Rail safety investigations & reports

Signals passed at danger by train 7750 at Marshall, Victoria on 2 January 2018

Investigation number:
RO-2018-001
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 2 January 2018 at about 1413, V/Line train 7750 was travelling from Waurn Ponds to Geelong as an empty car service not carrying passengers. Shortly after passing Marshall Railway Station, the train passed two signals at Danger. After passing these signals, the train entered the single line section between Marshall and South Geelong, and also the Marshalltown Road level crossing before the crossing booms had lowered. The driver applied braking as the train entered the crossing and the train came to a stop.

The 1305 V/Line Melbourne to Warrnambool passenger service, train 8865, had departed Geelong at about 1410 and was proceeding towards Marshall on the same single line section. The trains were scheduled to cross using the loop track at Marshall. The train controller in Melbourne was monitoring the progress of both trains in order to operate the points and signals at Marshall to effect the crossing. When he became aware that train 7750 was passing signals at Danger, the controller initiated a radio emergency fleet call instructing both trains to stop. When stopped, the distance between the trains was about 940 m.

What the ATSB found

The ATSB found that the driver of train 7750 did not respond to the Stop indications of signals MSL10 and MSL8 at Marshall. He subsequently made an emergency brake application, either after noticing that the Marshalltown Road level crossing booms were not lowered or possibly in a delayed recognition of signal(s) MSL10 and/or MSL8 being at Stop. The driver’s performance was probably influenced by symptoms associated with nicotine withdrawal, having not applied a nicotine patch on this day.

Following this incident, the driver of train 7750 tested positive for an inactive metabolite of cannabis, with levels suggesting use within the previous 7 days. It could not be determined whether cannabis use had affected the driver’s performance at the time of this incident.

V/Line’s drug and medical regimes had not previously identified that this driver had been using cannabis, and the driver had not been subject to random drug testing during his employment with V/Line.

The signalling system at Marshall was not fitted with any form of positive train protection system and was reliant on driver compliance with signal indications.

What's been done as a result

V/Line has installed a train protection system at this location to stop a train that has passed a signal at Danger. The system also has several over-speed sensors to prevent a train entering the Marshalltown Road level crossing when unprotected.

V/Line continues with planning for the provision of three-position signalling for this section as part of other infrastructure projects.

Safety message

Nicotine withdrawal can affect a driver’s performance. To minimise adverse impacts, attempts by safety-critical workers to stop smoking should be managed under medical supervision.

Rail operators should consider fitting authority-overrun intervention at locations (like Marshall) that present a heightened risk due to rail operations on a single, bidirectional track.

Download final report
[Download  PDF: 2.57MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

General details
Date: 02 January 2018   Investigation status: Completed  
Time: 1413 AEST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Marshall   Investigation phase: Final report: Dissemination  
State: Victoria    
Release date: 15 January 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train 1 details

Train 1 details
Line operator V/Line  
Train operator V/Line  
Train registration 7750  
Type of operation Empty cars  
Sector Passenger - regional  
Damage to train Nil  
Departure point Waurn Ponds, Victoria  
Destination Geelong, Victoria  

Train 2 details

Train 2 details
Line operator V/Line  
Train operator V/Line  
Train registration 8865  
Type of operation Passenger  
Sector Passenger - regional  
Damage to train Nil  
Departure point Southern Cross Station, Victoria  
Destination Warrnambool, Victoria  
Last update 15 January 2020