Rail safety investigations & reports

Fatality at Heyington Railway Station, Toorak, Vic., on 22 February 2014

Investigation number:
RO-2014-005
Status: Completed
Investigation completed

Final Report

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What happened

At about 2355 on 22 February 2014, an 18 year old male was fatally injured at Heyington Railway Station in Toorak, Victoria when he fell between a moving train and the platform. He was running alongside the moving train when he fell attempting to board it, while passengers inside the train were forcibly holding the carriage doors open.

What the ATSB found

The train was equipped with a traction interlocking device to prevent the train from moving while its carriage doors were open. The device, as designed, deactivated after a period of time and allowed the train to depart with the doors held open.

Due to the curvature of the track, a wide gap existed between the mid-body of the carriage and the platform.

What's been done as a result

Metro Trains Melbourne (MTM) has commenced a risk review of the door open traction interlock timing on their rolling stock.

In order to minimise the gap between the train and platform, MTM has realigned the track at Heyington railway station and a rubber finger coping has been installed along the entire edge of the platform face. Further, a barrier has been constructed at the platform entrance to deter passengers from running for the train.

MTM has also completed a survey of all the stations with curved track and platforms of higher risk have been identified. In the short term these platforms have had ‘Mind the Gap’ signs painted on them. Announcements are also made to warn passengers of the gap. Works plans have been developed to institute further risk measures in the long term.

Safety message

Rail operators should ensure that safety systems fitted to passenger trains are designed and operate to ensure the safety of patrons in the event of interference with the normal operation of train doors.

Download Final Report
[Download  PDF: 2.15MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Appendices

Safety Issues

Go to RO-2014-005-SI-01 - Go to RO-2014-005-SI-02 - Go to RO-2014-005-SI-03 - Go to RO-2014-005-SI-04 -

The train could be moved with the carriage doors open

As designed, the traction interlock automatically deactivated after a period of time. This allowed traction to be applied and the train to depart with the carriage doors open.

Safety issue details
Issue number: RO-2014-005-SI-01
Who it affects: Train passengers
Status: Safety action pending

Inadequacy of the doors open warning device

The train door open/close indicator on the driver’s control console was inadequate as a warning device once the traction interlock had deactivated. 

Safety issue details
Issue number: RO-2014-005-SI-02
Who it affects: Train passengers
Status: No longer relevant

Standards for train / platform clearances

The existing standards stipulated minimum clearances between trains and platforms but did not consider the effect of the resulting gaps with respect to safe accessibility. 

Safety issue details
Issue number: RO-2014-005-SI-03
Who it affects: Train passengers
Status: Adequately addressed

Train / platform clearances

Due to the curvature of the track, a wide gap existed between the platform and train at the Heyington Railway Station. There are several stations on the Melbourne metropolitan rail network where wide gaps exist between platforms and trains due to track curvature. These gaps pose a risk to passengers.

Safety issue details
Issue number: RO-2014-005-SI-04
Who it affects: Train passengers
Status: Safety action pending
General details
Date: 22 February 2014   Investigation status: Completed  
Time: 2355 EDT   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Heyington    
State: Victoria    
Release date: 27 April 2016   Occurrence category: Incident  
Report status: Final   Highest injury level: Fatal  

Train details

Train details
Line operator Metro Trains Melbourne  
Train operator Metro Trains Melbourne  
Train registration TD2100  
Type of operation Passenger  
Sector Passenger - metropolitan  
Damage to train Nil  
Departure point Glen Waverly Railway Station  
Destination Flinders Street Railway Station  
Last update 14 November 2018