Investigation number
2002/002
Occurrence date
Location
Salisbury
Report status
Final
Investigation type
Occurrence Investigation
Investigation status
Completed
Occurrence category
Accident
Highest injury level
Fatal

level crossing on Park Terrace, SalisburyAt 15:33:01 on 24 October 2002
passenger train 5AL8 collided with a car and scheduled bus on the
Salisbury Interchange controlled level crossing on Park Terrace. As
a result of the accident four people were killed and 26 injured. A
small sedan car and the bus were effectively destroyed. In addition
two other road vehicles were damaged. The locomotive and the first
vehicle of the consist sustained minor damage. There was no
derailment of any rail vehicles.

The standard gauge track owned and operated by ARTC, runs
parallel to two broad gauge tracks operated by TransAdelaide. These
three tracks share the northern rail corridor, which runs through
Salisbury.

As train 5AL8 approached the level crossing on Park Terrace from
Adelaide, the driver and co-driver saw stationary road vehicles
across the standard gauge track. The driver of the locomotive acted
promptly in sounding a sustained warning on the horn, applying the
emergency brakes and putting the throttle to idle. Two cars
reversed clear of the track to a position between the standard
gauge and the TransAdelaide tracks. The small sedan and the bus
were unable to move because of other vehicles, though the driver of
the sedan managed to jump out of her car and run clear.

The sighting distance from the train cab to the standard gauge
crossing was approximately 250 m. The train could not stop in time
to prevent the collision and came to a halt 183 m to the north of
the Park Terrace level crossing.

The report concludes that the locomotive, rolling stock, rail,
signalling infrastructure and the boom gate barriers at the
crossing, up to the time of the collision, were in good condition
and operated as designed.

Prima facie the road vehicles stationary on the rail tracks had
entered the crossing when the drivers could not drive through the
crossing because the crossing, or road beyond the crossing, was
blocked. On this view the immediate causal factor was the
non-observance of the Australian Road Rules 1999. From a systemic
point of view, however, the accident was more complex with a number
of causal factors relating to:

  • road design (the number of entry/exit points);

  • road traffic lights and the inter-link with the level crossing
    warning system;

  • the width of the crossing;
  • probable lack of awareness by road vehicle drivers of the road
    traffic rules as they relate to level crossings;

  • the lack of 'near hit safety' reporting at level
    crossings;

  • the lack of a focused body to oversight and undertake risk
    based assessments of level crossing safety.

The investigation found little evidence from records that Park
Terrace level crossing was of public concern from a rail safety
perspective. There were recorded concerns and direct observation
that, when the traffic lights at the Salisbury Highway intersection
were red, traffic did, on occasions, queue over the Park Terrace
crossing. On the basis of direct observation, such an accident at
Park Terrace was foreseeable.

The response to the accident by the emergency services and
railway companies was timely. The first emergency persons to
respond crawled beneath train 5AL8, a dangerous but understandable
reaction to reach the injured. Police established tight control at
the level crossing, but commuters and onlookers were able to access
the adjacent lengths of track although the TransAdelaide passenger
service continued running.

The report details 13 key conclusions:

  1. The immediate cause of the collision between train 5AL8, the
    white Nova Holden WOJ 601 and Serco bus number 246 (VYV 786) was
    that the drivers of the road vehicles entered the level crossing,
    in contravention of the Australian Road Rules, at a time when they
    were unable to drive through the crossing and were blocked by other
    vehicles.

  2. The driver and co-driver of locomotive NR 34, reacted promptly
    in sounding a warning of train 5AL8, applying emergency brakes and
    returning the throttle to idle. Neither the driver nor the
    co-driver could have taken any action that would have prevented the
    collision with the white Holden Nova or Serco bus number 246 (VYV
    786) operating the 401 service.

  3. Locomotive NR 34 and the 25 vehicles of the consist comprising
    train 5AL8 were in working order, were properly maintained and were
    fit for purpose. There were no deficiencies in the consist that
    contributed to the collision.

  4. The railway infrastructure (track circuitry, signals, level
    crossing warning signals and the boom barrier) worked as designed
    within standard time limits.

  5. Following the collision, the on train staff servicing the
    passenger vehicles of train 5AL8 acted promptly to assist the
    injured at the scene of the accident until they were able to
    relinquish care to the emergency services.

  6. The response of the emergency services was timely.
  7. The road traffic lights at the junction of Park Terrace, Gawler
    Street, North Lane and the Bus Interchange and the link with the
    level crossing warning signals worked as designed.

  8. The road traffic signals at the Salisbury Highway/Park terrace
    intersection did not work as designed or as recommended by
    Australian Standard AS1742.14, in that the link with the railway
    crossing had been broken at some time and the special
    queue-clearing phase was not operational. There was no effective
    maintenance or checking system in place to monitor the continuing
    operation of the queuing phase of the lights and the links with the
    traffic Control Centre. The non-operation of the special queuing
    phase was probably not a significant factor in the collision of 24
    October.

  9. The road traffic on the western side of the level crossing for
    traffic crossing Salisbury Highway or turning onto Salisbury
    Highway was halted at the traffic signals causing traffic to
    back-up over the level crossing.

  10. The backing up of westbound traffic across some part of the
    level crossing was not unusual and had become an accepted factor of
    driving in Park Terrace.

  11. The complexity of the Park Terrace road system over a distance
    of 175 m from the bus interchange turning just east of the level
    crossing to the stop line at Salisbury Highway, increased the
    probability of road vehicles backing up to the level crossing in
    that:

    - Road vehicles exiting or entering the Station car park and
    crossing or from the outside westbound lane, right turn lane, or
    attempting to enter the eastbound lane potentially restrict traffic
    flow.

    - Road vehicles exiting or entering the Eureka Tavern car park
    across the traffic.

    - Heavy traffic southbound on the Salisbury Highway restricts the
    opportunity for traffic in the left turn lane to join the Salisbury
    Highway.

  12. Based on observed behaviour of road vehicle drivers, a
    collision between traffic queued at Park Terrace and a train was
    foreseeable. However, the absence of any specific reports of near
    miss incidents or accidents between trains and vehicles at Park
    Terrace had led to a belief that there was no significant
    risk.

  13. The lack of initial site control following the collision and
    during the immediate emergency phase increased the risk of
    pedestrian onlookers being struck by trains, either through any
    possible movement of train 5AL8 or the TransAdelaide services.

The Salisbury level crossing review report by Mr Vince Graham of
January 2003 made a number of recommendations (attachment 2), which
are endorsed by this report. Mr Graham also made interim
recommendations in early November that the track speed 500 m on
either side of Park Terrace should be limited to 50 km/h. This
report recommends that train speed restrictions introduced as a
safety measure in the vicinity of level crossings should be further
reviewed taking into account the new traffic arrangements and
safety measures and the different types and characteristics of
trains on the standard and broad gauge tracks.

In addition the report recommends:

RR20030001
Road traffic signals adjacent to level crossings be regularly
monitored to ensure that all links and functions within the system
are operational.

RR20030002
Traffic flows through Park Terrace should be measured to assess
the practicality of extending the timing on a link to force
westbound traffic from Park Terrace to take account of the worst
case timing scenario, while maintaining the existing timing of the
boom barrier closing.

RR20030004
The rail industry should attempt to devise a confidential hazard
reporting system that embraces the whole industry in the one
system.

RR20030005
ARTC and TransAdelaide review their notification and communication
procedures when responding to accidents on the shared rail
corridor, particularly between the train control centres and the
accident site.

RR20030006
The rail companies and emergency services examine ways in which
early effective site control and control of public access might be
further improved.

RR.20030007
Standards Australia develop a standard for the marking of a 'do
not enter unless clear' area across level crossings, with a view to
providing appropriate cues to help road vehicle drivers assess the
space available on the other side of the crossing.

RR20030008
Transport SA should review the provisions of the Road Traffic
Regulations 1996 to determine whether or not any existing
penalty
covering the drivers of vehicles that stop or park within the
boundary of rail level crossings is appropriate.

Note: This investigation was undertaken by
the ATSB on behalf of the State Government of South Australia.
Media enquiries should be directed to the SA Government's media
contact, Emma Brown (08) 8204 8261.