Rail safety investigations & reports

Level crossing collision between truck and passenger train 8753, Phalps Road, Larpent, Victoria, on 13 July 2016

Investigation number:
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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[Download  PDF: 3.14MB]

What happened

At about 1541 on 13 July 2016, a Warrnambool-bound passenger train collided with a semi-trailer at the Phalps Road level crossing in Larpent, Victoria. The level crossing was fitted with Stop signs and the truck entered the crossing in front of the train.

As a result of the collision, the train’s locomotive and all passenger cars derailed. The locomotive driver, train conductor, 18 passengers and the truck driver were injured. There were no fatalities.

What the ATSB found

The ATSB found that when the truck driver stopped to look for trains, his view along the track was restricted due to the acute road-to-rail angle and the limited view through the truck passenger-side window. The driver’s view was less than that required to see the train and the truck driver entered the crossing and into the path of the train unaware of the train’s approach.

The acute road-to-rail angle of the intersection at the Phalps Road level crossing also meant that the required viewing angle from a road vehicle exceeded the requirements of the Australian Standard for crossing design. At the time of the incident, many other public road crossings on the V/Line regional rail network, including 35 on passenger lines, were also non-compliant with the Australian Standard for crossing design due to their acute road-to-rail angle.

In February 2015, the Phalps Road level crossing was approved for upgrade to active protection. However, neither V/Line nor the Colac Otway Shire Council took measures to mitigate the known risks associated with the sighting limitations at the crossing, pending this upgrade. 

At many other acute-angle crossing locations on the network, processes used by V/Line did not result in the deployment of available risk controls.

The train was operated within the speed limit and the handling of the train did not contribute to the collision.

What's been done as a result

The Phalps Road level crossing was upgraded to active protection in August 2016.

V/Line has taken several further safety actions. Of the 35 passenger line crossings non-compliant with sighting angles, 24 have been either upgraded to active protection, had train speed restrictions applied, or in one instance, restricted access gates fitted. Safety actions on the remaining 11 crossings were pending. Several other crossings with sighting non-compliance have been prioritised for upgrade. One has been reassessed as compliant with the standard.

In addition, the Victorian Level Crossing Safety Committee has established a Passive Crossing Working Group. The Group’s activities will include work around low cost technologies for active crossing protection, and exploring the option of including ‘limited sighting’ crossings on the VicRoads heavy vehicle network maps.

Safety message

Rail infrastructure and road managers should ensure that risk assessment processes take account of available risk controls for hazards stemming from poor sighting at acute-angle level crossings and actively pursue their implementation.

Road users should be particularly cautious at passively-controlled acute-angle level crossings where their vision to the left may be affected by the road vehicle cabin design.

Download Final report
[Download  PDF: 3.14MB]

The occurrence


Safety analysis


Safety issues and actions

General details

Sources and submissions

Safety Issues

Go to RO-2016-009-SI-01 - Go to RO-2016-009-SI-02 - Go to RO-2016-009-SI-03 - Go to RO-2016-009-SI-04 - Go to RO-2016-009-SI-05 -

Risk controls at Phalps Road level crossing

Available risk controls to manage the risk posed by known sighting deficiencies at the Phalps Road level crossing were not deployed by V/Line or the Colac Otway Shire Council.

Safety issue details
Issue number: RO-2016-009-SI-01
Who it affects: V/Line Pty Ltd
Status: Adequately addressed

V/Line and Colac Otway Shire Council interaction

The interaction between V/Line and the Colac Otway Shire Council was ineffective at addressing identified sighting issues at the Phalps Road level crossing.

Safety issue details
Issue number: RO-2016-009-SI-02
Who it affects: V/Line Pty Ltd
Status: Adequately addressed

Risks at other acute-angle level crossings on network

More than 100 level crossings in the V/Line regional rail network (including 35 at the intersection of passenger lines and public roads) were non-compliant with the left-side viewing angle requirements of AS 1742.7:2016. These crossings had an acute road-to-rail angle that affected the ability of drivers to sight trains approaching from their left.

Safety issue details
Issue number: RO-2016-009-SI-03
Who it affects: V/Line Pty Ltd
Status: Partially addressed

Risk assessment and deployment of available risk controls

V/Line’s level crossing assessment processes did not result in deployment of available risk controls at many passively protected acute-angle level crossings.

Safety issue details
Issue number: RO-2016-009-SI-04
Who it affects: V/Line Pty Ltd
Status: Partially addressed

Inaccuracies in ALCAM survey data

Errors remained within the ALCAM database due to the type of equipment used to measure road and rail bearings during ALCAM surveys in 2009.  

Safety issue details
Issue number: RO-2016-009-SI-05
Who it affects: All owners and operators of rail transport services in Victoria
Status: Adequately addressed
General details
Date: 13 July 2016   Investigation status: Completed  
Time: 1541 EST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Larpent   Investigation phase: Final report: Dissemination  
State: Victoria    
Release date: 28 June 2019   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  

Train details

Train details
Line operator V/Line Pty Ltd  
Train operator V/Line Pty Ltd  
Train registration 8753  
Type of operation Passenger service  
Sector Passenger - regional  
Damage to train Substantial  
Departure point Southern Cross Station, Vic.  
Destination Warrnambool, Vic.  
Last update 03 April 2020