Rail safety investigations & reports

Safeworking irregularity at Glenrowan, Victoria on 29 October 2013

Investigation number:
Status: Completed
Investigation completed


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What happened

On 29 October 2013, the Australian Rail Track Corporation (ARTC) was undertaking a program of ballast remediation and drainage maintenance on the bidirectional west track between Benalla and Wangaratta, Victoria. This required Absolute Occupation of the west track and Track Force Protection on the east track due to the proximity of the track workers and their machinery. Worksite protection was put in place at 0644, which involved placing flagmen and Audible Track Warning signals (ATWs) either side of the worksite.

The worksite at Glenrowan used two radio channels for communications. One channel was used for safety critical communication between the flagmen and the track force coordinator, the second was used for worksite communication between the track workers, including the track force coordinator. The track workers relied on the track force coordinator for safety critical communication since they had no direct communication with the flagmen.

At approximately 0730, V/Line passenger train 8610, travelling between Albury and Melbourne on the east track, stopped at Wangaratta to pick up passengers. The track force coordinator at Glenrowan was made aware of the train by the flagmen on the west track. The track force coordinator then instructed the flagmen on the east track to remove the ATWs and allow the train to pass the work site unrestricted. This was done without informing the work site supervisor or any of the track workers.

At about 0744, the outer flagman observed train 8610 and contacted the inner flagman to let her know that the train was approaching. The inner flagman attempted to contact the track force coordinator multiple times, but did not get a response. The track force coordinator was in conversation with the work site supervisor and not within earshot of either of his radios. The inner flagman then tried to alert the track force coordinator by whistle without success.

At about the same time, the work site supervisor observed train 8610 approaching and called out ‘Train on’ on the work site radio. The track workers also saw the train and took action to ensure that they and their machines were clear of the east track. The driver of Train 8610 did not notice anything unusual as the train passed through the worksite (without incident) at about 0746.

After the incident, the work site supervisor took control of the site and, following an on-site assessment of the incident, called a halt to the works at Glenrowan. At 0900, the track force coordinator contacted the network controller to advise there had been an incident and that track protection on the east track at Glenrowan was lifted until further notice. The track force coordinator contacted the network controller again at 1030 to report the details of the near-miss incident at Glenrowan between track workers and train 8610.

The track force coordinator was tested for the presence of alcohol or other drugs which proved negative.

Safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Australian Rail Track Corporation

As a result of this occurrence, the Australian Rail Track Corporation has advised the ATSB that they are taking the following safety actions:

  • A post-incident meeting was held with all BRP personnel to discuss the incident and reinforce the necessity to follow procedures when providing track protection.
  • The program manager instructed all site personnel that ATWs were to be left on track to warn of trains approaching worksites.
  • Follow up training and recertification was provided regarding the relevant network safeworking rules.
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General details
Date: 29 October 2013   Investigation status: Completed  
Time: 0748 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Glenrowan    
State: Victoria    
Release date: 23 January 2014   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator ARTC  
Train operator V/Line  
Train registration 8610  
Type of operation Passenger  
Sector Passenger - regional  
Damage to train Nil  
Departure point Albury, Vic  
Destination Melbourne, Vic.  
Last update 14 November 2018