Executive summary
What happened
On 3 February 2020, a fire in a signalling equipment hut at Wallan in Victoria resulted in damage to the signalling system on the standard gauge rail network operated by the Australian Rail Track Corporation (ARTC). Repair of the signalling system would take several weeks and ARTC commenced managing rail traffic over a 24 km section between Kilmore East and Donnybrook using administrative systems. The section was predominantly a single bi-directional track which included a crossing loop at Wallan.
Trains were initially being managed through this 24 km section under the existing train working protocols that limited train speeds to no more than 25 km/h. This speed limit led to significant delays and ARTC developed train working arrangements that would permit trains to operate at normal track speeds. For passenger trains, this was up to 130 km/h. The arrangements that were established used (paper-based) train authorities to give drivers permission to travel through the section without signals operational, and also required an accompanying qualified worker (AQW) to ride in the cab with the driver. The first train authority under these new arrangements was issued on the evening of 6 February.
After the initial loss of signalling, the crossing loop at Wallan was not used and the points at either end of the loop were then locked in their normal (straight) position. Then, on 20 February, trains were to be routed through the loop to clean contamination from the rail head in preparation for signalling system testing. Around mid-afternoon, the points at each end of Wallan Loop were changed to their reverse position to route trains through the turnout to the loop track.
That evening, NSW Trains (TrainLink) was operating XPT train ST23 from Sydney to Melbourne. Train ST23 entered the affected section at Kilmore East and after travelling about 15 km derailed in the turnout at the northern end of Wallan Loop. The derailment occurred at about 1943. As a result of the derailment, the leading power car of train ST23 overturned and slid on its side for some distance. The driver and the AQW in the driver’s cab of the power car did not survive the accident. Eight passengers were seriously injured,
[1] and a reported 53 passengers and the 5 passenger services crew members sustained minor injuries.
What the ATSB found
The investigation found that train ST23 derailed due to its speed exceeding the infrastructure design speed by a significant margin. The train entered the turnout to Wallan Loop travelling at a speed of between 114 and 127 km/h following an emergency brake application a short distance before the turnout. The maximum permitted operational speed for the turnout was 15 km/h and the train could not negotiate the turnout at its higher speed.
There was no evidence identified to suggest that the driver was incapacitated leading up to the derailment, and no evidence to suggest a rolling stock or a track defect had contributed to the derailment.
Several scenarios that may have led to ST23 not slowing for the loop turnout were considered. The leading power car was not fitted with in-cab voice or video recording devices and the absence of information on the interactions within the driver’s cab reduced the certainty of this finding. On the balance of evidence, it was concluded that the driver of ST23 probably expected to remain on the straight track through Wallan and was operating the train with that expectation.
The driver had likely developed a strong expectation that ST23 would be travelling on the straight track through Wallan. The driver of ST23 had operated the XPT service through the location 8 times in the 12 days prior, and on all occasions the loop track at Wallan was locked out of service consistent with the arrangements not to use the crossing loop at Wallan while signalling was non-operational.
Information on the routing of ST23 through Wallan Loop on the evening of 20 February was provided to the driver in a modified train authority document given to them at Kilmore East. However, the train working arrangements that were established by ARTC on 6 February did not include protocols that would confirm the driver’s understanding of the authority and excluded the requirement for the driver to read back the train authority to the network control officer. Expectations based on past experience influence the perception of information and it is probable that the driver did not recognise the text changes made to the train authority from those issued to them on their 8 previous trips.
The train working arrangements that were established to manage traffic while the signalling system was not functioning deviated from ARTC network rules and there was ineffective management of the risks introduced by this deviation. There were several safety factors that increased safety risk including weaknesses in ARTC risk management, the train working arrangements, risk controls (including a reliance on manual processes), and stakeholder engagement. For the routing of trains through Wallan Loop on 20 February, it was concluded that there were several available and practical risk controls that were not used by ARTC.
Weaknesses were also identified in the distribution and collection of safety information. It was found that NSW Trains did not have a functioning process for obtaining safety critical information for its Victorian operations from the ARTC web portal (WebRAMS).
It was also found that the configuration of the driver’s cab contributed to the adverse outcome for the driver and AQW. The side door of the power car detached when the car overturned. This resulted in track ballast and earth entering the cab and trapping the driver and the AQW. Efforts by members of the train crew and emergency services to assist those trapped was thwarted by a lack of ground-level access to the cab. It was found that contemporary industry standards did not address the loading of the side-doors of driver cabs during overturn, and ground-level access to train crew trapped in an overturned vehicle.
Soon after the derailment, some passengers self-evacuated the train. It was found that the methods of providing safety information to passengers through briefings, onboard guides and signage did not provide reasonable opportunity for all passengers to have knowledge of what to do in an emergency. Systemic weaknesses in the training of passenger services crew by NSW Trains was also identified.
Other findings are made with respect to potential barriers to safety improvements on the ARTC rail network. These address shared risks between the rail infrastructure manager (RIM) and rolling stock operators (RSO) and the slow, and uncoordinated, adoption of technologies. There continues to be a high reliance on administrative controls and a slow take up of technological solutions by ARTC to improve safety.
What has been done as a result
ATSB identified 15 safety issues against which organisations were requested to advise on their proactive safety actions. The details of these actions, and ATSB comment on these actions, are described in the Safety issues and actions section of this report.
Six safety issues were allocated to ARTC. ARTC advised that it has introduced an updated management process for deviations from ARTC Network Rules (for planned or unplanned works). ARTC advised that this process required a risk assessment involving stakeholders, the development of appropriate controls for implementation by each stakeholder, and ARTC Executive approval of the risk assessment and plan. Three safety issues pertaining to network user engagement and distribution of safety information remained open, and updates will be provided on the ATSB website.
Six safety issues were allocated to NSW Trains. NSW Trains advised that it has developed new procedures for the daily access of the ARTC WebRAMS system for safety information and has also amended procedures to include confirmation of receipt of safety critical information by train crew prior to them starting their day of operations. NSW Trains also advised of changes to crew emergency response training, although 2 related safety issues remain open. The ATSB has made one recommendation to NSW Trains that it undertake further work to improve the methods used to provide safety information to passengers.
One safety issue was allocated to ActivateRail, a contractor to ARTC. Relevant to this safety issue, ActivateRail advised that it has introduced additional control processes pertaining to its participation in projects. ActivateRail also committed to ongoing and future risk management awareness training of its consulting and professional services staff.
The Rail Industry Safety and Standards Board (RISSB) has committed to consider the outcomes of this investigation in a review of the Australian Standards for body structural requirements (locomotive) and access and egress. The outcomes of the RISSB review of these standards will be reported on the ATSB website.
Safety message
Central to this occurrence was the breakdown of risk management processes following deviation from established network rules. Critical to successful risk management in degraded network conditions is the involvement of network users in the identification and assessment of emergent risks, and user participation in the development of appropriate risk controls.
This occurrence also highlighted an over reliance on administrative controls and the missed opportunities to use existing and emerging technologies to manage risk associated with human error. To improve safety outcomes, the rail sector must move faster and together in embracing technology to improve its management of safety risks.
