Investigation number
1999/002
Occurrence date
Location
Ararat
Report release date
Report status
Final
Investigation status
Completed
Occurrence category
Accident
Highest injury level
Serious

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 behelpful. There was no evidence to suggest
otherwise.The two crew members of the stationary ballast train saw
that a collision wasimminent and escaped from the locomotive
shortly before the impact. They were notinjured.

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

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

The device used to unlock the points and permit their movement,
was stored in ametal box near the points. This box was secured with
a padlock of a type widely usedon the Victorian non-urban rail
network. The employee who moved the points hadbeen issued with a
key of this type in order to perform his normal duties, even
thoughit was generally considered that personnel with his limited
qualifications would notnormally be issued with such a key.

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

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

Although this accident was triggered by the unsafe and
unauthorised actions of anemployee, the accident had its origins in
a number of organisational and systemdeficiencies.

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 haveconcerns about the integrity of
main lines. The two organisations are applying riskassessment
methodologies to determine whether further measures are required
toimprove the error tolerance of the system at those locations. Any
progress on those reviews has been acknowledged in Section 10.1
Local safety action.