Rail safety investigations & reports

Level crossing irregularity involving passenger train 3MA8, North Geelong, Victoria, on 8 January 2019

Investigation number:
RO-2019-002
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 8 January 2019, as The Overland passenger train, 3MA8, approached the Thompson Road level crossing at North Geelong, Victoria, the train crew noticed that the flashing lights had not activated and the boom gate had not lowered as expected. While the crew noticed the irregularity, it was too late to take substantive action and the train passed through the level crossing unprotected. The crew reported that several road vehicles were in the vicinity of the level crossing at that time, but none were in the danger zone.

What the ATSB found

The ATSB found that, in preparation for stage one track work, the Thompson Road level crossing was to be isolated for the broad and dual-gauge tracks only. The level crossing protections for the adjacent standard-gauge track, which was to continue operating as normal until stage two works at a later date, were to remain active. However, the signalling tester, following the isolation plans provided, mistakenly isolated the level crossing for the stage two work, in addition to stage one. While the stage one and stage two works were to be conducted separately, the signalling tester‑in-charge provided the signalling tester with the isolation plans for both stages in one package.

VicTrack, through their contractor UGL Engineering Limited, did not provide the tester-in-charge or signalling testers with specific instructions detailing the scope of work to be conducted at each stage of the project, but rather, only provided packaged isolation plans for the entire project. The absence of these instructions increased the risk of the works being incorrectly implemented.

What has been done as a result

As a result of this occurrence, VicTrack has advised that improvements had been made at the task‑based level by including specific work instructions for each task associated with each isolation plan.

Safety message

A work instruction is a step-by-step guide on how to perform a specific task or activity, in support of a process or procedure. They are an important defence within a safety system for ensuring the work is performed safely and as intended. This occurrence highlights the importance of providing clear, concise, and detailed work instructions to reduce the risk of errors during critical safety work.

Download final report
[Download  PDF: 468KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issue

Go to RO-2019-002-SI-01 -

No specific instructions provided

VicTrack’s contractor, UGL Engineering Limited, did not provide signalling testers with specific instructions detailing the scope of work to be conducted at each stage of a project, but rather, only provided packaged isolation plans for the entire project. The absence of these instructions increased the risk of the works being incorrectly implemented.

Safety issue details
Issue number: RO-2019-002-SI-01
Status: Closed – Adequately addressed
General details
Date: 08 January 2019   Investigation status: Completed  
Time: 1053 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): North Geelong   Investigation phase: Final report: Dissemination  
State: Victoria    
Release date: 22 September 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train details

Train details
Line operator VicTrack  
Train operator Journey Beyond/Pacific National  
Train registration 3MA8  
Type of operation Passenger  
Sector Passenger - regional  
Damage to train Nil  
Departure point Melbourne, Victoria  
Destination Adelaide, South Australia  
Last update 22 September 2020