Office of the Chief Investigator - Rail Safety Investigation Report No 2011 / 05

At about 0743 on 20 April 2011, Combino Tram 3515 operated by Yarra Trams arrived at Melbourne University terminus from the city. The tram was to terminate at this stop and then shunt, changing direction for the return journey. However, at the time of its arrival, all three shunts1 at the terminus were occupied.

To clear the tram stop platform, the duty traffic officer overrode the automatic control systems and manually moved the points to allow Tram 3515 to enter the first shunt and abut a tram that was already stabled there. As the tram moved into the shunt the points moved under it. The front bogie travelled into the shunt and the rear bogie travelled along the straight. This resulted in both tram bogies derailing. There was no reported injury to persons or damage to the tram or infrastructure.

The investigation found that the tram derailed when the automatic Points Controller moved the points, seeking to place the tram in the second shunt. The automatic Points Controller had functioned as designed and the points would have been locked in position and not have moved, had the tram been detected moving towards the points, which it was not.

The investigation determined that the failure of the system to initially detect Tram 3515 was due to defects in a number of the tram's earth brush units that are mounted within the wheel assembly and facilitate an electrical connection between the rails. These units have a history of malfunctioning in the Combino tram.

The investigation found that the Melbourne University terminus control systems had been designed to stable only one tram in each shunt position but the operator had changed their operational practice to allow two trams to be stabled in the first shunt without conducting an adequate risk assessment and without considering infrastructure design.

Since the incident Yarra Trams have initiated operational and engineering procedures to mitigate the risk of a similar incident occurring.

The investigation makes a recommendation to Yarra Trams that it review internal processes for changing operational practices.

Rail Safety Investigation Report No 2011/03

On Wednesday 9 March 2011, trains at Pakenham and Sandringham overran the end of the track and derailed. In both instances:

• The trains were being stabled and were not conveying passengers at the time of derailment.
• Significant damage was caused to infrastructure as well as to the trains involved.
• There were no reported injuries.
• The trains comprised two Siemens three-car sets forming six-car trains.
• The investigation found that in both incidents the trains were travelling at speeds exceeding that permitted in the sidings, low adhesion conditions existed, braking performance was less than expected by the drivers and end-of-track protection was ineffective. Neither train was fitted with sanders to assist braking in low adhesion conditions.

Since the incidents, Metro Trains Melbourne (MTM) has:

1. Issued alerts to train drivers regarding their obligation to adhere to posted speeds.

2. Completed a risk review of all stabling sidings to inform future infrastructure works at sidings, including end-of-track protection.

3. At Sandringham – installed steel buffer-stops at the end of siding tracks 1 and 2.

4. At Pakenham siding track 5 – relocated the catenary support structure struck by the derailed train to a position clear of the overrun zone.

5. Completed the installation of sanders on all Siemens trains, including the two six- car sets involved in these incidents.

This investigation makes recommendations in the areas of train driver supervision.

[Communication Issues:

The driver attempted to make an emergency call to Metrol but without success.]

Rail Safety Investigation Report No 2010/15

On 30 December 2010, a Warrnambool-to-Melbourne V/Line passenger train suffered a fire on the locomotive at Marshall railway station. The fire was attended by the Country Fire Authority (CFA) and the locomotive and train were subsequently permitted to continue to Melbourne. There were no reported injuries.

The investigation found that the locomotive had been operating with a pre-existing equipment defect; a fault in the dynamic braking system. The locomotive had been mistakenly removed from a repair facility and placed into operation prior to receiving the remedial attention intended. The fire occurred as a result of the unattended defect.

Since the incident, a process has been developed to prevent rolling stock from being operated when it is under attention for maintenance or repair. V/Line have drawn their locomotive and train drivers' attention to the requirement to properly record fault events in the Locomotive Fault Report Book, and has undertaken to develop a process to improve the response of fleet management personnel to situations where vehicles that are logged as being defective are found to still be in service.

The investigation makes recommendations regarding the maintenance of the N-class locomotive dynamic brake cooling fan, the set-up of the dynamic brake grid protection system, and the development of procedures relating to the return-to-service of rolling stock that has been the subject of maintenance.

Office of the Chief Investigator - Rail Safety Investigation Report No 2010/11

On 2 November 2010, two locomotives of a broad-gauge Pacific National three locomotive consist travelling from the Melbourne Dock area to the South Dynon Maintenance Depot derailed when attempting to enter the Melbourne Operations Terminal in West Melbourne. The route selected did not support the track gauge that the locomotives were operating on. However, the network controller's Visual Display Unit indicated that broad-gauge was available. A verbal authority was issued for the locomotives to proceed beyond the controlling signal, which was displaying Stop. The derailment was a consequence of the locomotives running out of gauge on a recently installed crossover that consisted of both dual and standard-gauge turnouts.

The investigation found that the in-field signalling system operated as designed and commissioned. It was also found that an anomaly with the Australian Rail Track Corporation's network controller's Visual Display Unit track gauge indication was not identified during the acceptance testing or the signal system commissioning processes.

The investigation also found that both Australian Rail Track Corporation and Pacific National did not provide route knowledge training for their operating personnel.

Since the event the Australian Rail Track Corporation has updated the Melbourne Metro network controller's Visual Display Unit to correctly reflect that broad-gauge is not available within or beyond the crossover in the Melbourne Operations Terminal.

The investigation makes recommendations to the Australian Rail Track Corporation in the safety management of risks associated with the use of dual-gauge points at interfaces with single-gauge trackage and with the processes for acceptance testing of signalling control systems.

The investigation also makes recommendations to both the Australian Rail Track Corporation and Pacific National in route knowledge training for network controllers and locomotive crews whenever new track and signalling infrastructure is introduced into the network.

Office of the Chief Investigator -Rail Safety Investigation Report No 2010/13

A Pacific National freight train carrying containerised steel departed Hastings (Western Port) in the early hours of 9 December 2010, destined for the Melbourne Steel Terminal. Near the end of its journey, seven wagons derailed as the train travelled up the embankment to the Loco Flyover rail bridge in West Melbourne. The derailment occurred near the network management interface between Metro Trains Melbourne (MTM) and V/Line. There were no injuries.
The investigation found that the derailment was the result of the track spreading and the consequent loss-of-gauge1. The first wheels to derail dropped inside the right-hand rail. Two possible scenarios for the initiation of the derailment were identified: one in MTM territory at catch point 412D, and the other in V/Line territory on the left-hand curving track ascending towards the flyover.

The investigation found that the track on the embankment to the flyover was not in a condition suitable for the transit of the steel train. In the weeks prior the steel trains had been subject to re-routing, but this was the first and only steel train to run over this section of track in either direction. It was unusual for this type of traffic to be routed via the broad-gauge track on the flyover and it is probable that the additional loads applied by the freight consist were sufficient to cause the track to spread.

The routing of the steel train over the Loco Flyover was the result of operational considerations, influenced by other routes being affected by works and a signal failure. This was not a pre-planned train movement; the decision was made in the hours prior and with the knowledge that the track was unrestricted and authorised to carry such traffic.

The investigation questioned the appropriateness of the track condition monitoring regime, which was based on the classification of the track as a siding by V/Line and MTM; even though, as utilised in this instance, it was available for traffic transiting to terminal destinations. In addition, the derailment occurred adjacent to main lines, including those used by suburban passenger services. While the derailed wagons remained upright, coupled and close to the route of the track, there existed the potential for the wagons to foul these other lines.

Since the event MTM has introduced changes to its track maintenance systems.

Recommendations are made to V/Line and MTM in the areas of track maintenance and communication protocols.

Office of the Chief Investigator, Rail Safety Investigation Report 2011/02

On the evening of 3 March 2011, a Comeng train being driven into Carrum No 3 siding could not be stopped before reaching the end of the line, causing it to overrun the end- of-line baulks, derail and collide with a steel stanchion supporting the overhead contact wire.

As a consequence, the stanchion was uprooted and the overhead contact wire parted. The stanchion fouled the adjoining main line causing rail services between Carrum and Frankston to be suspended.

There was also considerable damage to the leading car of the train.

The investigation found that the two drivers involved did not follow standard operating procedures when changing driving ends, resulting in the train being driven into the siding without the braking system correctly set up.

Since the incident Metro Trains Melbourne has issued a Train Driver Safety Bulletin advising drivers to “fully and correctly” comply with documented procedures at all times, and the likely consequences of not complying.

The investigation found that Comeng trains can be operated without normal braking being available and recommends that Metro Trains Melbourne consider the provision of a suitable intervention system to prevent such occurrence.

Office of the Chief Investigator, Rail Safety Investigation Report No 2010/09

On 15 October 2010 at about 1140, the locomotives and the leading wagon of the Pacific National Mildura to Appleton Dock freight train No 9102 derailed at 127D points at South Dynon Junction. This set of points connected the recently constructed North Dock Line to the existing Australian Rail Track Corporation network. The derailment occurred during the South Improvement Alliance ‘Missing Link’ Stage 3 commissioning works that involved the introduction of the North Dock Line together with other track and signalling infrastructure between South Dynon Junction and Appleton Dock. Train No 9102 was the first revenue train to operate through the commissioning area and was done so under the local signaller’s authorisation.

As a consequence of the derailment, rail traffic was disrupted and Dock Link Road was closed to road traffic for several hours. The site was cleared at 1430 on 16 October 2010; however, the Greensill Lead connection to the North Dock Line was not commissioned until June 2011.

The investigation found that the broad-gauge blade of 127D points was not connected to the dual-control point machine and that it was secured against movement for the broad-gauge route towards the North Dock Line. The derailment was caused by the left-hand point blade of 127D points being in the Reverse position while the right-hand broad-gauge point blade was secured against the standard-gauge rail in the Normal position. This resulted in the locomotives and lead wagon attempting to traverse two routes.

The derailment was a consequence of the failure of the commissioning planning, operations and safeworking processes to identify the condition of 127D points, and the signallers not ensuring the integrity of the route set for train No 9102.

The investigation makes recommendations to South Improvement Alliance in the areas of the processes for identifying the position of field equipment prior to train movements and the practices applied by signallers.

The investigation also recommends that the Victorian Network Managers review the Australian Rail Track Corporation Network Rules and Procedures (TA20) and the Public Transport Corporation 1994 Book of Rules and Operating Procedures in relation to the operation and working of dual-control point machines when in the Hand mode.

Office of the Chief Investigator - Rail Safety Investigation Report No 2009/11

Department of Infrastructure Office of the Director of Public Transport

Safety and Technical Services Branch May 2001

At 14:32 on Wednesday 26 July 2000 the 14:22 Glen Waverley express train (No 2020) to Flinders Street collided with the 14:11 Glen Waverley train (No 2018) to Flinders Street which was stationary at Holmesglen Railway Station. Train 2018 was carrying passengers, train 2020 was not carrying passengers. Each train consisted of six cars and both trains were severely damaged.

The Minister for Transport directed that an independent investigation be conducted in accordance with the Transport Act 1983, Section 129U.

The investigation and report preparation were conducted in accordance with draft standard AS 4292.7 - Railway Safety Incident Investigation.

Findings

The 14:11 Glen Waverley to Flinders Street train (2018) was stationary at Holmesglen Station from 14:27:05 on 26 July 2000. At 14:32:30 train (2020) which was the 14:22 Glen Waverley to Flinders Street express (empty cars) collided with it from the rear while the Driver of train 2018 was in the rear car (569M) of his train attending to a saloon door fault.

After exercising train brake tripping procedures at Automatic Signal DG484 train 2020 proceeded to Holmesglen at a speed which did not comply with Rule 1 Section 3 of the 1994 Book of Rules and Operating Procedures.

There was no evidence of any failure in the signalling system or any other safety electrical or mechanical system fitted to either train or to the infrastructure in place at the time of accident.

Glenbrook Accident

Finalisation of this report was held in abeyance pending public presentation of the report by the Special Commission of Inquiry into the Glenbrook rail accident of 2 December 1999 in New South Wales in which seven passengers were killed and fifty-one passengers were hospitalized.

Issues related to trains passing signals at danger were of significance in that Inquiry and it was considered important that the investigation of the Holmesglen incident have regard to the details, findings and recommendations reported by the Special Commission of Inquiry which handed down its Final Report in April 2001.

[Communication Issues

Evidence shows that train 2018 arrived at Holmesglen Station at 14:27:05 and the Driver of that train approached the rear of his train at 14:31:25 to investigate the door fault. This would appear to be a significant delay. Had the Driver of train 2020 been aware that train 2018 was delayed at the platform he would in all probability have acted differently. Use of the train radio system to provide a secondary safety defence against likely hazards where trains are delayed in excess of a predetermined time needs to be considered consistent with clarification of the intention of Rule 1 Section 13. - Page 35]

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

 Rail Safety Investigation Report No 2010/06

Full Title:

Train-to-Train Collision Metro Trains Melbourne Train 5863 Pacific National Train 9319 Between Roxburgh Park and Craigieburn 4 May 2010

At about 20:35 on 4 May 2010, a Flinders Street to Craigieburn Metro Trains Melbourne suburban train, travelling on the Down broad gauge line, ran into the rear wagon of a stationary Pacific National freight train midway between Roxburgh Park and Craigieburn stations. At the time, the freight train was stopped at a signal waiting for the departure of an Up suburban train occupying the Down line platform at Craigieburn.

The driver and 14 passengers on the suburban train were treated by paramedics on site with the driver and four passengers subsequently being taken to hospital. The two crew members of the freight train were uninjured. Both trains were extensively damaged with the freight train being propelled about 30 metres forward from the point of impact.

The investigation determined that the driver of the suburban train had passed two automatic signals after departing Roxburgh Park that presented a stop aspect. When passing the signals the driver did not comply with the network Rules and operating procedures. The train was then operated at speeds up to 69 km/h, also in contravention of the Book of Rules and Operating Procedures 1994. The reason for the driver’s actions could not be determined.

No faults were found with any rolling stock, track or signal infrastructure.

The investigation makes recommendations with respect to the network’s ability to monitor the application of and compliance to Section 3 Rule 1 of the Book of Rules and Operating Procedures 1994, the number of automatic signals currently on the system, the acceptance and application of industry standards for train tail signals, train speed limiting devices after passing signals at stop and train crashworthiness.

[Communication Issues

Almost immediately after the impact the Craigieburn signaller contacted train 9319 by the local radio to advise that he would now allow their train to proceed. The crew said that they then informed the signaller that they had been struck by a following train. The crew contacted Centrol using the emergency call feature of the train-to-base radio to arrange protection for the adjacent running lines. They also contacted Junee control to stop rail traffic on the adjacent standard gauge track. - Page 12

The Craigieburn communications system combines radio and telephone (landline and mobile) which provides the signaller with the ability to receive or initiate communication with Metrol, Centrol and all trains. However, when signallers are required to perform safeworking duties outside the office, they are out of contact for incoming calls unless the incoming call is directed to their mobile phone. - Page 35]

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2011/04

At about 1600 on 24 March 2011, an X’Trapolis train collided with the end-of-track baulks at Macleod Railway Station platform 3 and subsequently the station wire boundary fence. The train was fully loaded but there was no injury to any occupant or other person. The leading car of the train sustained minor damage with the baulks being destroyed and the fencing damaged.

The investigation determined that at the time of the incident low-adhesion conditions were present at the wheel-rail interface. These conditions were contributed to by vegetation matter from surrounding foliage and moss from the platform that had been washed onto the track during the platform cleaning process. The end-of-track baulks were poorly maintained and not fit for purpose.

Recommendations are made to the rail operator concerning the maintenance of infrastructure as it relates to vegetation and end-of-track baulks, and to conduct a review of the adequacy of end-of-track protection.

[No communication issues noted]

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2011/01

A defective tram on the city-bound track along St Kilda Road was preventing movements on the city-bound portion of St Kilda Road between the Domain Interchange and the CBD. City-bound tram services on St Kilda Road were being diverted from Domain Interchange via Park Street and Kings Way thence onto Sturt Street for access to the city. This diversion is provided-for by a turnout connecting Kings Way and Sturt Street. Such diversions are required infrequently, and on this occasion the diversion had been in effect for about 20 minutes prior to this incident.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2010/10

Between 10 October and 21 October 2010, the South Improvement Alliance was engaged in commissioning signalling and track infrastructure upgrades associated with the Melbourne–Sydney rail corridor upgrade Missing Link Project. The upgrades affected the North Dynon, South Dynon Junction and Appleton Dock areas of operation on the Australian Rail Track Corporation network. During this period it was necessary to render the signalling system inoperative and to manage rail traffic utilising a sub- system of administrative procedures.

On 20 October 2010 at about 2040, a Pacific National shunt movement that required access to the main line was being conducted from the Melbourne Freight Terminal. When the shunt move was setting back from the main line into the Melbourne Freight Terminal two wagons in the middle of the rake derailed at points 133D on the main line at South Dynon Junction.

Damage was sustained to the motor, rodding and blades of 133D points, track infrastructure and trackside signalling equipment. There were no injuries and all wagons remained coupled and upright with minimal damage. Points 133D were unavailable for use until 1030 on 21 October 2010.

This was the fourth main line derailment associated with South Improvement Alliance commissionings in the South Dynon Junction general area since January 2009.

The investigation found that points 133D were incorrectly set for the shunt movement and that these points sustained damage when the locomotive wheels trailed through the points during the hauling movement from Melbourne Freight Terminal to the main line.

The investigation also found that the senior signaller did not adhere to the South Improvement Alliance work instructions when setting the route for the shunt movement over points 133D.

The investigation found that Skilled Rail Services did not employ a formal or robust process in the appointment of senior signallers for these commissioning works associated with the Missing Link Project.

The investigation has recommended that the network manager, Australian Rail Track Corporation, and South Improvement Alliance review the practice of permitting the access of normal revenue services to the network during infrastructure commissionings that require the signalling system to be rendered inoperative.

The investigation also recommends that South Improvement Alliance and Skilled Rail Services review the roles, responsibilities and training of signalling staff for commissioning works.

[No communication issued identified]

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2010/10

Between 10 October and 21 October 2010, the South Improvement Alliance was engaged in commissioning signalling and track infrastructure upgrades associated with the Melbourne–Sydney rail corridor upgrade Missing Link Project. The upgrades affected the North Dynon, South Dynon Junction and Appleton Dock areas of operation on the Australian Rail Track Corporation network. During this period it was necessary to render the signalling system inoperative and to manage rail traffic utilising a subsystem of administrative procedures.

On 20 October 2010 at about 2040, a Pacific National shunt movement that required access to the main line was being conducted from the Melbourne Freight Terminal. When the shunt move was setting back from the main line into the Melbourne Freight Terminal two wagons in the middle of the rake derailed at points 133D on the main line at South Dynon Junction.

Office of the Chief Investigator, Transport Saftey (Victoria, Australia)

Rail Safety Investigation Report No 2010/08

At about 2200 on 3 September 2010, a tram travelling out-of-service as a ‘transport car’1 was proceeding along Flemington Road toward the city. At the intersection with Abbotsford Street the driver mistakenly altered the setting of the points ahead. When the traffic lights permitted him to proceed across the intersection, his tram took the route set for the turn into Abbotsford Street and was struck by an oncoming tram crossing the intersection from the opposite direction.

The incident resulted from the incorrect action of the driver of the transport tram in changing the setting of the points.

There was significant damage to both trams and reported minor injuries to two passengers.

The report makes recommendations to Yarra Trams relating to;

• An administrative process to manage operating staff members who may require leave due to personal reasons.

• The possible provision of interlocking between the operation of points and traffic signals at intersections.

• The standard of presentation of instructional material to operating staff.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)
Rail Safety Investigation Report No 2010/05

At about 2035 hours1 on 21 March 2010, the 2010 hours Up Metro Trains Melbourne (MTM) Electric Multiple Unit (EMU) suburban passenger service from Lilydale contacted the rear-end locomotive of an engineering maintenance train (plant train) near Ringwood Station in a sideswipe collision.
Moving in the Down2 direction, the plant train had been admitted to and stopped on the Up Belgrave track but its trailing end was fouling the route set for the MTM suburban passenger train. The passenger train was travelling on the authority of a proceed indication on a fixed signal. The signal panel indicated the plant train had cleared the points and the interlocked track circuit when it stopped for the driver to discuss requirements with track works staff. This enabled the signaller to set a route and clear an Up Home signal for the suburban train to approach platform 2, however although the track circuit was free and permitted the route to be set for the passenger train
movement, there was insufficient space for the MTM train to pass across the rear of the stationary plant train without contacting it.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Investigation Report No 2010/04

On 17 March 2010, at about 0030, a Metro Trains Melbourne (MTM) Comeng train was departing the Croxton Railway Station when the driver observed sparks and flames emanating from the undercarriage of the last motor car of the train. The driver stopped the train and disembarked the passengers. The fire was subsequently extinguished by the Metropolitan Fire Brigade.

The train was carrying about 50 passengers at the time of the incident. None of the occupants were injured in the incident.

Damage was sustained by the linebreakers, linebreaker casing and equipment, undercarriage components and electrical cabling of car 449M. The paint work on the left side of the train’s exterior also sustained fire and smoke damage. The pantograph sustained corking damage and the overhead contact wire parted due to overheating.

The investigation found that there had been a flash-over of the No1 traction motor of car 449M. It was also found that the contacts of one linebreaker created a sustained arc between its contacts and the casing. The intense heat generated from this arc melted the steel casing and ignited the fiberglass insulation material causing the fire. The investigation was unable to establish with certainty the initiating cause of the incident due to the severe fire damage and the fact that MTM was unable to provide records of the testing or repair of the flashed-over traction motor.

It is possible that the fault initiated at the linebreaker and an electrical short circuit between the linebreaker contacts and its casing resulted in the generation of intense heat that started the fire. It is also possible that a short circuit in the traction motor (evidenced by the flash-over) tripped two linebreakers, but the defective third linebreaker did not trip and struck an arc between its contacts and the casing resulting in the fire.

The investigation found that a substation’s circuit breaker settings were incorrectly adjusted and as a result the train was not protected against over-current. The failure of the substation circuit breaker to operate correctly allowed the continuation of an excessive current flow resulting in the overheating and parting of the overhead contact wire.

The investigation concluded that the train’s electrical components and the substation circuit breaker were not maintained to a satisfactory standard and this led to the mechanical and electrical failure of these components.

The investigation recommends that MTM reviews the maintenance requirements, standards, and maintenance frequencies for train and substation electrical components. The investigation also recommends that MTM maintains records of electrical equipment maintenance and repairs.

[Communication Issues:

The driver "tried to use the train radio, but as it was “dead” he contacted Metrol through his mobile phone, advised them of the situation, and requested that the fire brigade and ambulance services be dispatched to the train". Page 11]

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2010/03

On 26 February 2010 the 1415 hours1 Melbourne (Southern Cross) to Bendigo V/Line service experienced fire caused by overheated brakes below the underframe of one car of the train. The train was halted at the Watergardens Station (Sydenham) whereupon it was established that the train had been running with the park brake applied on both bogies of the lead car of the intermediate Diesel Multiple Unit (DMU). The disc-brake pads of these axles were alight and the fires were extinguished by the crew. There were no injuries to passengers or crew.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2010/01

Train 1003 was to operate empty from Flinders Street Station to the Epping maintenance facility after completing services during the morning peak. The train, which arrived about seven to eight minutes late, was to be driven by a different driver who was to complete his shift on arrival at Epping.

At 0853, train 1003 departed platform 14 when the signal controlling its departure (home signal 160) was indicating a stop aspect. As the train passed the signal its train stop contacted the trip valve on the train and the train’s brakes were applied, bringing the train to a stop.

After about 30 seconds the train recommenced its journey, ran through a set of points (points 60) before travelling towards Jolimont Station on the Up Clifton Hill line; against the flow of traffic. The driver reported that when he realised the train was travelling on the Up line instead of the Down line he brought the train to a stand. When the train came to a stand, the lead car was facing train 1242 and about 46 metres from it.

There was no injury to any person or damage to either train. Points 60 received minor damage and required repair by maintenance staff.

Office of the Chief Investigation, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2009/13

On Thursday 15 October 2009, the down Marshall V/Line train derailed and re-railed between South Kensington and Footscray stations. The train was brought to a stop under emergency braking when the driver became aware of abnormal running. There were no injuries to any of the passengers or the crew of the train.

A track inspection revealed a broken rail, damage to the facing points in the turnout and several fractured short screws and dislodged spring clips. The evidence indicated that the down leg had rolled and the wheel flange had ridden on it. The investigation concluded that as the train approached the turnout the rail rolled and fractured as a result of excessive torsion.

The train was inspected and allowed to resume its scheduled service. A detailed inspection of the train the following day revealed severe wheel damage. The track was repaired and services resumed the following morning.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2009/09

At 1702 on 15 July 2009, a motor vehicle driven by a 24 year old male entered the active Edithvale Road level crossing, Edithvale. The motor vehicle was driven under the lowered boom barrier into the path of the 1601 Flinders Street to Frankston service which was running express from Mordialloc to Frankston due to faulty doors on the train. The front of the lead-car of the Comeng train impacted the right side of the motor vehicle pushing it for some distance along the track.

The driver of the motor vehicle received fatal injuries. The two train drivers, the only persons on board the train, were uninjured

At the time of the collision the sun was low in the north-west sky and its glare is likely to have restricted visibility for the motor vehicle driver as he approached the crossing.

Office of the chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2009/08

In those cases where an investigation is curtailed or a full investigation report is not considered warranted, the Chief Investigator may issue a Brief Report. A Brief Report will typically include the particulars of the event, a description of the incident, a summary of pertinent investigation information and key findings and, as applicable, a description of identified safety issues and recommended safety actions.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2009/05

The Siemens-manufactured Nexas train was first introduced into service on the Melbourne metropolitan train network in 2003 as part of a program to upgrade the ageing suburban fleet. Its procurement and subsequent operation spans three rail operators: National Express Group Australia, Connex and MTM (Metro Trains Melbourne).

Since its introduction, the Nexas has been involved in a relatively high number of reported overrun events when compared to other types of train operating on the network. The six platform overruns between 8 February and 3 March 2009 suggested that systemic issues remained unresolved and triggered this investigation. In the event at Ormond Railway Station on 25 February 2009, the train overran the platform by about 250 metres and entered the North Road level crossing before the boom barriers had fully lowered. There were further reported overrun events in 2009, 2010 and in 2011 prior to the finalisation of the report.

The investigation examined the Ormond event, the broader history of overruns and other investigative material related to overrun on the Melbourne network. During the investigation it became evident that the proportional contribution of factors would have varied between events and that the investigation should take a holistic view of overrun events in its identification of those factors most likely to have contributed.

The investigation concluded that the predominant condition associated with the overrun events was the presence of low levels of adhesion between wheel and rail. In considering this condition and other factors potentially contributing to platform overruns, the investigation explored five thematic areas: the environment, the track, the train, train handling and network risk management.

The Environment

The majority of overrun events have occurred with rail head moisture resulting from light rain or dew. The investigation concluded that moisture combined in particular proportion with rail head contaminants such as iron oxides and mineral clay produces a liquid suspension sufficient to result in low coefficient of friction conditions including instances of low shear strength within the interfacial layer. Environmental conditions that encourage the formation of such a medium are seen as the typical pre-condition for the development of low levels of adhesion between wheel and rail on the Melbourne metropolitan network.

The Track
The contact conditions and the level of adhesion between wheel and rail can be influenced by the track geometry and the rail head profile. The investigation concluded that the condition of the track was generally within the tolerances defined for the network and while its condition may have contributed in some instances, the track was unlikely to have been highly contributory to the frequency of overrun events. However, the investigation did conclude that maintaining track in ideal condition would contribute to maintaining a good wheel-rail contact interface with the potential to optimise braking performance.

The Train
The higher relative frequency of overrun events involving Nexas trains suggested that characteristics of the train or the train’s interaction with its operating environment were contributory. The investigation concluded that there was no identified defect on Nexas trains involved in the overrun events but as an integrated system the Nexas was more prone to overrun than other types of train running on the network. Those features of the train identified as most likely to be contributing to the overrun events related to the train’s influence on adhesion between wheel and rail and the response of the braking system during a wheelslide event.

Train features potentially impacting adhesion are those that can affect the wheel-rail contact conditions and the interfacial layer. Such features include the wheel’s geometric interface with the track, wheel surface condition, axle loads and braking equipment configuration. The investigation concluded that, when compared to the X’Trapolis, the other late-model train operating on the suburban network, the most significant differentiating factor affecting the wheel-rail interface was the use by the Nexas of disc brakes for friction braking and the absence of tread brakes. Disc brakes do not provide the wheel conditioning and adhesion enhancing qualities of tread brakes that act directly on the wheel tread surface to remove friction modifying contamination. As an integrated system, other physical features of the train such as weight may also have contributed to the formation of low-adhesion conditions at the wheel-rail interface.

The second area to have potentially contributed to overrun was the braking system’s response to a wheelslide event. The Nexas is fitted with WSP (wheelslide protection) systems to manage braking performance in low-adhesion conditions. The investigation found that the WSP associated with the EP (electro-pneumatic) friction braking system had been proved by independent testing to have no design or software-related defect and to have performance comparable with similar (bogie-controlled) systems. However, the investigation concluded that the bogie-controlled WSP system is inherently less capable than more refined axle-controlled systems. It was also identified that during a severe wheelslide event as may occur under braking in low- adhesion conditions, there can be a lag in braking effort during and after the transition from ED (electro-dynamic) to EP braking while the system attempts to bring axle rotation back to train speed and recover its estimate of ground speed. High levels of wheel creep3 during a wheelslide event may also exacerbate the loss of braking effort by reducing the available adhesion at the wheel-rail interface.

Train handling
The investigation concluded that driving techniques could in some instances have contributed to the onset of wheelslide and an overrun event. The very good dry braking performance of the Nexas may have established high driver expectation and heavy braking in more difficult conditions can induce early transition to WSP-assisted braking. Enhanced guidance for driving in adverse conditions was developed in 2008. However, the investigation concluded that train handling in adverse conditions could continue to be improved by providing drivers with a deeper understanding of the train’s braking systems and more specific guidance on operational practices in reduced- friction conditions.

Network risk management
The management of train operations provides the opportunity to minimise the frequency of overrun and the potential for adverse consequences. To this end the previous network manager, Connex, and the current manager, MTM, have used a number of strategies to mitigate risk associated with platform overrun. This has reduced the frequency of overrun. However, the investigation concluded that at the time of the Ormond incident on 25 February 2009 there remained the potential for severe consequences and that the network risk management systems that were in place were inadequate.

Other investigation conclusions
The investigation found that performance requirements for braking in low-adhesion conditions were not adequately defined within the procurement documentation for the train. The investigation also found that acceptance testing did not fully verify the braking performance of the Nexas for some conditions that were later to be experienced in service.

The investigation concluded that the purpose of conducting full wet-track testing of trains involved in an overrun event was unclear. To date, in no case of post-overrun testing has a Nexas train been found to have had a defect that significantly contributed to the event. Train behaviours are systemic to the fleet and not particular to individual car-sets.

Safety actions taken since the events
Following the overrun events in February and March 2009, the rail operators introduced new operating procedures and reinforced a number of others. Such mitigating strategies have included speed restrictions for Nexas trains at several locations. The roll-out of defensive driving training to existing drivers was also completed in 2009.

MTM has advised that sanding devices have been fitted to the Nexas fleet, with implementation completed on 18 June 2011. MTM has concluded that based on international experience and local testing, the application of sand to the wheel-rail interface should eliminate most overruns caused by low-adhesion conditions.

Recommendations
The investigation makes recommendations to Metro Trains Melbourne in the areas of train performance monitoring, track condition monitoring and driver training.

The investigation makes recommendations to the Department of Transport and Metro Trains Melbourne in the area of rolling stock procurement, including the definition of performance requirements and whole-of-train acceptance criteria.

[Communication Issues:

The driver said that after the train stopped, he was unable to contact the train controller at Metrol on the train radio and used his mobile phone. (Page 35)]

Report No 2009/05

The Siemens-manufactured Nexas1 train was first introduced into service on the Melbourne metropolitan train network in 2003 as part of a program to upgrade the ageing suburban fleet. Its procurement and subsequent operation spans three rail operators: National Express Group Australia, Connex and MTM (Metro Trains Melbourne).
Since its introduction, the Nexas has been involved in a relatively high number of reported overrun events when compared to other types of train operating on the network. The six platform overruns between 8 February and 3 March 2009 suggested that systemic issues remained unresolved and triggered this investigation. In the event at Ormond Railway Station on 25 February 2009, the train overran the platform by about 250 metres and entered the North Road level crossing before the boom barriers had fully lowered. There were further reported overrun events in 2009, 2010 and in
2011 prior to the finalisation of the report.
The investigation examined the Ormond event, the broader history of overruns and other investigative material related to overrun on the Melbourne network. During the investigation it became evident that the proportional contribution of factors would have varied between events and that the investigation should take a holistic view of overrun events in its identification of those factors most likely to have contributed. The investigation concluded that the predominant condition associated with the overrun events was the presence of low levels of adhesion between wheel and rail. In considering this condition and other factors potentially contributing to platform overruns, the investigation explored five thematic areas: the environment, the track, the train, train handling and network risk management.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2009/03

On 15 January 2009, at about 1633, Tram 946 departed the Southbank Tram Depot and travelled along Normanby Street to Melbourne city. At about 1700, just after crossing the La Trobe Street - Spencer Street intersection, a fire broke out in the under-floor motor area of the tram. The driver stopped the tram and the six passengers on board disembarked.

No passengers were injured in the incident. The tram driver suffered from smoke inhalation during his attempt to extinguish the fire.

The tram sustained damage to its No.1 and No.3 traction motors, undercarriage components, electrical cabling and the pantograph. The paint work on the left side of the tram exterior also sustained fire damage. The overhead cable melted and parted due to overheating.

The investigation found that there was an insulation failure that resulted in a short circuit of the field windings of No.1 traction motor. The short circuit caused an abnormally high current flow that resulted in overheating of the electrical components in the system.

The investigation found that tram electrical components were not maintained to a satisfactory standard or maintained to the manufacturer’s specification which led to the mechanical failure of components. The investigation also noted that the ‘off vehicle’ overhaul frequencies for electrical components were excessive.

It was found that the electrical current tripping threshold of the substation circuit breaker has been increased and as a result Tram 946 was not protected for over-current which contributed significantly to the escalation of the incident.

The investigation recommends that Yarra Trams reviews the maintenance standards and maintenance frequencies for electrical components in their evaluation of the tram maintenance program. The investigation also recommends that Yarra Trams ensures that tram drivers undergo basic fire fighting training.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2009/02

The trip was uneventful prior to the final stop at Cranbourne Railway Station.

At Cranbourne, the train failed to stop in sufficient time, overrunning the platform, riding over the track baulks and impacting the earth embankment at the end of the line.

The train came to rest about 10 metres past its designated stopping position.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2008/12

At about 0738 on 11 December 2008, the last two wagons of a ballast train running on the Defined Interstate Rail Network derailed shortly after passing across the Down Street level crossing in Longwood, north-east of Seymour. The derailed wagons were a ballast wagon and a ballast plough wagon. The derailment caused damage to the track and the derailed wagons. No persons were injured.

The investigation found that it is probable the derailment was the result of the leading right-hand wheel of the second last wagon, the last ballast wagon, climbing the righthand rail about 25 metres after passing across the level crossing.

Modelling undertaken by the investigation indicated that the wheel-climb was due to the dynamic response of the ballast wagon to the track geometry through the level crossing and in the 25 metres following the crossing. The track ballast was fouled with mud and track irregularities were probably exaggerated by the dynamic action of the train.

In addition to the track geometry, other pre-conditions likely to have been factors in the derailment occurring at this point were the loaded state of the wagon, the configuration of the wagon suspension, the condition of the wheels and the train speed.

The Australian Rail Track Corporation advised that since the incident the site has been reinstated using concrete sleepers, the track lifted 100 mm, the level crossing renewed and more robust processes implemented for the reporting and assessment of mud holes.

The investigation makes recommendations in the areas of track standards and inspection, interaction between rolling stock and track, the loading of ballast wagons and operator safety management systems.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2008/11

This investigation has been conducted to examine those aspects of the disruption to Oaks Day 2008 train services that impacted specifically, or had the potential to impact upon public safety. These aspects concern the causes of the train stoppages that resulted in uncontrolled passenger detraining. The investigation does not examine matters of commercial concern for the operator.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2008/09

As train 8417, the 1425 V/Line passenger service to Traralgon, ran non-stop through Springvale railway station its left-hand driver’s cab rear-view mirror struck a person standing on the platform. The victim sustained an injury to their right upper arm. The victim and her companions left the platform and walked across the adjacent railway level crossing to the booking office located on Platform 1. They reported the incident and an ambulance was called. The victim was taken to hospital.

Office of the Chief Investigator, Transport Safety (Victoria, Australia)

Rail Safety Investigation Report No 2008/07

At the time of the incident there was heavy road traffic along St Kilda Road near the Arts centre. The track in this section slopes upwards by about 150 mm from the Southbank Boulevard intersection and is level across the ‘safety zone’ and tram platform stop.