Investigation number
RO-2019-019
Occurrence date
Location
19.4 km Armadale line, Perth, Western Australia
State
Western Australia
Report release date
Report status
Final
Investigation level
Defined
Investigation type
Occurrence Investigation
Investigation phase
Final report: Dissemination
Investigation status
Completed
Occurrence category
Incident
Highest injury level
Serious

Safety summary

What happened

At about 1555[1] on 26 October 2019, Transperth passenger train service 5077CP[2] travelling from Perth to Armadale stations in Perth, Western Australia arrived at platform two of the Gosnells Railway Station.

As multiple passengers alighted the train[3] and moved along the platform toward the exit gate, a young male child travelling with his family exited the train from the front door of the third railcar. Shortly after alighting, while family group members stopped to attend to a sibling, the young male child separated from the group. The child walked among the other passengers but wandered toward the edge of the platform and the side of the stationary railcar.

Around the same time, the driver of 5077CP[4] was preparing to depart the train from the platform. The driver viewed the Driver Assist Video (DAV) monitor located on the driver’s console (Figure 1) to check passengers had completed boarding/alighting the train. The DAV displayed vision from a CCTV camera[5] of the platform and along the side of the train from front to back. The angle of the camera was sufficient to provide drivers a view along the side of the whole train.

Satisfied the doors were clear, the driver then operated the controls to commence the sequence of processes to close the doors. The driver’s attention then focused toward checking the indication displayed on the trackside signal #453 and the status of the Dorothy Street level crossing ahead.

Figure 1: View of driver’s panel

Figure 1: View of driver’s panel.
Source: ATSB

Source: ATSB

There were still numerous passengers across the width of the platform walking toward the station exit adjacent to the last (fourth) railcar. As the doors were closing, the child crossed the painted safety line (Figure 2) and continued to approach the edge of the platform before turning and looking back toward his family group. He stumbled against the side of the third railcar adjacent to its rear door and accidentally stepped off the edge of the platform coping, falling between the railcar and platform to the track formation below. Nearby persons on the platform and the child’s family members responded almost immediately raising an alarm to passengers on-board the train or reaching down between the platform and railcar trying to retrieve the child.[6]

Figure 2: Typical platform showing painted safety line

Figure 2: Typical platform showing painted safety line. 
Source: Transperth ‘Get on Board’ safety education program.

Source: Transperth ‘Get on Board’ safety education program.

As train 5077CP commenced to move, a passenger in the third railcar responded to the persons on the platform and contacted the driver via the emergency passenger intercom, calling for the driver to stop. The driver, unaware of the reason for the emergency call,[7] reacted swiftly, applying full service braking to stop the train.

The train travelled around 12 metres before stopping. During the movement of the train, a family member of the child sustained injuries either from contact with the side of the railcar or the platform edge. After the train stopped, family members lifted the child from the track and onto the platform. Police incident reports indicated the child was uninjured during the fall and retrieval.

Emergency services attended Gosnells Station. An ambulance transported the injured family member to hospital for assessment/treatment. Another family member took the young child to hospital. Following clearance from WA Police and train control, train 5077CP departed Gosnells Station for Armadale at about 16:12. Transperth relieved the train crew from duty at Claisebrook Station to conduct follow-up enquiries.

Findings

These findings should not be read as apportioning blame or liability to any particular organisation or individual.

  • A young child separated from his family group and wandered close to the platform edge before losing footing and falling between the platform and adjacent railcar.
  • The swift reaction by the driver to stop the train in response to an alarm raised by a passenger via the internal emergency intercom system very likely prevented more serious injuries from being received by the young child or other family members.

Purpose of safety investigations

The objective of a safety investigation is to enhance transport safety. This is done through:

  • identifying safety issues and facilitating safety action to address those issues
  • providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.

It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.

Terminology

An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.

Publishing information

Released in accordance with section 25 of the Transport Safety Investigation Act 2003

Published by: Australian Transport Safety Bureau

© Commonwealth of Australia 2020

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__________

  1. The 24-hour clock referenced to Western Standard Time (WST): Coordinated Universal Time (UTC) + 8 hours.
  2. Train 5077CP was an electric multiple unit comprised by four railcars.
  3. Passengers could board/alight each railcar via two doors on the platform side of the train.
  4. Train 5077CP was crewed by two drivers, a trainee and driver trainer. The trainee was at the controls of the train at the time of the occurrence. Transperth passenger trains did not have a guard on-board.
  5. The CCTV images transmitted wirelessly to the train from a camera installed on the platform structure.
  6. Gosnells railway station did not have platform staff.
  7. An image from the platform mounted CCTV camera was not displayed on the driver assist video monitor once the train commenced departure from a platform or following activation of the emergency passenger intercom.
Train Details
Train number
5077CP
Train damage
Nil
Departure point
Perth Station, Western Australia
Rail occurrence type
Collision
Destination
Armadale Station, Western Australia
Rail Operator
Transperth
Rail Operation Type
Suburban Passenger