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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.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Appendices

 

Safety issues

RO-2014-005-SI-01 - RO-2014-005-SI-02 - RO-2014-005-SI-03 - 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 type: Occurrence Investigation 
Location   (show map):Heyington  
State: Victoria  
Release date: 27 April 2016 Occurrence category: Incident 
Report status: Final Highest injury level: Fatal 
 
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
 
 
 
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Last update 22 August 2016