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What happened

At about 1901[1] on 22 August 2014, a V/Line train travelling the Werribee line on the Melbourne Metropolitan Rail Network collided with a stationary Metro Trains Melbourne (MTM) passenger train between Maidstone Street level crossing and Kororoit Creek Road. The MTM train had come to an unintended stop due to a loss of air pressure in its braking system. The V/Line train had stopped at an Automatic[2] signal that was indicating a Stop aspect and after a short while proceeded past the stop signal. Trains can proceed past an Automatic signal at Stop under conditions specified by an operating rule. Shortly after passing the signal, the train collided with the rear of the stationary MTM train at 43 km/h. The MTM train was carrying 51 passengers at the time of the collision. The driver and conductor on the V/Line train, the driver of the MTM train and eight passengers on the MTM train sustained minor injuries in the incident.

What the ATSB found

The ATSB found that the operating rule permitted the V/Line train to proceed past a signal at Stop into a section that was occupied by the MTM train. The V/Line train was operated past the signal at Stop in a manner contrary to the operating rule and proceeded at a speed that reduced the opportunity to observe the train ahead and stop in time. The rule placed reliance on the train driver to provide separation between trains by line-of-sight observation and was not an effective defence against errors.

The ATSB also found that the marker lights on the MTM train (Comeng type) did not meet the requirements of the Australian Standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007 for permissive working[3]. This standard was developed by the Rail Industry Safety Standards Board (RISSB) and although MTM had adopted this Standard, it was not implemented on the Comeng trains in their fleet.

What's been done as a result

Metro Trains Melbourne has amended the existing procedure in Section 3 Rule 1 of The Book of Rules and Operating Procedures 1994 for permitting trains to pass an uncontrolled, unmonitored signal at Stop. The new amendments incorporate a procedure, which requires train drivers to contact and respond to an automated voicemail facility providing their details, the rail vehicle details and details of the signal at Stop.

Metro Trains Melbourne has advised the ATSB that a modification is being developed to increase the intensity of the marker lights of Comeng trains to a level compliant with the Australian Standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.

Safety message

The rules pertaining to permissive signalling rely on a train driver to provide separation between trains by line-of-sight observation. In the hierarchy of hazard controls, rule based controls are considered the least effective defence against human error or violations. Train operators should institute additional risk mitigation measures, where safeworking systems allow permissive working.

__________

  1. The 24-hour clock is used in this report and is referenced from Eastern Standard Time (EST).
  2. See signalling arrangements section.
  3. Permissive working allows two or more trains to enter the same signal section subject to specific operational rules.
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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

 
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Preliminary report released 13 November 2014

The information contained in this Preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this Preliminary report. As such, no analysis or findings are included in this report.

The Occurrence

MTM Service 6502

At about 1840 on 22 August 2014, Metro Trains Melbourne (MTM) passenger train 6502 departed Werribee Railway Station on its scheduled service to Flinders Street Station. The train arrived at Laverton Railway Station at about 1852 without incident.

Figure 1: Location map – Greater Melbourne

RO-2014-016 - Fig 1
 
Source: Copyright Melway Publishing 2013, Edition 41 with annotations by the Chief Investigator, Transport Safety (Victoria)

The train departed Laverton Railway Station and all signal aspects from Laverton were at clear normal speed (Green over Red). At about 1855, the train achieved a maximum speed of 115 km/h — the maximum authorised line speed for this section of track. The train then passed signal GG630 (Figure 2) that was also indicating a clear normal speed aspect, and had just crossed over Cherry Creek, when the driver heard a ‘loud bang’ from under the train. He noted that the brake pipe pressure had decreased and the brake cylinder pressure had increased. There was an immediate reduction in speed and the driver placed the brake handle to the full service braking position. When the train came to a stop, he placed the Reverser to the off position, which automatically applied the spring park brake. The train came to a stop at 1855, with the rearmost car, 427M, at about the 16.53 rail km mark. 

The driver looked back and concluded that the train had not derailed and that it was not fouling the adjacent running lines. He called Metrol to advise them of the location of the train and that the train had lost brake pipe pressure. He then made an announcement on the public address system to the passengers to advise them that the train would be delayed due to a defect. The driver then called Metrol for authority to go on the track.

Figure 2 – Collision location and signals

RO-2014-016 - Fig 2
Source: Metro Trains Melbourne with annotations by the Chief Investigator, Transport Safety (Victoria)

V/Line Service 8280

At about 1802 on the same evening, V/Line train 8280 departed Geelong for Southern Cross Railway Station. The train was returning to Southern Cross Station in preparation for a scheduled passenger service, and it was crewed by a driver and a conductor but carried no passengers. At about 1832 the train came to a stand at Automatic signal GG1178 (between Little River and Werribee) which was at Stop and resumed its journey about 19 seconds later. After passing through Laverton Station, it proceeded at about 90 km/h past Automatic signal GG672 which was indicating a normal speed warning (Yellow over Red). The train then arrived at Automatic signal GG630 which was indicating a Stop aspect (Red over Red) and stopped for about eight seconds before resuming its journey. Trains are allowed to proceed past an Automatic signal at Stop under conditions specified by a rule in The Book of Rules and Operating Procedures 1994.

The collision and post collision events

After passing signal GG630 the V/Line train reached a speed of 43 km/h and collided at this speed with the rear of the stationary MTM service 6502 at about 1901. The MTM train was shunted about 30 metres due to the impact and the impacted cars stopped at about the 16.5 rail km mark, approximately 1210 m from signal GG630. The driver of the MTM train was thrown onto the cab floor by the impact. The V/Line driver was trapped between the train control console and the seat but managed to extricate himself by lowering the seat. He got out of his cab, walked towards the MTM train and spoke to passengers to inquire as to their wellbeing and then spoke to the MTM driver who was still in the cab of his train.

The driver and conductor on the V/Line train, the driver of the MTM train and four passengers from the MTM train sustained minor injuries in the incident. Both trains sustained significant damage (Figure 3 & 4).

Figure 3 – Impacted trains

RO-2014-016 - Fig 3
 Source: Chief Investigator, Transport Safety (Victoria) 

Figure 4 - Train damage

RO-2014-016 - Fig 4
 Source: Chief Investigator, Transport Safety (Victoria) 

Context

Location

The collision occurred on the MTM rail network between the Maidstone Street and Kororoit Creek Road level crossings in Altona.

Figure 5 - Location of collision

 RO-2014-016 - Fig 5
Source: PASS Assets (Public Transport Victoria) with annotations by Chief Investigator, Transport Safety

Track and environmental conditions

The track infrastructure in this section consisted of a Broad Gauge East Line, a West Line and an independent parallel Standard Gauge line (Figure 2). Both trains were operating on the West Line. From the Maidstone Street level crossing the track is tangent with a slight downhill gradient towards Cherry Creek and Kororoit Creek level crossing. Clear sighting is available up to and beyond Cherry Creek from the Maidstone Street level crossing. The weather conditions were fine and it was a clear night with light winds.

Train and crew information

MTM Train and Crew

The MTM train 6502 was of the Comeng type and consisted of two, 3-car sets, 338M - 1092T - 484M and 487M - 1052T - 427M.

The MTM driver at the time of the incident had about 2½ years train driving experience. He held the required qualifications to operate the train, was route certified and assessed as medically fit for duty.

Following the collision the MTM train driver underwent mandatory drug and alcohol testing, the results of which were negative.

Post incident inspection and testing revealed that the train’s rear tail lights were operational.

V/Line Train and Crew

The V/Line train 8280 was a VLocity Diesel Multiple Unit consisting of VL05 (units 1105 and 1205), VL12 (units 1112 and 1212) and VL39 (units 1139, 1339 and 1239).

The V/Line train had two crew members, a driver and a conductor. The driver had been driving trains since qualifying in 1989 and was employed as a train driver by V/Line for the last 11 years. He held the required qualifications to operate the train, was route certified and assessed as medically fit for duty.

Post incident testing indicated that the trains head lights were operational and the train’s data logger indicated that the train’s headlights were on at the time of the incident.

Signalling system and rules

A three position colour light signalling system is in place between Laverton and Newport. Three position signals provide information to drivers regarding the compliance speed for the block and information on the the aspect of the signal ahead.  Multiple aspect signalling allows closer spacing of signals such that braking distances are spread over two signal blocks, allowing higher line speeds for the sector and can consist of Home (Absolute) and Automatic signals (Permissive).

Home signals are usually directly controlled by a signaller or train controller as well as by track circuits. Home signals are Absolute signals and are not to be passed when displaying a Stop aspect unless written or verbal authority is provided as specified in the Book of Rules and Operating Procedures 1994.

Automatic signals are not directly controlled by a signaller or train controller but by the passage of trains (track circuits) and their function is to provide separation between trains travelling in the same direction on the same track in accordance with the line speed and headway requirements of that section of track. 

A Permissive signal is an Automatic signal that is able to be passed at Stop under conditions specified by a rule in The Book of Rules and Operating Procedures 1994.

Ongoing investigation activities

The ATSB investigation is continuing and will focus on the:

  • Operation of the signalling system.
  • Operating rules pertaining to Permissive signalling systems and compliance.
  • Use of Permissive signalling systems in other jurisdictions.
  • Previous incidents associated with Permissive signalling systems.
  • Performance of train external lighting systems.
  • Use of safety technologies to maintain train separation.
  • Crashworthiness performance of the trains.
  • Mechanical condition of the trains, actions of the train crew and situational factors.

 

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Safety issues

RO-2014-016-SI-01 - RO-2014-016-SI-02 -  

Permissive Signalling System

The rules pertaining to passing a permissive signal at stop, place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.

Safety issue details
Issue number:RO-2014-016-SI-01
Who it affects:Rail Operators on Melbourne Metropolitan Rail Network
Status:Safety action pending


 

Passenger Train Marker Light Standards

The marker lights on some MTM passenger trains do not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.

Safety issue details
Issue number:RO-2014-016-SI-02
Who it affects:Rail Operators on Melbourne Metropolitan Rail Network
Status:Safety action pending

 
General details
Date: 22 August 2014 Investigation status: Completed 
Time: 1901 EDT Investigation type: Occurrence Investigation 
Location   (show map):Altona  
State: Victoria  
Release date: 06 July 2016 Occurrence category: Accident 
Report status: Final Highest injury level: Minor 
 
Train 1 details
Line operator: Metro Trains Melbourne 
Train operator: Metro Trains Melbourne 
Train registration: TD6502 
Type of operation: Passenger 
Sector: Passenger - metropolitan 
Damage to train: 406 
Departure point:Werribee Railway Station
Destination:Flinders Street Railway Station
Train 2 details
Line operator: Metro Trains Melbourne 
Train operator: V/Line Pty Ltd 
Train registration: TD8280 
Type of operation: Empty cars 
Sector: Passenger - metropolitan 
Damage to train: 406 
Departure point:Marshall Railway Station
Destination:Southern Cross Railway Station
 
 
 
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Last update 18 November 2016