Rail safety investigations & reports

Derailment of XPT ST23, Wallan, Victoria, on 20 February 2020

Investigation number:
RO-2020-002
Status: Active
Investigation in progress

Interim report

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This Interim Report details factual information established in the investigation’s evidence collection phase and ATSB interim observations of that evidence. An Interim Report has been prepared to provide progress information to the public and the rail industry, and information on safety actions so far taken. This Interim Report does not contain findings or safety factors, that will be detailed in the Final Report. The information contained in the Interim Report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 (Cth).

Prior to the occurrence

At about 2343[1] on 3 February 2020, the Australian Rail Track Corporation (ARTC) identified that Centralised Traffic Control (CTC) signalling had been disrupted on the Somerton to Albury line between Donnybrook and Kilmore East. A subsequent investigation by ARTC determined that a road vehicle had struck overhead wiring in Wallan, impacting power supplies to the rail signalling system. A fire in the Wallan signalling hut led to extensive damage to equipment and cabling.

As a result of the damage to the signalling system at Wallan, ARTC commenced managing rail traffic through the location using Caution Orders. Under this instrument, trains were required to proceed cautiously, resulting in significant delays to rail services using this section of the standard-gauge network. As repair of the signalling system was expected to take a significant period of time, alternative train working arrangements to Caution Orders were considered by ARTC.

ARTC commenced managing rail traffic through the location using a Train Authority[2] instrument on the evening of 6 February.[3] The instrument was used for the 24 km section between Kilmore East (at about the 63.8 km[4] mark) and Donnybrook (at about the 40.2 km mark). Wallan Loop was located between these locations, from the 49.058 km mark to the 47.268 km mark.

Notification to network users of the change to the use of Train Authorities was by an ARTC Train Notice.[5] The relevant Train Notice (TN 266) was issued on 6 February, updated on 7 February and further amended on 13 February. In the arrangements established, the points at Wallan Loop had been set for the straight and locked in that position. ARTC did not impose any additional speed restrictions through the section. The maximum permitted speed for the XPT when travelling on the main line through Wallan was 130 km/h.

On 19 February, Train Notice TN 266 was supplemented with a further Train Notice (TN 367) advising of a change at Wallan Loop, with trains to be diverted through the loop for a short period on 20 February. The purpose of routing trains through the loop was to remove any contamination that may have developed on the rail head while the loop track was not being used.[6] This was in preparation for signal system testing and re-establishment of the CTC signalling system over the coming days.

Between 1453 and 1536 on 20 February,[7] the points at either end of Wallan Loop were manually reconfigured from their Normal position to their Reverse position.[8] This change meant that rail traffic travelling in either direction after this time would be diverted from the main line into the crossing loop track (No.2 Road). Train Notice TN 367 reflected this change and also specified a 15 km/h speed limit for entry into the loop, and a limit of 35 km/h when exiting the loop. Between 1600 and 1837, Track Force Protection[9] for the laying of conduit was also in place near Wallan, between the 46.3 km and 45.4 km marks.

The first train to pass through Wallan Loop in this altered configuration was southbound V/Line train 8620. Immediately prior to train 8620 departing Kilmore East, the train controller advised the driver that they were going to be the first train through Wallan Loop in the past 72 hours. It departed Kilmore East at about 1623 and the Train Authority was cancelled at 1647 for its arrival at Donnybrook.

The second train through the loop was northbound V/Line train 8625. When stopped at Donnybrook and during exchanges between the driver and the network controller, there was no mention by either party of transiting through Wallan Loop. The train departed Donnybrook at about 1857. Train ST23 operated by NSW TrainLink was to be the third train through the loop.

Train ST23 from Sydney to Albury

On 20 February 2020, passenger train ST23 departed Central Station in Sydney, New South Wales (NSW) at 0741, just after the scheduled departure time of 0740. ST23 was to travel through NSW, and into Victoria to its destination in Melbourne (Figure 1).The service was scheduled to stop at several stations en-route to arriving at its final destination at Southern Cross Station (Melbourne) at 1830 that evening. ST23 comprised leading power car XP2018, five passenger cars of varying configuration, and a trailing power car.

Figure 1: Train route from Sydney to Melbourne

Train route from Sydney to Melbourne

Source: Google Maps, annotated by CIT

The train proceeded south and arrived at Junee in southern NSW at 1452,[10] about 85 minutes behind schedule. ST23 was a single-driver operation, and there was a change of driver at Junee. The train departed Junee at 1456 and continued south, arriving in Albury on the NSW-Victorian border at 1637. There was a change in passenger services crew at Albury. The new passenger services crew comprised a Passengers Services Supervisor (PSS), a crew member training for the supervisory role, and three passenger attendants.

Train ST23 from Albury

The train departed Albury at 1644, about 89 minutes behind schedule, and entered the Victorian section of its journey. After departing Albury, the PSS made an announcement covering a welcome, the delay, and emergency procedures. Tickets were checked and crew walked through the passenger cars checking door locks and equipment. Later, the driver was provided with a snack while stopped at Wangaratta Railway Station and the train departed that station at 1722.[11] Beyond Benalla, the focus of several attendants was on meal activities in the buffet car. The crew described the journey as normal although passengers were reported to be frustrated with the delays.

At about 1840, ARTC Network Control[12] contacted the driver of ST23 regarding a network alarm that had been received.[13] Later in the communication, the network controller advised the driver that due to the altered train working, ST23 would come into Kilmore East and wait until a V/Line train had passed. As part of this communication, the controller mentioned that ‘you’re going via the loop there at Wallan’. The response from the driver did not reference the train’s route via the Wallan crossing loop.

Train ST23 at Kilmore East

The service continued south before coming to a stand at Intermediate Home[14] signal KME28, that was at Stop. It was about 1856. There was a standard-gauge passing lane at Kilmore East, with designated East and West Lines, and ST23 had been routed via the East Line (Figure 2).[15]

Figure 2: Kilmore East standard-gauge passing lane (shown in black)

Kilmore East standard-gauge passing lane (shown in black)

The schematic shows the track at Kilmore East including the passing lane. Only the signalling for the standard-gauge track is shown.
Source: ARTC, modified and annotated by CITS

The driver of ST23 contacted ARTC Network Control at about 1904 and inquired when they might receive permission to proceed. ST23 was required to wait until the V/Line train 8625 had cleared the single-line section.

At around this time, several rail workers were preparing for the arrival of ST23 at signal KME16. These rail workers were to assist with the alternate train working that had been implemented between Kilmore East and Donnybrook. Amongst these rail workers were an in-field signaller and an Accompanying Qualified Worker (AQW).[16] The AQW would board the train and accompany the driver from Kilmore East to Donnybrook. Both the signaller and the AQW had just started their shift and ST23 was the first train they were assisting that evening.

At about 1915 while ST23 was stopped at signal KME28, the in-field signaller positioned near signal KME16 contacted ARTC Network Control to advise that he had come on shift and taken over from the previous in-field signaller. During this call, Train Authority number 17 (TA17) for ST23 to proceed between Kilmore East and Donnybrook was issued to the on-ground signaller by the network controller. The controller read TA17, describing that the authority was issued in accordance with Train Notices 266 and 367, that the points at Wallan Loop were set and secured for number 2 track, and that there was a maximum speed entering the loop of 15 km/h, and a maximum speed exiting the loop of 35 km/h. There was then a full read back of TA17 by the in-field signaller. The network controller noted the time of the read back as 1920. A Condition Affecting Network[17] number 7 (CAN7) was then completed by the signaller under the instruction of the controller. This notice was to warn train crew of the condition of the Wallan-Whittlesea level crossing protection, and that the protection was being manually operated. The read-back of CAN7 by the in-field signaller was noted by the controller as being completed at 1921.

ST23 was held at signal KME28 on the East Line until the northbound V/line passenger train 8625 had transited the Donnybrook to Kilmore East single-line section, passed signal KME2 and was travelling along the West Line through Kilmore East. The V/Line train was clear of the single-line section by about 1925 and, soon after, ST23 was given permission by the network controller to proceed to Home Departure signal KME16,[18] still on the East Line within the Kilmore East location.

ST23 arrived at signal KME16 at about 1931. The train was met by several rail workers that included the in-field signaller and the AQW. The AQW boarded the lead power car and joined the driver at the head of the train. It was intended that the AQW would accompany the driver of ST23 for the 24 km section to Donnybrook. The XPT cab was not fitted with a cab voice recording facility (and was not required to be), and there is no record of the conversation between the AQW and driver.[19]

At about 1932 while the train was stopped at signal KME16, the driver and ARTC Network Control communicated via the train radio. This exchange included confirmation by the driver that he was in possession of ‘authority 17 and CAN number 7 filled out the same way it has been’.

During this communication between the network controller and driver, the controller did not read the content of TA17 to the driver and there was no read back of the content of TA17 by the driver.[20] The controller commented ‘points all set for the loop’. The driver’s response to the controller did not reference transiting via the crossing loop or number 2 track at Wallan. There was no communication between the controller and driver regarding the maximum speed of 15 km/h for entering the crossing loop.

The derailment of train ST23

The train departed signal KME16 at about 1934 and entered the single-line section towards Wallan. The line speed for the XPT between Kilmore East and Donnybrook was 130 km/h.[21] After departing from signal KME16, the speed of the train was increased and maintained between 100 km/h and 120 km/h.

The AQW was to ensure that the level crossing protection[22] at Wallan–Whittlesea Road in Wallan was in place for the passage of the train.[23] A Level Crossing Keeper (LCK)[24] was located at the crossing to perform the manual activation. The AQW contacted the LCK at approximately 1941, when the train was at about the 52 km mark. The LCK reported activating the crossing protection at Wallan–Whittlesea Road, and confirmed its activation to the AQW. This phone call lasted about 53 seconds and the LCK did not recall anything unusual about the communications with the AQW. The call had been completed when the train was about 4.5 km from the level crossing and 2.7 km from the entry to Wallan Loop.

At about 1943, ST23 was approaching the northern end of Wallan Loop at about the track’s line speed. A brake application was made a short distance before the turnout, probably between 50 and 153 m from the points. This slowed the train a small amount before it entered the turnout travelling at a speed probably between 114 and 127 km/h. The train was not able to negotiate the turnout to the crossing loop track at this speed and derailed. The leading power car rolled onto its left side. All vehicles derailed excepting the rear power car (Figure 3).

Figure 3: Aerial photograph of derailment site

Aerial photograph of derailment site

Source: ATSB

Emergency response

At the time of the derailment, there were 155 passengers,[25] six train crew and the AQW aboard the train. The driver and AQW were in the driver’s cab, four passenger services crew were in the buffet car (the third passenger car) and another passenger services crew member was in the second passenger car.

After the train came to a stop, the PSS called the train crew on a hand-held radio and received responses from the other members of the passenger services crew. However, the driver did not respond and the AQW was not in possession of a NSW Trains issued radio.

Around this time, members of the train crew attempted to report the emergency using their radios. A V/Line signaller based at Wallan heard and responded to one of the emergency calls. The Wallan signaller contacted Centrol[26] and, at about 1945, Centrol contacted ARTC Network Control at Junee relaying the information that the XPT may have derailed. In this conversation, Centrol also advised ARTC that V/Line would stop trains on the broad-gauge tracks that ran parallel to the standard-gauge. In response to the Centrol call, ARTC initiated its response.

Emergency services recorded the first ‘000’ call for assistance from a train passenger, time-stamped 19:45:06.[27] This was followed by a series of calls from other passengers, members of the train crew, and members of V/Line and ARTC.

Around this time or soon after, some passengers started to self-evacuate from the train. A member of the train passenger services crew was allocated to manage passengers on the track, and two services crew members remained on the train to attend to passengers. The other two passenger services crew went to the lead power car. Here, they entered the power car through its the right-side cab door, accessible from the ‘top’ of the car laying on its left side. Finding it difficult to assist from within the cab, they then went to the outside and attempted to gain ground-level access by breaking the windscreen of the driver’s cab.[28] However, attempts by the passenger services crew to gain this ground-level access were unsuccessful.

The first emergency services to arrive on site was Victoria Police at about 2003, followed by further emergency, medical and fire services. However, both the driver and the AQW did not survive the accident.

As a result of the movement of the passenger cars during the derailment, eight passengers were seriously injured and 53 received minor injuries. The five passenger services crew located in the passenger cars also received minor injuries.

__________

    1. All times are Australian Eastern Daylight Time (AEDT) and use the 24-hour clock.
    2. An instruction in the prescribed format issued by the Network Control Officer in connection with the movement of a train. RISSB Glossary of Terms, viewed 30 March 2020, <https://www.rissb.com.au/glossary/>.
    3. The first Train Authority was issued at 2042 on 6 February.
    4. Rail-km from Melbourne.
    5. Operational information issued by or on behalf of the Rail Infrastructure Manager. RISSB Glossary of Terms, viewed 30 March 2020,< https://www.rissb.com.au/glossary/>
    6. Residues such as iron oxides can hamper electrical connection between wheel and rail and impact performance of signalling systems.
    7. A track warrant for this activity was taken between these times.
    8. The Normal position of the turnouts was for ‘straight-through’ traffic, and the Reverse position was for the loop.
    9. A system used to protect a worksite.
    10. Stopping times at stations are as recorded by NSW TrainLink.
    11. 87 minutes behind schedule.
    12. The ARTC Network Control office for this section of track is located in Junee in NSW.
    13. An alarm had been received by network control for a possible signal passed at danger (SPAD) at Tallarook, 23 km NE of Kilmore East. The network controller indicated that there had been power outages at this location, that may have showed up as a SPAD. The driver indicated that all signals had been ‘clear’ through Tallarook.
    14. This signal protected the broad-gauge crossover going into the Apex ballast quarry. It is called an ‘Intermediate Home’ because it is in an intermediate location along the passing lane.
    15. The passing lane was about 7 km in length. A ‘passing lane’ is an extended crossing loop long enough to be considered a short section of bi-directional double track.
    16. The term used in Train Notices for the worker that would accompany the driver between Kilmore East and Donnybrook.
    17. A Condition Affecting Network is a warning provided of an unsafe condition affecting, or potentially affecting, the network.
    18. Home Departure signal KME16 was protecting the turnout at the end of the passing lane. Permission for passing this signal at Stop was included in the Train Authority.
    19. Currently in Australia, locomotive and train operating cabs are generally not fitted with voice recording devices.
    20. In the extant version of Train Notice TN 266, read back of the Train Authority by the driver was not required
    21. Within this section, there were 115 km/h speed restrictions applied to some sections of track.
    22. Boom barriers and flashing lights at this location.
    23. Active protection on the other level crossings on the Kilmore East-to-Donnybrook section were working normally and it was only the Wallan-Whittlesea Road level crossing that required local operation.
    24. The person who activated the level crossing protection locally at the crossing, colloquially referred to as the bellhop.
    25. Passenger numbers based on available data from the operator.
    26. V/Line’s network train control centre located in Melbourne.
    27. The emergency services call centre time stamp.
    28. Using tools sourced from the train’s emergency breakdown kit.
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Context

Safety actions

Ongoing investigation

Preliminary Report

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The occurrence

On 20 February 2020, passenger train XPT ST23 departed Central Station in Sydney, New South Wales (NSW), at about the scheduled departure time of 0740.[1] The service was scheduled to stop at several stations en-route to its final destination at Southern Cross Station in Melbourne, Victoria that evening at 1830 (Figure 1).

Figure 1: Train route from Sydney to Melbourne

Figure 1: Train route from Sydney to Melbourne.
Source: Google Maps, annotated by Chief Investigator, Transport Safety

Source: Google Maps, annotated by Chief Investigator, Transport Safety

The train proceeded south and arrived at Junee in southern NSW at 1452,[2] about 85 minutes behind schedule. At Junee there was a change of driver before the train continued south, arriving in Albury on the NSW-Victorian border at 1637, still about 85 minutes behind schedule. There was a change in passenger car crew at Albury.

The train departed Albury at 1644 and entered the Victorian section of its journey. The service continued south, stopping at several stations before coming to a stand at Intermediate Home[3] signal KME28 at Kilmore East, at about 1856. Signal KME28 was at Stop, and the driver contacted Network Control at about 1904 to inquire when he might receive permission to proceed. There was a standard-gauge passing lane at Kilmore East, with East and West Lines (Figure 2).[4]

 

Figure 2: Kilmore East passing lane (standard-gauge track shown in black, with signals)

Figure 2: Kilmore East passing lane (standard-gauge track shown in black, with signals).
Source: ARTC, modified and annotated by Chief Investigator, Transport Safety

Source: ARTC, modified and annotated by Chief Investigator, Transport Safety

The XPT waited at signal KME28 on the East Line until the north-bound V/line passenger train 8625 had transited the Donnybrook to Kilmore East single-line section, passed signal KME2 and was travelling along the West Line through Kilmore East. The V/Line train was clear of the single-line by about 1925 and, soon after, the XPT was given permission by Network Control[5] to proceed to Home Departure signal KME16,[6] still on the East Line within the Kilmore East location.

As a result of damage to signalling equipment, a 24 km section from Kilmore East signal KME16 (at about the 63.8 km mark)[7] to Donnybrook (at about the 40.2 km mark) was being managed using an alternative safeworking system.[8] Wallan was located in this section, about 48 rail-km from Melbourne.

At signal KME16, XPT ST23 was met by several rail workers, including a Signaller and an Accompanying Qualified Worker (AQW).[9] The AQW boarded the lead power car and joined the driver at the head of the train as part of the alternative safeworking system in place for the 24 km section to Donnybrook.

At about 1932 while the train was still stopped at signal KME16, the driver and the Network Control Officer communicated over the radio about the Train Authority[10] for the section through to Donnybrook. The train then departed signal KME16 and entered the single-line towards Wallan. The line speed for the XPT in this section was 130 km/h and after departing, the speed of the train was increased towards this line speed.

One function of the AQW was to ensure that the level crossing protection[11] at Wallan–Whittlesea Road in Wallan was in place for the passage of the train.[12] The Level Crossing Keeper[13] positioned at this level crossing reported receiving a call from the AQW and activating the crossing protection.

The train was now approaching Wallan. Earlier that afternoon, the points at either end of Wallan Loop had been changed from their Normal position to their Reverse position.[14] This change meant that rail traffic, in both directions, would be diverted from the Main Line (straight) into the loop track (No.2 Road). A Train Notice[15] reflected this change and also specified a 15 km/h speed limit for entry into the loop, and a limit of 35 km/h for exiting the loop.

At about 1943, XPT ST23 was approaching the northern end of Wallan Loop at about the track’s line speed. Recordings from the train indicate an Emergency brake application a short distance before the points. This slowed the train a small amount before it entered the turnout travelling at a speed in excess of 100 km/h. The train was not able to negotiate the turnout to the loop track at this speed and derailed. All vehicles derailed excepting the rear power car (Figure 3).

Figure 3: Aerial photograph of derailment site

Figure 3: Aerial photograph of derailment site.
Source: ATSB

Source: ATSB

During the derailment sequence, the leading power car rolled onto its left side and the XPT driver and the AQW sustained fatal injuries. Three passengers were seriously injured and 36 received minor injuries.[16] Five train crew that were in the passenger cars also sustained injuries.

Context

Track information

The XPT service was running on the national standard-gauge track that connects Sydney and Melbourne. The track is part of the Defined Interstate Rail Network (DIRN) and is managed by the Australian Rail Track Corporation (ARTC).[17]

The standard-gauge track between Kilmore East and Donnybrook was a single, bi-directional line that serviced the XPT, V/Line passenger services and rail freight. There were passing lanes at Kilmore East and Donnybrook and a 1,550 m crossing loop at Wallan. The northern entry to this loop was located about 1.8 km north of Wallan–Whittlesea Road (Figure 4).

Figure 4: Wallan Loop (standard-gauge track shown in black, with signals)

Figure 4: Wallan Loop (standard-gauge track shown in black, with signals).
Source: ARTC, modified and annotated by Chief Investigator, Transport Safety

Source: ARTC, modified and annotated by Chief Investigator, Transport Safety

Train information

The first XPT (Express Passenger Train) commenced service in 1982. The XPT fleet is operated by NSW TrainLink[18] and provides passenger services in regional NSW and between the east coast capital cities of Melbourne, Sydney and Brisbane. XPT vehicles are maintained by Sydney Trains[19].

The XPT ST23 running on 20 February 2020 included five passenger cars (Figure 5). The leading three vehicles were manufactured by ABB Transportation in Dandenong, Victoria and commissioned in 1993. The trailing four vehicles were manufactured by Comeng in Granville, NSW and commissioned between 1981 and 1984.

Figure 5: Train configuration

Figure 5: Train configuration.
Source: ATSB, vehicle images supplied by Sydney Trains

Source: ATSB, vehicle images supplied by Sydney Trains

Train data logger

Both power cars were fitted with a Hasler RT data logger. The data logger is an electro-mechanical device that records speed, distance, time, a combined power-vigilance parameter, and brake cylinder pressure parameters. These parameters are recorded on a waxed paper tape (roll). The Hasler system also included an analogue speedometer located on the driver’s console.

The train’s speed is derived from the measurement of the rotation of the left hand wheel on the second axle of the power car. In order for this rotation to be translated into distance (and speed), an average wheel diameter is assumed. Actual speed may deviate from that recorded (and displayed) due to differences between this assumed diameter and the diameter of the actual wheel providing the feed to the Hasler system.

The Hasler tapes from the two power cars were recovered at the accident scene and examined by the ATSB. Corrections to the recorded speed were made to account for the differences between the assumed wheel diameter and the actual wheel diameter on each power car. The results from both recorders indicated a speed of about 130 km/h approaching Wallan Loop.[20] The Hasler analogue speedometer would have read less than this, probably between the 125 km/h and 130 km/h marks.[21]

The data from both recorders indicate that there was an Emergency brake application nearing the turnout to the loop, and an associated small reduction in speed prior to the train entering the loop. The Hasler recordings will be the subject of further detailed analysis and review against other evidence.

Train crew and passengers

The XPT is a single-driver operation. The driver of the XPT was designated as a Regional Driver, and at the time of the derailment, an AQW was also in the driver’s cab. Both the driver and AQW suffered fatal injuries in the derailment.

Within the passenger vehicles, there were five further crew members including a Passenger Service Supervisor, Senior Passenger Attendant and three Passenger Attendants. All five have reported injuries.

There were 153 passengers recorded as being on the train at the time of the derailment, of which 39[22] have reported injuries.

Management of rail traffic (safeworking)

Safeworking is an integrated system of operating rules and procedures that defines the interaction between workers and engineered systems for the safe operation of a railway.[23] Of primary concern is safe operations including train separation and speed management according to infrastructure.

Relevant to this occurrence, the signalling infrastructure used for standard-gauge traffic through Wallan was damaged as a result of a fire in a track-side equipment hut on 3 February 2020. From 6 February, Train Authority Working was established to manage traffic between Home Departure signals DBK6 and DBK18 at Donnybrook[24] and KME4 and KME16 at Kilmore East.[25] The alternative safeworking arrangements permitted only one train in the section between Donnybrook and Kilmore East at any one time, and Wallan Loop was not being used for trains to cross or pass. From the commencement of Train Authority Working on 6 February, Wallan Loop was configured for trains to travel along No.1 Road.[26] This changed to the No.2 Road on 20 February.

Further investigation

The areas explored and requiring further investigation include:

  • Derailment sequence: Further investigation will include a detailed examination and review of available evidence to refine the derailment sequence.
  • Track condition: To date, site observations and preliminary review of track data have not identified adverse conditions directly contributing to the derailment. Further investigation will include the detailed examination of post- and pre-occurrence track geometry and maintenance information.
  • Rolling Stock condition: To date, site observations and vehicle workshop inspections (that commenced 6 March) have not identified adverse conditions directly contributing to the derailment. Inspections are ongoing and include detailed inspection of vehicles and testing of braking and driver safety systems.
  • Crew and passenger survivability: Detailed survivability inspection of the leading power car XP2018 and all passenger vehicles is complete. A passenger survey is being conducted researching passenger experiences of the derailment and subsequent evacuation and emergency response.
  • Train operation: Further investigation will include a detailed examination of the operation of the train drawing on a wide range of evidence sources.
  • Management of train operations: Further investigation will include a detailed examination of the alternative safeworking systems used to manage rail traffic at this location from 6 to 20 February 2020.
  • Other areas of investigation: Further areas of investigation may be identified as the investigation progresses.

Acknowledgements

The ATSB would like to acknowledge the significant assistance provided by all involved parties during the initial investigation, particularly in the context of the impact of COVID-19 on business operations and the community.

Train details

Train operator:

NSW TrainLink 

Persons on board:

Crew: 6 +1

Passengers: 153[27]

Fatalities:

Crew: 1+1

Passengers: 0

Other Injuries:[28]

Crew: 5

Passengers: 39

Damage:

Substantial, to train and track

 

__________

The information contained in this report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this update. As such, no analysis or findings are included in this report.

__________

  1. All times are Australian Eastern Daylight Time (AEDT).
  2. Stopping times at stations are as recorded by NSW TrainLink.
  3. This signal protected the broad-gauge crossover going into the Apex ballast quarry. It is called an ‘Intermediate Home’ because it is in an intermediate location along the passing lane.
  4. The passing lane was about 7 km in length.
  5. ARTC network control for this section of track is located at Junee, NSW.
  6. This Home Departure signal was protecting the turnout at the end of the passing lane.
  7. Rail-km from Melbourne.
  8. Safeworking is described in this report at section, Management of rail traffic (safeworking).
  9. The term used in Train Notices for the worker that would accompany the driver between Kilmore East and Donnybrook.
  10. An instruction in the prescribed format issued by the Network Control Officer in connection with the movement of a train. RISSB Glossary of Terms, viewed 30 March 2020, <www.rissb.com.au/glossary>.
  11. Boom barriers and flashing lights at this location.
  12. Active protection on the other level crossings on the Kilmore East-to-Donnybrook section were working normally and it was only the Wallan-Whittlesea Road level crossing that required local operation.
  13. The person who activated the level crossing protection locally at the crossing, colloquially referred to as the bellhop.
  14. The Normal position of the turnouts was for ‘straight-through’ traffic, and the Reverse position was for the loop.
  15. Operational information issued by or on behalf of the Rail Infrastructure Manager. RISSB Glossary of Terms, viewed 30 March 2020,<www.rissb.com.au/glossary>
  16. Injury information accounts for physical injuries and does not include non-physical injury or distress.
  17. ARTC is a statutory corporation fully owned by the Government of Australia.
  18. The brand name of NSW Trains, an agency of Transport for NSW.
  19. Sydney Trains maintains trains on behalf of NSW Trains through a service agreement. Sydney Trains is an agency of Transport for NSW.
  20. The results of the interim analysis. Further analysis will be undertaken and reviewed against other evidence sources.
  21. This difference is because the actual wheel diameter was greater than that used as input to the Hasler system.
  22. This figure may be updated during the investigation.
  23. RISSB Glossary of Terms, viewed 30 March 2020 <www.rissb.com.au/glossary>
  24. DBK6 and DBK18 were at a similar km location at Donnybrook, servicing the West Line and East Line respectively.
  25. KME4 and KME16 were at the same km location at Kilmore East, servicing the West Line and East Line respectively.
  26. Utilising manual operation and clipping of the points.
  27. The number of passengers on board at the time of the derailment may be updated during the investigation.
  28. Injury data may be updated during the investigation.
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Initial Summary

Initial summary: 21 February 2020

The Australian Transport Safety Bureau (ATSB), in collaboration with the Victorian Government’s Chief Investigator, Transport Safety (CITS), is investigating the derailment of the XPT passenger train ST23 near Wallan, Victoria on 20 February 2020.

Victoria’s Chief Investigator, Transport Safety will lead the investigation, under delegation from the ATSB, with support from the ATSB as well as New South Wales’ Office of Transport Safety Investigations (OTSI). CITS conducts rail investigations in Victoria on behalf of the ATSB under the Transport Safety Investigation Act 2003.

As part of the investigation, investigators will examine the track infrastructure, the XPT power cars and carriages, and map the accident layout. The ATSB will also obtain and analyse available information and records, including the train data logger, signaling data, and maintenance records for the train and track infrastructure. Further, investigators will consider vehicle crashworthiness and human factor aspects, and interview involved parties and witnesses.

A final report will be released at the end of the investigation.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

Any passengers and witnesses who may have any information, photographs and video they feel is of relevance to the investigation are asked to contact the ATSB by calling 1800 992 986 (then press 1).

General details
Date: 20 February 2020   Investigation status: Active  
Time: 1943 AEST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Wallan   Investigation phase: Examination and analysis  
State: Victoria    
Release date: 10 June 2021   Occurrence category: Accident  
Report status: Interim   Highest injury level: Fatal  
Anticipated completion: 1st Quarter 2022    

Train details

Train details
Line operator Australian Rail Track Corporation  
Train operator NSW TrainLink  
Train registration ST23  
Type of operation Passenger Service  
Sector Passenger - regional  
Damage to train Substantial  
Departure point Sydney, New South Wales  
Destination Melbourne, Victoria  
Last update 11 June 2021