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Final Report Investigation Into the Collision Between Connex

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Final Report Investigation Into the Collision Between Connex Final Report Investigation into the Collision between Connex Passenger Trains at Holmesglen Station on Wednesday 26 July 2000 Department of Infrastructure Office of the Director of Public Transport Safety and Technical Services Branch May 2001 EXECUTIVE SUMMARY 1. The Incident 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. 2. 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. Conclusions are detailed in Section 5 of the Report. 3. Recommendations Stemming from the findings thirteen (13) recommendations have been made as detailed in Section 6 of the Report. Seven (7) require action by Connex Trains Melbourne, six (6) have system-wide implications requiring action by the Department of Infrastructure. 4. 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. Executive Summary Page 1 of 1 TABLE OF CONTENTS 1. INTRODUCTION........................................................................................................1 1.1 Incident...............................................................................................................1 1.2 Investigation.......................................................................................................2 2. INDEPENDENT INVESTIGATION.........................................................................3 2.1 Site Inspection....................................................................................................3 2.2 Co-ordination with CTM...................................................................................3 2.3 Video and Audio Evidence ................................................................................3 2.4 Operational Procedures and Standards...............................................................3 2.5 Simulation..........................................................................................................3 2.6 Work Related Fatigue.........................................................................................4 2.7 Other Reports .....................................................................................................4 3. FACTUAL INFORMATION......................................................................................5 3.1 Collision Location - Homesglen Station..............................................................5 3.2 Rolling Stock.........................................................................................................5 3.3 Infrastructure.........................................................................................................6 3.4 Injuries...................................................................................................................8 3.5 Loss and Damage ..................................................................................................8 3.5.1 Rolling Stock ...........................................................................................8 3.5.2 Infrastructure..........................................................................................11 3.6 Personnel.............................................................................................................11 3.6.1 Train Driver Details...............................................................................11 3.7 Operating Procedures..........................................................................................12 3.7.1 Driver Responsibilities ..........................................................................12 3.7.2 Protection of Trains ...............................................................................13 3.8 Driver Training....................................................................................................15 3.8.1 Employment and Training Record - Driver of Train 2020....................17 3.8.2 Driving Record - Driver of Train 2020..................................................18 3.9 Medical................................................................................................................20 3.10 Driver Fatigue .....................................................................................................21 3.11 Train Maintenance...............................................................................................21 3.11.1 Train 2018..............................................................................................22 3.11.2 Train 2020..............................................................................................22 3.11.3 Train Braking Systems ..........................................................................22 3.12 Track....................................................................................................................22 3.13 Train Control.......................................................................................................23 3.14 Signalling Equipment..........................................................................................24 Table of Contents Page 1 of 2 3.15 Environmental Factors ........................................................................................25 3.16 Recorded Information.........................................................................................25 3.16.1 Sequence of Events................................................................................25 3.16.2 Video Records.......................................................................................26 3.16.3 Audio Transcripts ..................................................................................26 3.16.4 Train Performance .................................................................................26 3.17 History of Similar Incidents................................................................................26 3.17.1 Aircraft 1998..........................................................................................27 3.17.2 Syndal 1989 ...........................................................................................27 3.17.3 Ringwood 1989......................................................................................27 3.17.4 South Dynon 1986.................................................................................28 4. ANALYSIS..................................................................................................................29 4.1 General................................................................................................................29 4.2 Driver Performance.............................................................................................29 4.3 Failed or Absent Defences ..................................................................................31 4.3.1 Prevention of an Unsafe Act..................................................................31 4.4 Local Factors.......................................................................................................31 4.4.1 Sighting of Holmesglen Platform..........................................................31 4.4.2 Train Examination.................................................................................31 4.4.3 Signalling System..................................................................................31 4.4.4 Braking System......................................................................................31 4.4.5 Train Crashworthiness...........................................................................32 4.5 Organisational Factors.........................................................................................32 4.6 Medical................................................................................................................32
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