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Final Report

Summary

What happened

On 12 April 2015, just prior to the 1542 Belgrave-to-Melbourne service arriving at Upwey station, the signal control panel located at Upper Ferntree Gully station lost functionality. As a result, the signaller, no longer had control or indication of signals and interlocking at Upwey.

To continue train operations through the area, procedural safeworking was instituted under the control of the signaller at Upper Ferntree Gully. By this time the Belgrave-to-Melbourne service was stopped at Upwey with the Departure signal at Stop. Having been advised of the signalling system failure, the driver of this service contacted the signaller at Upper Ferntree Gully for further instructions. A short time later, at about 1551, the train departed Upwey and proceeded to Upper Ferntree Gully without authorisation.

What the ATSB found

The ATSB found that the train passed both the Upwey Home Departure and the Upper Ferntree Gully Home Arrival signals at Stop without authority. The departure from Upwey was possibly influenced by the driver’s anxiety at having to operate the points machine a short distance beyond Upwey.

The ATSB also found that there was a missed opportunity to contact the train after it was detected as having departed Upwey unauthorised.

What's been done as a result

MTM has reviewed training provided to drivers in the operation of Dual Control Points Machines. MTM is also considering [1] the incorporation of SPAD alarms at this location, and [2] modifying the communications network to capture all safeworking communications at Upper Ferntree Gully.

Safety message

An extra degree of responsibility and situational awareness is demanded of staff under conditions of degraded signalling and procedural safeworking.

The occurrence

Context

Safety analysis

Findings

Sources and submissions

 
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