beam. The train was so close to the truck as they both approached the crossing, and was also sounding its whistle, it is not possible to determine what level of conspicuity, if any, would have alerted the B-double driver.
A number of factors were identified as being critical to safe railway operation at Saleyards level crossing. The level of protection at the Saleyards Road level crossing could be improved for heavy goods vehicles accessing Saleyards Road from the east. The sighting distance, based on a train speed of 80 kph, may be insufficient to allow a heavy goods vehicle to cross and clear the level crossing in safety.
Additionally, the risk assessment process used by VicRoads and the Benalla Rural City Council to determine the level of protection used at railway level crossings on approved B-double routes could be improved.
The investigation makes several safety recommendations to the Victorian Department of Infrastructure, VicRoads, Benalla Rural City Council, Freight Australia, West Coast Railway, Rail Tram and Bus Union, Standards Association of Australia, and the Victorian Level Crossing Committee. The recommendations relate to reviewing railway level crossings on B-double routes, footplate visitors, fatigue management, and Australian Standards. One review should encompass level crossing protection treatments and include any significant changes such as traffic flow and type, speed and vegetation. The active involvement of the rail industry in level crossing issues is also recommended. A community education programme is recommended to address the dangers of railway level crossings to road and pedestrian users.
Additional recommendations include consideration of the type of road and rail traffic as part of the Australian Standard for level crossing protection.
For copies and enquiries of the report please contact the Victorian Department of Infrastructure, Public Affairs Division. Telephone (03) 9655 6263.
|Date:||13 October 2002||Investigation status:||Completed|
|Release date:||23 February 2006|
|Report status:||Final||Occurrence category:||Incident|
|Highest injury level:||Fatal|
|Type of operation||Passenger|
|Damage to train||Substantial|
|Departure time||1142 EST|