Rail safety investigations & reports

Derailment of freight train 9204V, Sims Street Junction, West Melbourne, VIC on 4 December 2013

Investigation number:
Status: Completed
Investigation completed


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What happened

The Pacific National broad-gauge freight train, No. 9204V, was travelling from Warrnambool to Appleton Dock, Victoria. Due to track works at West Footscray Junction—to repair damage arising from a previous derailment—the train was despatched from Tottenham Yard toward the port via an alternative route, the adjacent dual-gauge Main line. Track circuit failures resulting from the track damage meant that Up-direction Home signals on the Main line were displaying Stop indications, and for this reason the train had departed Tottenham yard on the authority of a Signalman’s Caution Order. The locomotive crew received two further Caution Orders en-route, the last of these being for Home signal DYN158.

Signal DYN158 protected a turnout that provided for a diverge of the standard-gauge line away from the broad-gauge, and the network control officer (NCO) had inadvertently set this turnout for a standard-gauge movement. The locomotive crew proceeded past the Home signal and through the points, resulting in derailment of the locomotive and one wagon at low speed.

What the ATSB found

The ATSB found that the NCO had established a standard-gauge route beyond signal DYN158 rather than the required broad-gauge route. Although the Train Control System software incorporated an on-screen gauge alarm to warn an NCO against setting an unviable route, in this instance that screen alert did not appear, since its generation was contingent on the gauge detection system that was not functioning. The signalling system had been degraded as a result of a previous derailment.

The Train Control System permitted the NCO to establish a route on an incorrect gauge for train 9204 and displayed that route as viable.

What's been done as a result

ARTC has introduced provisions to ensure that modifications made to the Phoenix Train Control System display are fully understood by Control Centre staff, and has also modified the Signalman’s Caution Order form to provide explicitly for the checking of the intended route and for the train crew to check the setting of points to be traversed.

The ATSB has recommended that ARTC undertakes further action to address the risk of directing trains onto incorrect gauge track in dual-gauge territory.

Safety message

When the signalling system and the functionality of safety intervention devices is degraded and an alternative process of safeworking is in use, there is a need for a heightened level of awareness and caution on the part of network control officers and train crew.

When designing control system safety mechanisms, such as the Gauge Alarm in this instance, the rail operator should consider all possible sub-system failures to ensure the intervention remains effective under all circumstances.


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Safety Issues

Go to RO-2013-027-SI-01 - Go to RO-2013-027-SI-02 -

Train Control System – design and screen display

The Train Control System permitted the NCO to set an unviable route for the train and then displayed it as viable. The train control system alarm designed to alert the NCO to the setting of an unviable route was nullified by the absence of gauge detection.



Safety issue details
Issue number: RO-2013-027-SI-01
Who it affects: ARTC network controllers
Status: Adequately addressed

Flaw in Caution Order form

A caution order instrument was used that lacked a specific requirement for train crews to check the points along their route. This requirement becomes critical under circumstances of signalling system degradation.

Safety issue details
Issue number: RO-2013-027-SI-02
Who it affects: ARTC network controllers
Status: Adequately addressed
General details
Date: 04 December 2013   Investigation status: Completed  
Time: 0150 EDT   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Sims Street Junction, West Melbourne    
State: Victoria    
Release date: 13 January 2015   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator ARTC  
Train operator Pacific National  
Train registration 9204  
Type of operation Freight  
Sector Freight  
Damage to train Minor  
Departure point Warrnambool, Vic  
Destination Dynon (Melbourne)  
Last update 03 April 2020