Collision between Freight Train 9784 and Ballast Train 9795, Ararat, Vic, 26 November 1999

Executive summary

On 26 November 1999, a Freight Victoria Ltd (Freight Victoria) employee moved the points at the Adelaide end of the Ararat yard shortly before a grain train was due to pass through Ararat on the main line. The employee's duties did not require him to move points, nor was he qualified or authorised to do so.

As a result of the employee's actions, the grain train was diverted into the Ararat yard, where it collided with a stationary ballast train. The employee subsequently reported that he had moved the points in order to be helpful. There was no evidence to suggest otherwise. The two crew members of the stationary ballast train saw that a collision was imminent and escaped from the locomotive shortly before the impact. They were not injured.

The two crew members on board the moving grain train applied emergency braking when they saw that the points were not set for the main line. They remained on board the locomotive and sustained serious injuries as a result of the collision.

The investigation determined that the system in operation at Ararat was fragile in the face of human error.

The device used to unlock the points and permit their movement, was stored in a metal box near the points. This box was secured with a padlock of a type widely used on the Victorian non-urban rail network. The employee who moved the points had been issued with a key of this type in order to perform his normal duties, even though it was generally considered that personnel with his limited qualifications would not normally be issued with such a key.

There was no system in place to prevent the points from being moved in front of an oncoming train. Such systems are in place at other locations on the Adelaide-Melbourne main line.

Additionally, there was no provision to inform Drivers on the main line or Train Control, of the movement or position of the points.

Although this accident was triggered by the unsafe and unauthorised actions of an employee, the accident had its origins in a number of organisational and system deficiencies.

The primary deficiencies identified in the course of this investigation were related to:

• hazard identification and the management of risk;
• safety training;
• interface management;
• system design;
• standardisation of procedures and safety systems;
• the control of safety-critical equipment;
• oversight of the activities of rail organisations; and
• safety promotion.

Both the Australian Rail Track Corporation (ARTC) and Freight Victoria have undertaken a review of their networks and have identified locations where they have concerns about the integrity of main lines. The two organisations are applying risk assessment methodologies to determine whether further measures are required to improve the error tolerance of the system at those locations. Any progress on those reviews has been acknowledged in Section 10.1 Local safety action.