Rail safety investigations & reports

Non-operation of level crossing protection at Colac, Victoria on 22 September 2018

Investigation number:
RO-2018-015
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 494KB]
 

What happened

On 21 September 2018, overnight track maintenance works being conducted in the Colac area had necessitated the isolation of the protection equipment at eight level crossings. On completion of the track work, equipment was to be reinstated and the operation of crossing protection equipment tested.

With the completion of the maintenance work, the track was returned to service and train services resumed on the morning of 22 September. However, the driver of a train transiting the area noticed that the level crossing protection equipment at the Hart Street level crossing was not operating. He stopped his train but was unable to prevent it from occupying the crossing. There was no road traffic at the time.

What the ATSB found

The ATSB found that V/Line did not have a documented detailed process for inhibiting and then reinstating level crossing protection equipment. The Signal Maintenance Technician (SMT) undertaking these activities partially restored the Hart Street level crossing equipment before attending to other tasks. He subsequently forgot to return to that crossing to complete its reinstatement and testing, and the track was returned to service with the protection at the Hart Street crossing not operational.

It was also concluded that, for the scope of works on this night, the allocation of a non-rail electrician to support the SMT was very likely of less assistance to the SMT than had a rail-qualified technician been provided.

What has been done as a result

V/Line has developed new procedures related to the task of inhibiting and reinstating level crossing equipment and conducted training for relevant employees in these procedures.

In addition, V/Line has reviewed its resourcing of complex and time critical tasks involving inhibiting and reinstating level crossing equipment.

Safety message

When isolating safety equipment, it is important to have formal procedures that require the recording of the equipment’s isolation, reinstatement and testing, in order to validate that restoration work is completed before rail services resume.

Download final report
[Download  PDF: 494KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issue

Go to RO-2018-015-SI-01 -

Process control

V/Line did not have a documented detailed process for inhibiting and reinstating level crossing protection equipment.

Safety issue details
Issue number: RO-2018-015-SI-01
Who it affects: Rail: Passenger - regional
Status: Adequately addressed
General details
Date: 22 September 2018   Investigation status: Completed  
Time: 0630 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Hart Street, Colac   Investigation phase: Final report: Dissemination  
State: Victoria    
Release date: 08 October 2019   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator V/Line  
Train operator V/Line Pty Ltd  
Train registration TD 8861  
Type of operation Scheduled passenger  
Sector Passenger - regional  
Damage to train Nil  
Departure point Melbourne Southern Cross Station, Melbourne  
Destination Warrnambool Railway Station  
Last update 11 October 2019