Rail safety investigations & reports

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

Investigation number:
1999/002
Status: Completed
Investigation completed

Summary

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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.

 

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General details
Date: 26 November 1999   Investigation status: Completed  
Location: Ararat    
State: Victoria    
Release date: 01 March 2000   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  
Last update 29 May 2014