Investigation number
Occurrence date
Report release date
Report status
Investigation type
Occurrence Investigation
Investigation status
Occurrence category
Highest injury level

An empty suburban electric express train collided with the back
of a suburban passenger train at number 4 platform Footscray
station just after 0828 on 5 June 2001. The passenger train had
about 20 people on board.

The emergency services, including the Police, Fire and Ambulance
services attended the scene. As both trains and the rail
infrastructure were operated by Bayside Trains, a subsidiary of
National Express, the National Express emergency plan was

The driver of the empty train suffered an injury to his left
elbow. Two passengers were taken to hospital for observation but
were released with no serious injury.

The evidence available to the investigation suggests strongly
that the driver's performance was impaired by a medical condition
leading to him being unable to recall events for a period of less
than two minutes, between the Maribyrnong River bridge and the
point of collision. The driver was taking a course of prescribed
medication, which combined with the early start to his working day
on the morning of the accident and a history of chronically
disturbed sleep, may have resulted in a sleep period (apnoeic
episode) while he was driving the train.

There are safeguards or defences to protect against such an
eventuality. On this occasion the defences in place failed to
prevent the accident. A number of defences were identified as being
inadequate in terms of design or application.

The investigation established that the maintenance of the trains
was not a factor in this accident. The signalling system and
automatic train stop operated within their design criteria. The
design criteria of the signal and train stop systems, however, were
such that the system could not prevent the collision given the
speed of the train involved.

Drivers of suburban trains are required to maintain a given
pressure on either a hand or foot pedal 'pilot valve', often
referred to as a 'dead-man's handle'. In the event of a driver
becoming incapacitated for any reason, the relaxing, or increase of
pressure on the pilot valve should automatically apply the train
brakes. Examination of relevant literature shows that pilot valves
can be intentionally or inadvertently circumvented. In certain
circumstances, the foot pedal can be maintained at the correct
pressure just by the weight of the lower leg, whether or not the
driver is incapacitated. Recommendation 7, below, is made in the
full understanding that alternative systems, such as vigilance
controls, may not be as effective in a metropolitan rail system,
given the density of traffic, the time gap between trains and the
workload of train drivers.

The alertness and fitness of drivers to perform their duties is
also a defence against accident. While the investigation did not
identify any significant defect with driver training, it did find
serious defects in the monitoring of driver's health and fitness to
operate mass public transport vehicles. The report concludes that
the driver of the express train, although experienced and skilled,
should not, on medical grounds, have been permitted to drive.

The investigation established that there was a lack of
communication and coordination between those responsible for driver
management and health professionals. The health standards used to
assess driver fitness were themselves deficient.

The report's recommendations are:

  1. Medical standards should be reviewed and amended to:
  • better monitor drivers' health and ensure a full past history
    and current medication regime is recorded, including monitor self
    medication of over-thecounter and non prescription medication.
  • include an appropriate assessment of the current physiological
    and psychiatric status of all drivers to ensure operators have all
    relevant information on which to base an informed decision on
    driver fitness;
  • include a system to identify drivers 'at potential risk', with
    provision for monitoring ongoing fitness;
  • ensure that medical examination periods are strictly adhered to
    and drivers suspended if not holding current medical license;
  • require drivers to produce proof of medical fitness at any
  • create an audit system that will allow confirmation of
    compliance with such standards.
  1. The medical examination procedures should be reviewed to manage
    any perception of a conflict of interest in the future medical
    fitness system and considers whether such examinations should be
    conducted by a panel of doctors appointed by, and responsible to,
    the Accreditation Authority.
  2. Australian Standard, AS 4292 should be reviewed in respect of
    the monitoring of the health and fitness of rail safety staff.
  3. The signalling system and overlap should be reviewed with a
    view to ensuring, to the extent practicable, that trains passing a
    signal at danger are stopped within a safe distance. In sections
    before a station this distance would ensure a train is brought to a
    halt before a possible collision with another train stopped at the
  4. The anti-collision posts on motor cars on Com Eng trains should
    be further investigated to identify any deficiency in their
  5. Rail accident response plans should be reviewed to provide
    procedures to ensure immediate safety of the track infrastructure,
    training for station staff at manned stations in immediate response
    procedures and rapid deployment of staff at unmanned stations.
  6. The use of hand and foot pilot valves should be reviewed, given
    their limitations, to determine whether the system can be made more
    effective or whether an alternative, equivalent system might make a
    better safeguard.
  7. The train system radio network should be reassessed for radio

Copies of the report are available from the Victorian
Department of Infrastructure's Customer Service Centre, Plaza
Level, 80 Collins Street, Melbourne or by telephoning (03) 9655