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What happened

On 16 February 2015, track maintenance was being conducted at Montgomery between Sale and Bairnsdale. To allow a passenger train to pass through the section, the maintenance gang cleared the track and track protection was lifted. However, when the gang vacated the line, an item of equipment was left on the track.

As the V/Line passenger train approached the work site, the driver saw the obstruction. In response, the driver made an emergency brake application but was unable to bring the train to a stand before it collided with the equipment. The train remained on the track and there were no injuries to passengers or rail personnel.

What the ATSB found

  • The ATSB found that an item of maintenance equipment had been moved along the track away from the immediate area of works. Subsequently, this equipment was overlooked when the track was cleared of workers and other tools.
  • The task of ensuring that the line was clear had cascaded to a third party within the maintenance gang. There was no formal system in place to manage this process of informal delegation.

What's been done as a result

As a result of this and other related Safeworking incidents V/Line has advised that a Safety Review of infrastructure rules, procedures and training has been implemented.

Safety message

Track maintenance personnel should be particularly vigilant to ensure that no obstruction remains on the line when authorising the passage of a train through a work site.

Network managers should ensure that systems and processes minimise the potential for maintenance equipment to be left on track.

 

 

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

 
 

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Safety issue

RO-2015-003-SI-01 -  

Safeworking systems and processes

There were no formal systems in place to manage the accepted practice of Protection Officers leaving a work site to return a Track Warrant and Train Staff, prior to ceasing works, off-tracking and ensuring the line was clear. This practice led to the informal delegation of responsibility for ensuring the track was clear to others at the work site.

Safety issue details
Issue number:RO-2015-003-SI-01
Who it affects:V/Line Pty Ltd
Status:Adequately addressed

 
General details
Date: 16 Feb 2015 Investigation status: Completed 
Time: 1032 EST Investigation type: Occurrence Investigation 
Location   (show map):Montgomery  
State: Victoria  
Release date: 09 Dec 2015 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Train details
Line operator: V/Line 
Train operator: V/Line 
Train registration: 8403 
Type of operation: Locomotive hauled passenger service 
Sector: Passenger - regional 
Damage to train: Minor 
Departure point:Southern Cross Station, Vic
Destination:Bairnsdale, Vic
 
 
 
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Last update 09 December 2015