Rail safety investigations & reports

Signal SST535 passed at danger involving passenger train 8239 and near collision with another passenger train Docklands, Melbourne, on 23 November 2020

Investigation number:
RO-2020-019
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

At around 1736 on 23 November 2020, V/Line loco-hauled passenger service 8239 from Southern Cross to Melton passed signal SST535 at stop, about 700 m north-west of Southern Cross Station. The signal was at stop to protect the movement of V/Line passenger service 8156 (Wendouree to Southern Cross) that was to cross ahead of train 8239. Train 8239 passed the signal at about 23 km/h and continued for about 200 m before stopping across the junction through which train 8156 would pass. The driver of train 8156 brought their train to a stop about 100 m prior to that junction. The drivers of both services had stopped their trains following an emergency broadcast from the controlling signaller. 

What the ATSB found

When approaching signal SST535 at stop, the driver of train 8239 was probably distracted by task unrelated thoughts. They did not respond to the indication of the signal and probably looked past to another signal further along the track that they incorrectly believed was the signal where they were to stop.

Once signal SST535 had been passed, the risk control to reduce the likelihood of a collision was primarily the action of the signaller to respond to system alarms. In this instance, the signaller responded by making an emergency broadcast to train 8156 and this was sufficient to stop that train. The driver of train 8239 also overheard this broadcast and stopped their train.

Some signals on the V/Line network were fitted with Train Protection and Warning System (TPWS) equipment that automatically initiated a brake application when a signal was passed at danger (SPAD). Signal SST535 was not fitted with TPWS and its absence at this signal increased the potential consequences of a SPAD. A 2014 V/Line risk assessment of signal SST535 had not considered a head-on or side-on collision as a credible scenario. Such a consideration would have increased the risk rating of this signal and probably led to the fitting of TPWS.

Train 8156 was approaching signal SST578 as train 8239 passed signal SST535 at danger. However, signal SST578 continued to show a proceed aspect and did not restore to danger until train 8156 had passed that signal. There were no further signals in front of train 8156 to warn that the junction ahead was occupied by train 8239. The V/Line signalling standards did not include specific reference to a design that would require signal SST578 to restore to danger in this scenario (flank-track protection).

What has been done as a result

V/Line Corporation has advised that a funding submission to fit TPWS to signal SST535 and other similar signals in the Southern Cross area was approved in July 2021. Plans are underway to complete this installation during 2022.

The Rail Industry Safety and Standards Board (RISSB) advised that flank - track protection has been recorded for inclusion when the signalling principles standard AS 7711 is next under review.

Safety message

This occurrence has highlighted the importance for passenger rail networks to have engineering controls in place to detect SPAD events and prevent potential consequences such as collision. In determining applicable SPAD risk controls, rail operators should consider all SPAD precursors and potential collision scenarios. 

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Glossary

Sources and submissions

About the ATSB

Summary

The ATSB is investigating a Signal Passed at Danger (SPAD) by passenger train TD8239, at Docklands, Melbourne, Victoria, on 23 November 2020.

At approximately 1634, the locomotive-hauled passenger train TD8239, travelling from Southern Cross to Wendouree (Ballarat), passed a signal that was at Stop. At the same time a VLocity train set was travelling towards Southern Cross Station and was approaching a possible conflict point with the outbound passenger train. Both trains were brought to a stop and there was no collision or injury.

This investigation is being led by Victoria’s Chief Investigator, Transport Safety (CITS). CITS conducts rail investigations in Victoria on behalf of the ATSB under the Transport Safety Investigation Act 2003.

Should safety critical information be discovered at any time during the investigation, the ATSB will immediately notify operators and regulators so appropriate and timely safety action can be taken.

A final report will be published at the conclusion of the investigation.

Safety Issue

Go to RO-2020-019-SI-01 -

Absence of authority-overrun protection

The absence of authority-overrun protection (such as TPWS) at signal SST535 increased the potential consequences of a SPAD.

Safety issue details
Issue number: RO-2020-019-SI-01
Status: Open – Safety action pending
General details
Date: 23 November 2020   Investigation status: Completed  
Time: 1635 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Docklands, Victoria, about 700 m north-west of Southern Cross Station   Investigation phase: Final report: Dissemination  
State: Victoria    
Release date: 07 December 2021   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 TD8239  
Type of operation Loco-hauled regional passenger service  
Sector Passenger - regional  
Damage to train Nil  
Departure point Southern Cross Station  
Destination Melton  

Train 2 details

Train 2 details
Line operator V/Line  
Train operator V/Line  
Train registration TD8156  
Type of operation DMU regional passenger service  
Sector Passenger - regional  
Damage to train Nil  
Departure point Wendouree  
Destination Southern Cross Station  
Last update 07 December 2021