At 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.