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.
Download final report
[PDF 2.2 MB
]
- Footplate refers to the locomotive
cabin of a steam locomotive.