Final Report


What happened

On 11 July 2015, the Melbourne to Albury service 8625 was approaching Wallan crossing loop when the train traversed the points into the loop road at excessive speed. As a result, the passengers and crew experienced a rough ride resulting in some passengers requiring medical attention from the on board service crew. The service crew reported the incident to V/Line operations and the train continued on to Seymour.

On arrival at Seymour, the train was met by a Regional Driver Supervisor (RDS). The RDS questioned the driver about the rough ride at Wallan and after a short discussion, the train departed making scheduled stops along the way.

Shortly after a stop at Euroa station, some of the passengers approached the conductor about persons in their care showing signs of discomfort and stress as a result of the earlier rough ride. The conductor decided to arrange for an ambulance to meet the train at Benalla station. Meanwhile, V/Line operations were arranging to have the driver of 8625 relieved of duty at Benalla.

On arrival at Benalla station, the conductor told the driver of 8625 that he was to be relieved of duty. Ambulance officers treated some of the injured passengers for minor injuries with one passenger and their carer taken to a nearby hospital. The service continued onto Albury with the new driver.

What the ATSB found

The ATSB found that the driver of train 8625 did not demonstrate effective train handling techniques when approaching a signal displaying a low speed aspect. As a result, 8625 traversed the points at a speed significantly greater than the allowable engineering speed.

In addition, the driver did not immediately report the severity of the incident to the ARTC train control or V/Line. As a result, the possibility of infrastructure damage exposed trains travelling on the Standard Gauge at Wallan to a potentially elevated safety risk.

The ATSB also found that V/Line did not have a procedure in place that specifically required other V/Line employees to report incidents in the event that a driver did not. Furthermore, the ATSB found that V/Line’s processes did not consider the potential for rolling stock or infrastructure damage in the event that a train had traversed a turnout at significantly greater speed than designed.

What's been done as a result

V/Line have developed and implemented a procedure, which acknowledges and addresses the risk associated with gross over-speed. They have also updated their Just Culture policy in relation to reporting and have incorporated redundant pathways to ensure reporting should a driver fail to do so.

Safety message

All incidents that could compromise the safety integrity of the network must be reported immediately to Train Control. Operators need to ensure robust reporting procedures are implemented.

For incidents that involved gross over-speed, train operators should implement procedures that identify and manage the risk appropriately.

The occurrence


Safety analysis


Additional safety action

Sources and submissions