Rail safety investigations & reports

Collision of passenger train TD 6591 with buffer stop, Newport siding, Victoria, on 25 February 2019

Investigation number:
RO-2019-006
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

At about 0931 Eastern Daylight-saving Time on 25 February 2019, Train TD 6591, an empty Comeng passenger train operated by Metro Trains Melbourne (MTM) collided with the end of line protection (buffer stop) at Newport siding, Victoria. The collision damaged the buffer stop and the front of the train. The leading carriage (333M) derailed, and the train driver (the only person on board) was hospitalised with minor injuries.

What the ATSB found

Recorded data showed that the driver applied the brakes 1.5 seconds prior to impact, which was after the train had passed the required stopping point. There were no driver inputs in the preceding 25 seconds, although no driver inputs other than a final brake application to stop the train were required during that period as the train was maintaining the required speed. While the train was equipped with a safety system (a pilot valve as part of the master controller) that was designed to apply the brakes in situations such as driver incapacitation, it was not activated to apply the brakes during the sequence of events. The recorded data indicated that sufficient pressure was maintained on the pilot valve (master controller). The driver may have been incapacitated for a period of time before the collision, however, the ATSB could not determine any details of incapacitation including duration and cause.

Although it was not identified as a contributory factor due to a day off prior to the accident, as a result of rostered work it is likely the train driver experienced levels of fatigue known to have an effect on performance during the week prior to the accident (but not on the day of the accident).

Safety message

This investigation highlights the importance of train safety systems to protect against driver error and incapacitation. In addition, drivers should maintain their health and fitness for work to reduce the likelihood of driver incapacitation, including adequate nutrition and hydration as well as consideration of the potential impact of fatigue. The ATSB SafetyWatch information on fatigue provides resources and guidance.

Download Final report
[Download  PDF: 308KB]
 
 
 

The occurrence

General details
Date: 25 February 2019   Investigation status: Completed  
Time: 0930 AEDT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Newport siding   Investigation phase: Final report: Dissemination  
State: Victoria    
Release date: 27 February 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  

Train details

Train details
Train operator Metro trains Melbourne  
Sector Passenger - metropolitan  
Damage to train Substantial  
Departure point Newport Station, Victoria  
Destination Newport siding, Victoria  
Last update 27 February 2020