Final Report


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.

The occurrence


Safety analysis


Safety issues and actions

Sources and submissions