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 4.7 Driver Training...... 33 4.7.1 General...... 33 4.7.2 Driver - Train 2020...... 34 4.8 Analysis of Crew Operating Procedures (Rules) ...... 34 4.9 Other Similar Incidents ...... 36 4.10 Rules in Other Organisations ...... 37
5. CONCLUSIONS ...... 38 5.1 Findings...... 38 5.2 Contributing Factors...... 38
6. RECOMMENDATIONS...... 40
REFERENCES...... 43
GLOSSARY...... 44
APPENDICES ...... 46
Table of Contents Page 2 of 2 Final Report
Investigation into the Collision between Connex Passenger Trains at Holmesglen Station on Wednesday 26 July 2000
1. Introduction
1.1 Incident
At 14:32 on Wednesday 26 July 2000 the 14:22 Glen Waverley train (No 2020) to Flinders Street collided with the 14:11 hours Glen Waverley train (No 2018) to Flinders Street which was stationary at Holmesglen Railway Station. Train 2018 was carrying passengers. Train 2020 was a scheduled express to Flinders Street Station and was not carrying passengers. Each train consisted of six cars and both trains were severely damaged. The track rail head was damaged and ballast was disturbed at the point of collision.
Ten (10) passengers and both train drivers were transferred to hospital. Other passengers requiring attention were treated at an emergency medical centre established at Holmesglen TAFE College International Centre adjacent to the site of the incident.
The accident scene was attended by Metropolitan Ambulance Service, Victoria Police and State Emergency Services personnel. Representatives of the train operating company (Connex Trains Melbourne - CTM), the rolling stock and infrastructure maintenance contractor (Alstom Melbourne Transport Ltd - AMT) and the Department of Infrastructure (Safety & Technical Services Branch, Office of the Director of Public Transport) also attended.
Recovery of the trains commenced in the mid-evening. The three cars consisting the leading unit of train 2018 were transferred to the Epping Train Depot. The trailing unit cars of train 2020 were transferred to Glen Waverley sidings. The six seriously damaged cars were cleared and stored off-track at the site. Track repair work was completed and train services resumed on 27 July with the 11:13 Flinders Street-Glen Waverley service.
Final Report Page 1 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 1.2 Investigation
In accordance with procedural requirements CTM established a Board of Inquiry which commenced its investigations on site immediately after the incident.
On 27 July 2000 the Minister for Transport directed that an independent investigation be conducted in accordance with the Transport Act 1983, Section 129U with Terms of Reference as follows:
The investigation will cover the following issues and any others found in the course of the investigation:
1. The events leading to the collision, including determination of the relative contribution of rolling stock, infrastructure and operating procedures.
2. Train maintenance systems, in particular the effectiveness and testing of brake systems in accordance with approved maintenance standards.
3. Signal and signal maintenance systems relevant to the accident.
4. Training and retraining procedures for operating staff.
The Investigation Team was led by Andrew Neal, General Manager, Safety & Technical Services Branch (STSB) and included internal specialists in train operations, rolling stock and risk management and had access to external experts in signalling, train braking systems and human behaviour. The investigation and report preparation were conducted in accordance with draft standard AS 4292.7 - Railway Safety Incident Investigation.
Final Report Page 2 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 2. Independent Investigation
2.1 Site Inspection
A preliminary inspection of the collision site was conducted as soon as emergency requirements were completed.
Photographic evidence was taken of rolling stock and infrastructure including signalling and associated mechanisms. The train stop and trip mechanism related to signal DG484 were impounded for off-site testing.
A detailed inspection of the site was carried out before normal train services resumed on 27 July. Measurements were taken to confirm infrastructure diagram dimensions and markings and sightings to reconstruct the scene and the key events leading to the collision.
2.2 Co-ordination with CTM
A joint panel of STSB and CTM investigators was established to interview the drivers of both trains, a maintenance employee of AMT who was present at Holmesglen Station at the time of the collision and the Glen Waverley Station Master. Information was also obtained from the Manager (Safety Standards) CTM, AMT infrastructure and rolling stock maintenance management staff based at Burnley and Epping respectively and representatives of Rail Training International Pty Ltd (formerly the Public Transport Corporation Driver Training Centre).
2.3 Video and Audio Evidence
Video tapes from security cameras at Holmesglen Station provided confirmation of movements of both trains before and after impact.
Video tapes from security cameras at Mount Waverley Station provided evidence of time and speed of train 2020 through that location.
Transcripts of radio communications by the Drivers of both trains and the AMT witness with Train Control were examined.
2.4 Operational Procedures and Standards
Procedures for trains detained at an automatic signal, trains stopped by accident, system failure, obstruction or any other cause, reporting on late running electric trains, rectification of faults on trains and for unattended cab were examined. Award conditions for train drivers, procedures for preparing driver rosters, arrangements for driver training and retraining and medical standards for drivers were also examined.
2.5 Simulation
On 10 August and 5 October the approach of train 2020 to the point of collision was simulated using trains of similar size and specification. This allowed for checks to be
Final Report Page 3 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 made of evidence provided by the Driver of train 2020 and of other evidence including markings on train stop equipment at signal DG484 and the running rail approaching Holmesglen Station.
2.6 Work Related Fatigue
The Centre for Sleep Research, University of South Australia was engaged to analyse work shift patterns for the drivers of both trains.
2.7 Other Reports
Investigation reports by Boards of Inquiry into accidents which had similarities with the Holmesglen incident were reviewed:
South Dynon 1986 Ringwood 1989 Syndal 1989 Aircraft 1998
Final Report Page 4 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 3. Factual Information
3.1 Collision Location - Homesglen Station
Holmesglen Station is 16 km from Flinders Street Station on the Glen Waverley line which is used for suburban passenger electric train traffic only. The Station is not staffed. It is equipped with video recording equipment for security purposes.
Glen Waverley line infrastructure consists of dual broad-gauge tracks. The line between Jordanville and Holmesglen has a 1 in 30 down hill grade which flattens out on the approach to Holmesglen where there is a left hand curve into the Station. The line speed for trains in the Jordanville - Holmesglen section is 95 km/h with a speed limit of 80 km/h applying to the curve approaching Holmesglen Station.
Signalling in the area is standard Victorian three position automatic signalling. Automatic Signal DG 484 which is connected with standard automatic train stop equipment governs entry to the Up platform at Holmesglen Station and is situated 555 metres from the Station in the Jordanville-Holmesglen section.
Figure 1 Approach to DG 484 from Jordanville
DG 484
3.2 Rolling Stock
The trains involved were scheduled services and each consisted of six (6) Comeng class cars fitted with LHB bogies and Knorr Bremse electro-pneumatic disc brake systems.
The consist of stationary train (2018) was:
Leading Unit 647M 1174T 590M Trailing Unit 570M 1135T 569M. The train was being driven from car 647M
Final Report Page 5 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 The consist of train 2020 was:
Leading Unit 612M 1156T 661M Trailing Unit 563M 1132T 564M. The train was being driven from car 612M
28.9m 715.0m to front of platform 706.0m Approximate stopping point to front of TD2018 prior to collision
Approximate stopping point of rear of TD2018 = 559m
To platform 550m
STATION ramp BUILDING
564M 1132 647M 1174T 590M 570M 1135T 569M 563M DG454 612M 1156T 661M to rear of 564M= 470.0m
to rear of 1132T= 494.0m DG460 to rear of 563M= 517.3m
to rear of 661M = 541.4m
N to rear of 1156T = 565.0m
to rear of 612M = 582.7m W E POSITION OF VEHICLES AFTER COLLISION BETWEEN TD2018/569M and TD2020/612M = 605.7m
to rear of 1135T = 628.5m
to rear of 570M = 651.0m S to rear of 590M = 673.4m
to rear of 1174T = 697.4m
to rear of 647M = 720.6m
LEGEND Carriage No Train TD2020 NOTE: Carriage All distances are approximate due to track configurations No Train TD2018 Diagram not to scale Signal Measurements taken from signal DG454
Figure 2 - Diagram of Location of Trains 2018 and 2020 after Collision
3.3 Infrastructure
As described in Section 3.1 the track approaching Holmesglen Station from the east is downhill to the Warrigal Road bridge which is approximately 50m to the east of the Station where the track curves to the south with an uphill section into the Station which is an island Station. There is vegetation on the south side of the track west of the Warrigal Road bridge on the approach from Jordanville.
Final Report Page 6 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Figure 3 Approach to Holmesglen Station from DG484
As described in Section 3.1 Automatic Signal DG484 protects the approach to Holmesglen Station from Jordanville. When the signal is indicating stop it is set to interact with an approaching train via the trainstop beside the track and trip mechanism on the train.
Figure 4 Signal DG484
For detail on train stop see Figure 5 below
Final Report Page 7 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Figure 5 Signal DG484 Trip stop
Fresh mark on stop consistent with being contacted by trip mechanism
Figure 6 Trip mechanism 612M Figure 7 Trip trigger 612M
3.4 Injuries
One passenger had to be freed from the rear end seat of car 570M. Including that person 10 passengers and both train drivers were taken to hospital.
Other passengers requiring attention or assistance were attended to by medical staff at a temporary emergency area provided in the Holmesglen TAFE College International Centre near the scene of the incident.
3.5 Loss and Damage
3.5.1 Rolling Stock Examination of the rail indicated that on impact stationary train 2018 was pushed approximately 38 metres along the track with its park brake on.
Final Report Page 8 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Figure 8 Marks on rail caused by Impact
3.5.1.1 Train 2018
Leading unit cars (647M 1174T and 590M) were not structurally damaged. The coupler and draw gear assembly on car 590M was damaged (impacted) beyond repair. The trailing wheelset of 590M was derailed. After it was rerailed the leading unit was towed to Epping Train Depot.
Of the trailing unit cars (570M, 1135T and 569M) car 570M was severely impacted by car 1135T. The leading bogie of car 1135T was suspended above the track. Car 1135T was structurally deformed. Couplings on all three cars 570M, 1135T and 569M were severely damaged. An anti-collision post in 570M collapsed as a result of the impact. The three cars of this unit were lifted from the track and placed track- side.
Final Report Page 9 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Figure 9 Damage to 570M caused by 1135T Train 2018
Figure 10 Damaged anti-collision post 570M
Anti-collision post
3.5.1.2 Train 2020
Leading unit cars (612M 1156T 661M) were damaged to the extent that it was necessary to lift them from the track for placement on-site. Car 1156T collapsed in the saloon area away from the doors and bent upwards at that point. Car 661M derailed and came to rest with its leading bogie resting against the Up platform.
Final Report Page 10 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Trailing unit cars (563M 1132T 564M) were not structurally damaged and were towed to Glen Waverley stabling yard. The leading coupler on car 563M was damaged (impacted) beyond repair.
3.5.2 Infrastructure
Damage to track was minimal. Some damage occurred to sleepers and ballast during operations to clear damaged cars from the track.
Rail-head marks on the track approaching the Warrigal Road bridge were consistent with emergency brake application. Because the LHB series Comeng are fitted with slip/slide sensing units, track marks were evident for a short distance only.
3.6 Personnel
Staff involved in the running of the trains concerned were the two train drivers and the duty train control officer for the Glen Waverley line at Metrol.
3.6.1 Train Driver Details
Driver 2018 Driver 2020 Gender Male Male Age 36 56 Years of Driving 14 4 Classification 4D 4D Continuation Training Completed Completed Date 31 May 2000 20 July 2000 Certification Competent Competent Medical Status Fit for duty Fit for duty Last Medical 12/2/98 23/9/99 Next Medical 12/2/02 23/9/00 Limitations Recorded Nil Nil
At interview on 31 July 2000 the Driver of train 2018 provided a detailed account of events before and after the collision including signal aspects and operation of his train prior to arriving at Holmesglen.
The Driver of train 2020 was interviewed on 7 August 2000 and provided an account of the events leading to the collision. He recalled that on approach to Jordanville, automatic signal (DG526) indicated clearance to proceed at normal speed subject to being prepared to stop at the next signal. The next signal was DG484 which he recalled was indicating stop.
He stated that after stopping his train at the signal, he waited for around 40 seconds. As he could not observe any train ahead he moved the train forward, passing the signal at stop. The trip apparatus on the train was activated. This discharged all brake pipe air pressure, automatically applied full emergency brakes and brought the train to rest. He then reset the trip and recharged the brake pipe. He indicated that he moved the master controller into the first notch for about five seconds in order to gain momentum. He then moved the master controller to the ‘Off’ position and stated that he thought the speed at the point of collision was at least 20 km/h.
Final Report Page 11 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Simulation tests as referred to in Section 2.5 were conducted to recreate events leading up to the collision. Simulation of train speed and train braking as described by the Driver of train 2020 indicated that the train would have been brought to rest some metres short of the Up platform at Holmesglen Station where train 2018 was standing. The tests confirmed that the speed which would have been achieved if the train had proceeded as described by the Driver would have been at a speed which would have satisfied the requirements of Section 3 Rule 1 which is described in Section 3.7.1 below.
Analysis of the speed of train 2020 at the point of impact is set out in Appendix 1. It indicates that the train was travelling at a speed in excess of 44.5 km/h, possibly as high as 65 km/h.
3.7 Operating Procedures
Current operational requirements for CTM train drivers are prescribed in the PTC Book of Rules and Operating Procedures 1994 (Rule Book). It replaced State Transport Authority Rules and Regulations 1987, the General Appendix and the Supplementary Booklet for Driver-Only Operation Rules and Procedures.
3.7.1 Driver Responsibilities
Driver duty and responsibilities are described in Section 10, Rules 2 and 3 of the Rule Book which cover general matters including:
· Driver punctuality · Authorised personnel in cabs · Competent employees maintaining driving skills · Articles to be carried by driver · Crewing of locomotives
Under Section 10 Rule 8b : Drivers to be Vigilant : drivers are required to:
remain alert and pay immediate attention to and obey all signals…….
and in accordance with Section 10 Rule 8c to:
regulate the running of the train to remain within the authorised speed………
Section 10 Rule 38 : Reporting of Irregularities and Faults : requires that:
the driver must advise the Train Controller by radio, or at the first station at which the train stops, and take extra care if any of the following circumstances arise:
1) irregularity in the working of signals 2) defects in signalling.
The Driver of train 2020 indicated that he believed that Signal DG484 was defective and stated that after proceeding beyond signal DG484 he reached into his bag to obtain a pen and his roster book to write down the number of the signal for the purpose of reporting it to Metrol. He stated that the reason why he thought the signal to be defective was that he could not see a train in the track section ahead.
Final Report Page 12 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 The site inspection (see Section 2.1) revealed that it is not possible to see the entire track section from DG484 to the next signal at Holmesglen Station owing to the curve in the track on the approach to the Station.
Section 3 Rule 1 : Detention at Automatic Signal states:
a) Train stopped at automatic signal.
The Driver must bring the train to a stand for 30 seconds if an automatic signal displays the ‘Stop’ signal. If the automatic signal is still at ‘Stop’ after 30 seconds, the Driver may proceed at a speed of extreme caution, being prepared to find the section occupied or obstructed.
1) Except where special instructions are issued to the contrary or where a disabled train requires assistance, a driver must not pass any signal when it is known there is a train in the section.
b) Driver Being Prepared to Stop
Even if the home or automatic signal next in advance may be at the ‘Proceed’ position, the Driver must be prepared to stop short of any obstruction until reaching the signal.
c) Intervals Between Trains
During inclement weather or bad visibility, the Driver must proceed at an appropriate speed to enable the Driver to stop within the distance visible ahead.
d) Parallel Lines (not applicable in this instance)
e) Two Trains in the Same Section
After entering a section, if a Driver sees the preceding train there, the train must be brought to a stand and must wait until the first train has proceeded on its journey unless verbally instructed by the Competent Employee or Driver of the first train to move cautiously forward.
While the Rules for proceeding beyond a signal indicating stop do not prescribe actual speed limits they require a speed at which the train can stop short of an obstruction.
3.7.2 Protection of Trains
Section 13 Rule 1 of the Rule Book covers: (in part)
Trains stopped by accident, failure, obstruction or from any cause.
Unless otherwise instructed, if a train is stopped in a section by accident, failure, obstruction or from any cause, all employees’ first duty is to ascertain if all running lines are clear of obstruction. This is not necessary if the train has arrived at the home signal or is within the protection of a home signal at an intermediate location.
(a) Duties of Driver
The Driver must immediately: 1. advise the Train Controller of all circumstances by train radio, 2. advise the exact location of the train by kilometre marker post, and 3. if applicable, inform the competent employee on the train of the circumstances by local radio.
Final Report Page 13 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 (b) Duties of Train Controller
The Train Controller must immediately: 1. take action to stop any following train, 2. instruct the signaller to place and maintain the fixed signals at the ‘Stop’ position on the obstructed line, 3. inform the signaller at the opposite end of the section of the circumstances, 4. advise the drivers of trains travelling on the parallel or opposite running lines to proceed with caution, and 5. if possible, inform the driver of the disabled train if a train is following on the same line, or is approaching 6. on any parallel or opposite line.
Late Running Electric Trains
CTM Quality Work Instruction Document Number HTOP1MO states in part:
Drivers Reporting Time Lost in Running
1. In order to get timely and accurate train running information train drivers are required to inform the Train Controller at Metrol (via the train radio) of any of the following instances;
· Where any irregularities or delays occur which cause a single delay of three (3) minutes or more
· Where minor delays accumulate to the extent that the train is running three (3) or more minutes late
2. Instances of injury to customers or employee, damage to vehicles or property or serious delays are to continue to be reported to the Train Controller at Metrol via the train radio. In addition the Driver is to submit a written Irregularity Report.
Rectification of Faults on Trains
CTM Quality Work Instruction Document Number BTOPIMO928 states in part:
After Initiating the Doors Close Sequence Whilst Stationary at a Platform
1. When a Driver becomes aware of the light in the door close button on the drivers console continually flashing after initiation of the normal door close sequence, the Driver must take the appropriate action to ascertain the reason for the light to continually flash, then where practicable, rectify the problem.
2. The Driver must make a Public Address announcement requesting that customers either remove any obstruction from the door(s) to allow the door to close, or cease trying to force the doors open.
3. Should the light in the doors close button continue to flash after the public Address announcenment has been made, the Driver must then apply and isolate the brake, apply the hand or park brake, then walk along the train to try to ascertain which door is causing the problem. Whilst walking along the train the Driver must carry out the investigation both visually and by paying attention to the audible door warning tones.
Final Report Page 14 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Cab Unattended Procedure
The procedure applied by CTM (Stage 6M Train Management – V/Line Freight Training Lesson No. MB42L2H) states when leaving the cab unattended except for changing ends and assisting customers with special needs the following applies:
Introduction
When a Driver is required to leave the driving compartment of an electric suburban train, the cab unattended procedure must be adhered to:
· to secure the train · ensure safety to the passengers · prevent unauthorised entry as per the Book of Rules and Operating Procedures and relevant Circulars
Except when changing ends and assisting customers with special needs, the Driver must ensure that the hand/park brake is applied, apply and isolate the automatic air brake, lock all doors and take the controller key.
During Normal Circumstances
When leaving the cab unattended, except for changing ends and assisting customers with special needs, the following applies:
· the brake controller handle must be placed into the EMERGENCY position · the automatic brake valve isolating cock and switch are to be isolated · return the brake controller handle to the RUN position · lock the reverser and remove the controller key · hand/park brake is replaced to the APPLIED position · the cab is then locked
On finding a fault with the doors on his train the Driver of train 2018 did not contact Train Control. At interview he explained that having radioed Metrol from Jordanville concerning his late running, Train Control responded to him after his train was stationary at Holmesglen Station where he advised Train Control that he was running 8 minutes late. Subsequent to this conversation he found that on attempting to depart Holmesglen Station there was a fault with the passenger doors. He did not advise Train Control regarding his further delay at Holmesglen.
3.8 Driver Training
The current driver training program for MET train drivers was introduced by the Public Transport Corporation (PTC) in July 1991. It was structured in ten (10) stages to be completed in two years (94 weeks). In the first year of training trainee drivers were required to complete Stages 1-4 which were common to both MET and V/Line driver qualification requirements. Stages 5-10 were designed to meet specific MET or V/Line driver requirements. In Stages 7 & 9 the trainee was provided with on the job training (OJT).
With the introduction of single person operation of trains (SPOT) in the Melbourne metropolitan system in 1994, metropolitan train guards were given an option to retrain as metropolitan train drivers. A six-month conversion course (Appendix 2) was developed to provide them with the opportunity to qualify as metropolitan train drivers.
Final Report Page 15 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 In April 1997 a revised MET driver training program was introduced. It was designed to meet driving requirements for the metropolitan electrified system and was structured into 10 stages to be completed over 63 weeks. Stages 1-5 primarily cover safeworking and route knowledge components. Stages 6-10 cover train driving, train management and fault detection and evaluation components. OJT is provided in Stages 7 and 9.
Once qualified drivers undergo continuation training which for CTM is specified in Procedure HTOP1 M-01. Continuation training is structured into 8 blocks each of 8 hours duration for a total of 64 hours to be completed at the rate of one block each six month period over four years (8 blocks x 8 hours = 64 hours). Continuation training is provided to ensure that drivers maintain knowledge and proficiency levels as specified in the MET Driver Training Syllabus Report. Procedure HTOP1M-01 which details the structure of continuation and remedial training states that continuation training subject matter will expose qualified drivers to knowledge and skills in the following areas:
· Safeworking covering rules and operating procedures including system signalling and exceptions.
· Electric Train Multiple Unit (EMU) Training including EMU faults and brake equipment.
· Operations training including track, signal, emergency procedures, radio communications and Underground Loop procedures.
· Simulator Skills Enhancement Training including simulated in-running fault scenarios with various train types and consists.
Continuation training is divided into two parts - one computer-based (CBT) and the other a mixture of classroom-delivered theory and OJT. Drivers are tested at the completion of each 8 hour block of continuation training. A driver who does not satisfy test requirements is required to undergo remedial training in the identified areas and is not returned to driving duties until all continuation requirements are satisfied.
The CBT component includes examination questions related to Automatic Signals. Of signal related questions the components related to Automatic Signals (effective from January 1996) are summarised in Table 1 below.
Table 1
Question Type % Two Position Automatic Signals 11.8 Home Signal – Failure of illuminated letter ‘A’ 55.9 Three Position Automatic Signal – passing at Stop 14.7 Three Position Automatic Signals - Other 17.6 Total 100.0
Final Report Page 16 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 As part of the continuation training process (procedure HTOP1M-01), drivers are also subject to Driver Safety Audits conducted by a qualified principal driver on a random ‘on the job’ basis including interviews with relevant crew managers.
3.8.1 Employment and Training Record - Driver of Train 2020
The Driver of train 2020 commenced employment with the Victorian Railways on 16 September 1974. Prior to 1980 and until 9 September 1995 he was employed as a Suburban Guard.
On 11 September 1995 he commenced the conversion course to qualify as a metropolitan electric train driver. He completed conversion training on 11 April 1996 and was appointed to the position of Locomotive Driver Single Person Operation (Metropolitan) on 15 April 1996.
Subsequent training records for the Driver concerned are set out in Tables 2, 3 and 4 below.
Table 2 - Continuation Training (Refer Appendix 3)
Continuation Training Block No Result Date 28 July 1996 13 Passed 21 November 1996 14 Passed 06 May 1997 15 Passed 10 October 1997 16 Passed 5 May 1998 Stage 1 Passed 11 January 1999 Stage 2 Passed 2 July 1999 Stage 3 Passed 10 November 1999 Stage 4 Passed 20 July 2000 Stage 5 Passed* * Passed following re-examination on the same day
Table 3 - Driver Safety Audit
Audit date Satisfactory Remedial Results Yes/No Training 2 May 1996 No Yes Reassessment to standards 20 August 1996 Yes No 12 March 1997 Yes No 21 October 1997 Yes No 11 May 1998 Yes No 1 October 1998 Yes No 1 April 1999 Yes No 8 September 1999 Yes No One non-conformance detected and rectified in the field. 19 February 2000 Yes No
Final Report Page 17 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Table 4 - Crew Manager – One-On-One Interviews
Date Results 21 November 1996 Satisfactory 20 October 1997 Satisfactory 11 January 1999 Satisfactory 12 February 1999 Satisfactory 2 July 1999 Satisfactory 10 September 1999 Satisfactory 30 June 2000 Satisfactory
3.8.2 Driving Record - Driver of Train 2020
An analysis of records for the Driver of train 2020 is summarised as follows:
Conversion Training - (Refer Appendix 2)
11 September 1995 - commenced as Trainee Driver
8 December 1995 - during Stage 7 (OJT) overshot platform by one passenger door; gave incorrect answers relating to signals en-route and demonstrated some difficulty in applying exceptions for the passing of signals at stop.
9 December 1995 - indication given of need for a ‘little more knowledge’ of curve speeds on some lines and requirement for more skill in use of auto air brake with 6 cars; stated as having a very good attitude and being keen to learn.
10 December 1995 - successfully completed examinations for Stages 1-7.
2 January 1996 - at Stage 9 (OJT) while driving in rain with a 6 car unit on the Glen Waverley line was assessed as having poor judgement in using auto-air braking; overshot Single Person On Train infrastructure at Jordanville; safeworking knowledge assessed as being of an average standard.
16 January 1996 - Stage 9 (OJT) completed satisfactory performance.
19 January 1996 - trainee progress report indicated that driver tends to have slight problems with auto air braking and that judgement needed fine tuning on medium to heavy grades; driver needed to watch medium speed aspects and for curve speeds as he did not always get the speed of his train ‘quite down to or below the required level’.
2 February 1996 - Stage 9 - driver seemed to lack confidence in train braking system resulting in some very slow approaches to platforms; safeworking discussed at length and found to be at average standard.
19 February 1996 - trainee progress report indicated that braking was the only area requiring attention; driver unsure of degree of force required to bring a train under control; matters noted for next assessment.
Final Report Page 18 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 8 March 1996 - Stage 9 (OJT) overshot drivers door at North Melbourne; went past 30 km/h caution board at 50 km/h.
25 March 1996 - trainee progress report indicated that driver was ‘a bit quick’ at platforms.
26 March 1996 - Stage 9 (OJT) was proceeding through a 40 km/h curve at 50 km/h until prompted; was unsure of curve speed on route; knowledge in signalling and safeworking assessed at a good standard.
7 April 1996 - trainee progress report indicated that Driver met standards for braking with auto air; successfully completed on job training.
17 April 1996 - passed final driving examination.
19 April 1996 - appointed Locomotive Driver Single Person Operation (Metropolitan).
Continuation Training and Driver Safety Audit
2 May 1996 - safety audit - two non-conformances detected one for over-speeding when passing signals and one for over-shooting a platform.
13 May 1996 - consequential remedial training and train management in particular curve speeds and signal aspects were successfully completed.
20 August 1996 - satisfactory driver safety audit.
12 March 1997 - satisfactory driver safety audit.
6 May 1997 - Block 15 continuation training satisfactorily completed.
10 October 1997 - Block 16 continuation training satisfactorily completed.
19 October 1997 - passed a home signal at stop at Belgrave.
20 October 1997 - consequential remedial training provided.
21 October 1997 -satisfactory driver safety audit.
5 May 1998 - satisfactorily completed Stage 1 of Continuation Training.
11 May 1998 - satisfactory driver safety audit.
1 October 1998 - satisfactory driver safety audit.
11 January 1999 - satisfactorily completed Stage 2 of Continuation Training.
1 April 1999 - satisfactory driver safety audit.
2 July 1999 - satisfactorily completed Stage 3 of Continuation Training.
Final Report Page 19 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 8 September 1999 - satisfactory driver safety audit; a non-conformance relating to procedures on discovering faulty equipment was rectified in the field; brake handling skills for all modes of braking were assessed as meeting minimum qualification requirements.
10 November 1999 - satisfactorily completed Stage 4 of Continuation Training.
19 February 2000 - satisfactory driver safety audit; assessed as using the brake skillfully to reduce train speed.
20 July 2000 - satisfactorily completed Stage 5 of Continuation Training after re- sitting examination questions.
3.9 Medical
All CTM staff in operational grades are required to undergo a medical examination in accordance with CTM procedure document HTHR1P-05.
Operational grades involved in training and safeworking are ranked in order of risk from A to D. Train drivers are ranked at the highest risk - A – and are required to undergo a full periodic physical and vision (PPV) examination by a fully qualified medical examiner at defined intervals (1, 2 or 4 yearly) depending on age.
The Driver of train 2020 is required to attend and undergo a PPV examination annually. Medical records provided by CTM show that he underwent a medical examination on 23 September 1999 and that he was assessed as fit for all duties. The Chief Medical Adviser, CTM informed the investigation that the Driver of train 2020 was assessed as having a minor visual acuity defect which, corrected by glasses, was within the CTM vision standard. The Chief Medical Adviser subsequently confirmed that the Driver needed to wear his glasses (while driving) to be within the CTM standard.
The Driver stated at interview on 7 August 2000 that he wore glasses for reading and that he did not require them for train driving.
The Driver regularly takes 60 mg of Pravachol (generic name, Pravastatin sodium) each evening as prescribed by his own doctor. He had taken this medication on the evening prior to the collision. Medical studies (MIMS – Monthly Index of Medical Specialities (Aust)1996) indicate that 3.8% of people taking the drug reported fatigue, 6.2% headaches and 3.3% dizziness. Approximately half of the reported side effects were attributable to the study drug. Headache was the only significant adverse reaction reported when compared to the placebo. Dizziness and fatigue were attributed to Pravachol approximately twice as often as to the placebo but the difference was not reported as being statistically significant
Procedure HTHR1P-05 does not require CTM staff to declare to their employer any change in medical condition/health which may impact on rail safety or performance of their duty. A drug free workplace & testing procedure (MTEPE3QP914) requiring review in November 1999, was made available to the investigation by CTM. It states that a person should contact the Public Transport Corporation Occupational Medical Unit if they have any doubt regarding their fitness for duty while on medication.
Final Report Page 20 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 It also requires the responsible manager to ensure the implementation and maintenance of a drug free working environment.
3.10 Driver Fatigue
Neither driver reported an abnormal sleep pattern during their previous sleep periods. The Driver of train 2020 reported that it was normal for him to wake once during the night and this occurred during the night prior to the collision. Neither driver considered that he was affected by any stressful life events.
The Driver of train 2018 had worked three shifts prior to the collision. Before this he had been on leave or booked-off for 29 days.
The Driver of train 2020 had worked shifts on nine consecutive days prior to the day of the collision. His last day off was Sunday 16 July. He had also worked from Thursday 13 July to Saturday 15 July (inclusive). He was also rostered to work on 27 and 28 July. This meant that he would have worked a cycle of 12 consecutive days and for 15 out of 16 days had the collision not occurred. Details of shifts worked are included in Appendix 4.
The University of South Australia Centre for Sleep Research was commissioned to conduct an analysis on the level of fatigue potentially attributable to the work schedule of the Driver of Train 2020. It concluded that fatigue levels would have been rising steadily throughout the previous 9 days due to the incidence of early morning starts which can cause an interruption to REM (Rapid Eye Movement) sleep periods which are important for mental alertness. The study found that fatigue levels on the two shifts prior to the shift on which the collision occurred were of an order to cause concern. It concluded that due to the later starting time of the shift on the day of the incident (allowing some recovery of the sleep debt incurred on the previous shifts) work related fatigue was at an insignificant level. A summary of the study is presented at Appendix 5.
3.11 Train Maintenance
The investigation examined the recent maintenance history of both trains. Attention was given to details which would explain why each train performed as it did on the day of the collision or which may have affected crashworthiness. A list of the defects of each car relating to brakes, structure, suspension, doors and lights in relation to car 569M at the rear of train 2018 and 612M at the front of train 2020 is given at Appendix 6.
Figure 11. Configurations of train 2018 and train 2020 Train 2018 647T 1174T 590M 570M 1135T 569M T Train 2020
612M 1156T 661M 563M 1132T 564M T
Final Report Page 21 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 3.11.1 Train 2018
The leading unit had been subjected to an ‘A’ examination on 20 July 2000 consistent with approved train maintenance requirements and schedules and was cleared for service operations.
The trailing unit had satisfactorily completed an ‘A’ examination on 14 July 2000. Prior to this and subsequent to a number of door faults experienced on Car 569M, contactors had been replaced. It was for a door fault on Car 569M that train 2018 remained stationary at Holmesglen Station.
Maintenance procedures state that a ‘C’ examination which includes maintenance of saloon doors should be conducted every 20,000 km. This examination was up to date. The unit was due for an ‘A’ type examination involving a field based examination of undercar equipment, repair and adjustment of brake rigging/cylinders and renewal of brake pads.
3.11.2 Train 2020
Car 612M - the lead car of the leading unit - had recorded tripcock faults resulting in the tripcock mechanism being replaced on 5 April 2000. The brake controller was replaced on 23 April 2000. On 20 July 2000 vertical shock absorbers were reported as being worn and due for replacement. The unit as a whole was due for ‘A’ and ‘B’ examinations.
The trailing unit had last completed an ‘A’ examination on 25 July 2000.
3.11.3 Train Braking Systems
The integrity and operating condition of brake systems and individual items of brake equipment on train 2020 were independently tested and found to be in an acceptable operating condition, capable of meeting standard brake performance for a Comeng train. A detailed report is included at Appendix 7.
3.12 Track
The track from Jordanville to Signal DG484 is relatively straight and has a downward slope of 1 in 30. The track from DG484 to Holmesglen Station is straight for approximately 400 metres with a downward slope of 1 in 40 before the approach to the Up platform which is on a 2000 metre radius curve.
Final Report Page 22 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Figure 11 View ahead at Signal DG484
Close inspection of the rail revealed marks consistent with skidding 45 metres from the down end of the Up platform at Holmesglen Station. These were the first physical indication of emergency braking by train 2020.
3.13 Train Control
The rail system on the Glen Waverley line consists of dual tracks (broad gauge) with Automatic Block Signalling. The object of the system is to prevent more than one train being in a track section at the same time. This is achieved by electrically securing fixed signals in the ‘Stop’ position unless the track section ahead of the signal is clear.
A trainstop is located beside each signal. A trainstop consists of a pivoted lever arm fixed outside the left-hand rail of the running line. When a signal shows ‘Stop’ the trainstop is elevated. If a train should pass a signal indicating ‘Stop’, the trainstop lever arm operates the tripcock valve connected to the train pipe and the train air brake is operated. The driver must personally ensure that the leading left-hand tripcock valve on his train is cut-in prior to departure from a stabling yard or a terminal Station.
If a driver proceeds beyond a fixed signal showing ‘Stop’, the trainstop will be in the raised position and application of the emergency brake on a suburban electric train is unavoidable.
An automatic signalling system controls the track between Jordanville and Holmesglen. The relevant signals are as follows:
· Signal DG526 at Jordanville Station platform is 1251 metres from signal DG484. It indicated normal speed warning when passed by train 2020.
Final Report Page 23 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 · The signal then controlling train 2020 was DG484 which is 724 metres from DG460 at the Up end of the Holmesglen Station Up platform. This was at red and its train stop was in the raised position.
· Stationary train 2018 was at Signal DG460. This was indicating green at the time of the collision.
Figure 12. Diagramatic layout of signals on approach to Holmesglen
DG460 Holmesglen
555 m
DG484
1251 m
DG526 6 Jordanville
3.14 Signalling Equipment
CTM signal equipment history for signals DG 484 and DG 526 and their trainstops is shown in Appendix 8.
The signalling system in the area of the incident was commissioned in 1964. Maintenance records show no major faults in the signalling system at the time of the incident. The trainstop at signal DG 484 had been removed, replaced and tested in May 2000 as a result of timber resleepering and ballast resurfacing of the track.
Visual inspection of the trip arm mechanism on the trainstop at DG484 revealed fresh marks most probably caused by contact with the trip trigger on train 2020. Analysis of the segment and pinion gear indicated that the gears had been lubricated with light grease. The standard requires lubrication by oil. There was no evidence to suggest that this affected the proper performance of the trainstop or was a factor relevant to the accident.
The searchlight relay in DG 484 was dated 24 July 1976 and there was no evidence to indicate that it had been serviced since then. Visual inspection of the mechanism under operational conditions indicated that it was fully functional.
The signalling system (including signal DG 484) was subject to independent tests subsequent to the incident.
Final Report Page 24 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 A full report on the verification of the signalling system is set out in Appendix 9. It concludes that the system was functioning in accordance with design requirements.
3.15 Environmental Factors
The accident occurred at 14:32:30. The weather at the time was overcast. The temperature was approximately 8 degrees Celsius. Light rain fell intermittently and witnesses recalled rain in the minutes prior to the incident which would have left the track wet at the time of the collision. The AMT employee present at Holmesglen Station at the time described the sky as being dark with some patches of blue and that although there were two or three heavy showers in the 15 minutes beforehand it was not raining at the time of the collision. The Driver of train 2018 recalled using his windscreen wipers on approach to Holmesglen.
The sighting of the Holmesglen Station Up platform is somewhat restricted by vegetation at the side of the track near the approach to the Warrigal Road rail bridge
3.16 Recorded Information
3.16.1 Sequence of Events
The following sequence has been constructed from recorded data and information obtained from relevant personnel.
Time Event 14:13:00 Train 2018 departs Glen Waverley Station (approximate time) 14:13:50 Train 2016 departs Mount Waverley Station 14:18:34 Train 2018 stops at Mount Waverley Station 14:22:00 Train 2018 departs Mount Waverley Station 14:23:00 Train 2020 departs Glen Waverley Station (approximate time) 14:26:37 Driver 2018 speaks by radio toTrain Controller re late running 14:26:53 Train 2018 enters Holmesglen Station (camera 8) 14:27:05 Train 2018 comes to rest at Holmesglen Station (camera 8) 14:27:11 Train 2020 enters platform at Mount Waverley Station 14:27:21 Train 2020 disappears from view of Mount Waverley Station (camera 8) 14:27:21 Passengers board train 2018 at Holmesglen Station 14:27:29 Train 2018 moves forward 1m (camera 8) 14:28:17 Train 2018 moves forward a further 2m (camera 8) 14:30:50 Driver of 2018 leaves cab and walks towards rear of train 14:31:15* Estimated time that Driver of 2020 passed signal DG484 allowing the automatic trip to operate the train brake 14:31.25 Driver of 2018 approaches back of train 14:32:30 Collision between 2020 and 2018 (camera 1)
Final Report Page 25 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Time Event 14:33:14 Passengers seen exiting train 2018 14:33:20 AMT employee arrives on platform at scene of accident 14:34:57 Driver of 2020 speaks to Metrol from 2018 by train radio to report accident 14:34:59 AMT employee contacts Metrol by mobile telephone 14:42:00 Metropolitan Fire Brigade arrives on platform 14:43:54 Metropolitan Ambulance Service arrives on platform 14:44:40 Victoria Police arrive on platform
* The exact time of this event could not be determined as the location was outside the Metrol (Train Control) area which records track circuit and signal indications.
3.16.2 Video Records
While the purpose of video equipment installed at Holmesglen and Mt Waverley Stations is for station security, some camera positions captured train movements. Videos from the cameras at each Station is time division multiplexed onto a single video cassette resulting in a 4 second time lapse between frames. Information obtained from this system was used to conduct the above sequence of events.
Information recorded on cameras at Mt Waverley confirmed that train 2020 was running within line speed limit.
3.16.3 Audio Transcripts
Voice recordings of communications between train controllers at Metrol and the Drivers of trains 2018 and 2020 were made available by CTM. The discussions between the Driver of train 2018 and Metrol at 14:26 concerning the late running of his train and communication between the Drivers and Metrol after the incident were recorded.
3.16.4 Train Performance
Neither train was equipped with data logging equipment. Some other modern rolling stock operating in Victoria is equipped with systems which typically record time, speed, brake pipe pressure, braking position and throttle notch settings. The availability of such a system on all trains would remove the need to rely on reports and recollections of staff involved in incidents such as this one.
3.17 History of Similar Incidents
A search of investigation reports on accidents with similarities to the Holmesglen incident revealed that while individual reports undertaken in Victoria are retained under PTC custodianship there is no single comprehensive record of accident reports detailing causes and recommendations.
Final Report Page 26 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Access to such source information is regarded as essential for on-going rail safety management and accident investigation. Reports on accidents at Aircraft 1998, Syndal 1989, Ringwood 1989 and South Dynon 1986 were reviewed.
3.17.1 Aircraft 1998
A collision between a suburban electric passenger train and a stationary freight train occurred at Home Signal LAV20 at Aircraft on 27 July 1998. The Board of Inquiry concluded that the driver of the suburban train failed to drive at a speed which allowed the train to be stopped within the distance which could be viewed ahead. The train had proceeded beyond Automatic Signal GG824 to the rear of signal LAV20 after triggering the trip mechanism at GG824. The train was estimated to be travelling at approximately 15 km/h at the point of collision. Weather conditions at the time allowed for a limited viewing distance.
The Board of Inquiry examined the possible conversion of Automatic Signals from permissive to absolute but concluded that although this may have prevented the incident concerned in other circumstances where permission is given by Train Control for a driver to pass a signal at stop, the driver may proceed in the belief that there is no obstruction ahead. For that reason it was felt that conversion may or may not be a viable proposition.
3.17.2 Syndal 1989
On 20 November 1989 a suburban electric passenger train collided with another which was stationary in the Up platform at Syndal Station resulting in 75 injuries. The Board of Inquiry found that the collision was due to human error in that the Driver of the second train after exercising train brake tripping procedures at Automatic Signal DG660 proceeded at a speed which was inappropriate to the conditions.
The Driver concerned first observed the stationary train when it was approximately 50-60 metres away. The estimated speed on impact was 40 km/h. The impact pushed the stationary train forward approximately two to three metres.
The Board of Inquiry recommended that more on the job supervision of drivers be provided by Electric Running Supervisors, that strict enforcement of Regulation 74 be applied by all Supervisory Officers and that foliage on the left hand curve approaching Syndal Station be removed and a program be implemented for its continued maintenance.
Regulation 74 has since been superseded by Section 3 Rule 1 in the Rule Book.
3.17.3 Ringwood 1989
On 16 October 1989 train 3610 (Up) collided with train 3006 (Up) which was stationary at Home Signal Post No.45. The Board of Inquiry found that the Driver of train 3610 made an error of judgement in the control of his train. The error of judgement was either in his manipulation of the train’s braking or his speed was such that he was unable to stop the train in the distance required.
Final Report Page 27 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 The Driver concerned had exercised train brake tripping procedures at Automatic Signal L828 prior to the collision. The speed on impact was estimated to be approximately 19 km/h which resulted in the stationary train being moved approximately three to five metres with 21 passengers being injured.
The Board of Inquiry studied Regulation 74 and concluded that it more than adequately covered the situation.
3.17.4 South Dynon 1986
On 8 October 1986 goods train 9118 passed through West Footscray Junction and subsequently stopped at Automatic Signal MG 272. The Driver noted that the marker light on the signal was not indicating. After waiting the required time he proceeded past the signal in the stop position as permitted by Regulation 74. The train reached a speed of 41.5 km/h before the emergency brake was applied and collided into the rear of goods train 9692 which was stationary at Home Signal 162. Train 9118 travelled 175 metres after application of the emergency brake and collided with the stationary train at a speed of 20 km/h.
The Board of Inquiry concluded that the Driver believed that the signal (MG 272) had failed and that the necessity to record that fact misled him into subconsciously thinking the section to the next Automatic Signal was clear. The Board recommended strict adherence to Regulation 74 and that a Home Signal be provided between Automatic Signals MG 272 and MG 242 after considering previous complaints regarding difficulties experienced in sighting and stopping at signal MG 242.
Final Report Page 28 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 4. Analysis
4.1 General
In common with many railway incidents, an unsafe act performed by an employee contributed to the collision at Holmesglen. It is not the objective of this investigation to attribute blame or liability but to consider how future occurrences may be prevented. To achieve this it is necessary to consider both the actions taken by the Driver of train 2020, the circumstances which may have motivated him to act as he did and the nature of the system which permitted actions taken by the Driver to result in the consequences which occurred.
4.2 Driver Performance
Evidence shows that the Driver of train 2020 erred in that he did not comply with Section 3, Rule 1 (Detention at Automatic Signal) being unable to stop his train ahead of the obstruction provided by train 2018 standing at Holmesglen Station.
According to the Reason Generic Error Modelling System (GEMS - Reason 1992) human performance problems result in both errors and violations. Errors can be divided into skill-based slips and lapses, rule-based mistakes and knowledge-based mistakes depending on the cognitive level at which the failure was committed.
Skill-based slips and lapses are associated with monitoring failures and typically occur due to inattention or over-attention to a task. Rule and knowledge-based mistakes are associated with problem solving failures which for rule-based mistakes may involve the misapplication of a good rule or the application of a bad or inappropriate rule. In knowledge-based mistakes, failures occur due to faults in causal thinking, bounded rationality or incomplete knowledge.
Violations can be divided into three major categories: routine, optimising, and necessary violations (Reason et al, 1994). Necessary violations usually arise from deficiencies in the organisation, such as inadequate tools or equipment, whereas optimising violations involve the achievement of personal goals and are modified by motivation. It is probable, from the evidence, that the Driver of train 2020 performed a routine violation.
This type of violation involves habitual corner cutting and is particularly encouraged if the organisation does not check from time to time that correct procedures are being followed. While there is evidence that CTM carries out checks on driver ability in the form of audits and continuation training, it is possible that compliance with the procedure for passing an Automatic Signal at stop may not have been adequately tested in the field. The procedure would be tested if a Driver was required to pass an Automatic Signal at stop in the course of a journey under audit.
In not complying with the rule regarding detention at fixed signals the Driver of train 2020 presumed that the track section ahead was clear. During interview he stated that he thought that the section was clear because he could not see a train ahead.
Final Report Page 29 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 For the Driver to presume that the track section was clear he would have to presume that a train was not standing at Holmesglen Station. This presumption could be made in part by the fact that the Driver, as he stated, had not seen the train ahead during his journey from Glen Waverley.
Investigation of the track on the day after the collision, together with a description of the incident by the Driver of train 2020 suggests that the position where emergency braking was applied corresponded to the position where the Driver of train 2020 would have first sighted the stationary train. The weather at the time of the incident was cloudy and the track was wet from previous rain. It is not considered that the weather or the minor visual acuity defect of the Driver affected visibility of the stationary train. Trees on the west side of the Warrigal Road bridge before the Holmesglen Station would have delayed the sighting of the train at the platform.
Driver fatigue was examined during the investigation. The Driver of train 2020 had been rostered for an additional shift in accordance with existing practices. An analysis (Appendix 5) of the level of fatigue attributable to both Drivers was conducted by the Centre for Sleep Research, University of South Australia. It indicated that for the Driver of train 2020 (Driver B):
· There was an occurrence on the 10th consecutive shift. · Fatigue levels had been rising steadily throughout the working of these shifts due to the preponderance of early morning starts. These starting times cause an interruption to REM sleep periods, which are important for mental alertness. · On the two shifts prior to the incident, fatigue levels were of an order to cause concern. · However, due to the later starting time of the shift on the day of the incident (allowing some recovery of the sleep debt incurred on the previous shifts) work related fatigue was at an insignificant level.
It is possible that the Driver may have experienced a degree of non-work related pressures. At interview he indicated that he had slept normally and that he had no added stress on himself prior to the incident.
Research on sleep, age and shiftwork (Marquie and Foret, 1999) has shown that shiftwork can cause a higher frequency of sleep disorders and that there are highly significant changes in sleep structure with aging. These issues have some relevance to the rail industry where the flexibility of working hours and the demand for high alertness levels are a requirement for operational staff. While there is no direct evidence that fatigue and reduction in alertness was a contributing factor to the collision it is an area which requires further study.
As described in Section 3.9 the Driver of train 2020 was taking prescribed medication. It is considered unlikely that the Driver would have been adversely affected to any significant degree by the medication but it is possible that it may have resulted in a subtle increase in fatigue or stress, unnoticed by the driver himself.
Final Report Page 30 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 4.3 Failed or Absent Defences
Using the terminology of the Reason Model of accident causation, defences are safeguards built into a system to provide protection against foreseeable hazards. Defences can prevent unsafe situations arising in the first instance, warn of an unsafe situation or reduce the consequences of a hazard should all other measures fail. It is generally expected that multiple lines of defence should be in place to prevent high consequence incidents.
4.3.1 Prevention of an Unsafe Act
While any unsafe act is unacceptable, such acts can be expected to occur from time to time. Safety features such as the train stop have been introduced to the rail system to prevent the occurrence of predictable unsafe acts.
The trip system does not have the physical capacity to prevent a train from progressing at an unsafe speed after the driver has completed train brake tripping procedures to proceed beyond a signal indicating stop. In some other rail systems defences such as train speed limiting devices are applied.
4.4 Local Factors
Unsafe acts occur in the context of local factors. These are aspects of the work environment which have the potential to make errors and violations more likely to occur. In the context of this incident a local factor was the training and knowledge of drivers and the layout of the track in the area of Holmesglen Station.
4.4.1 Sighting of Holmesglen Platform
Vegetation on the approach to Holmesglen Station limited the view which the Driver of train 2020 had of platform 1 and train 2018.
4.4.2 Train Examination
It was noted that leading car 612M was due for examination. The investigation found no evidence that the absence of this examination contributed to the incident.
4.4.3 Signalling System
While some minor maintenance issues were identified (Section 3.15.1) the investigation found that the signalling system did not contribute to the cause of the incident.
4.4.4 Braking System
As detailed in Section 3.15.2 the investigation found that the braking system on train 2020 was in an acceptable operating condition and did not contribute to the cause of the incident.
Final Report Page 31 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 4.4.5 Train Crashworthiness
The energy absorption feature in the couplings was considered to have operated effectively and in accordance with the intended design considerably reducing the damage to the cars on initial impact ( 569M and 612M)
Consequent severe damage to 590M occurred as a result of car 1135T riding up and impacting the rear of that car. The car body of 1156T crumpled in the seating area approximately one third of the way along the carriage. The cause of this crumpling is not readily explainable but is thought to be as a result of it taking the additional forces which resulted from the rebound forces combined with the inertia forces of the following four cars.
The recommendation by CTM in the Board of Inquiry report that all new passenger cars designed for operation in this environment is noted. It should also be noted that new trains on order for Victoria will comply with modern European energy absorption methods and principles.
4.5 Organisational Factors
CTM informed the investigation that 197 shifts were rostered to operate the timetable on 26 July and that a driver is rostered to work 19 shifts in a 28 day period and to have 4 weeks leave at the conclusion of each 37 week period. The estimated number of drivers required to work the timetable and to comply with rostering requirements was 301.
On 26 July there were 260 drivers and eight (8) driver - trainers employed. This analysis suggests that the driver roster needs to be examined along with the total number of drivers required. It is possible that this situation contributed to the accident in that it occurred on the tenth consecutive shift worked by the Driver of train 2020 and his fatigue levels on the two shifts prior to the accident “were of an order to cause concern”.
4.6 Medical
The driver of train 2020 underwent a medical examination on 23 September 1999 in accordance with Company procedures and was passed fit for all duties.
CTM procedure HTHR1P-05 does not require employees to declare any change to medical condition/health which could impact on rail safety or performance of duty. While CTM is a drug free workplace and testing procedure (MTEPE3QP 914) is in place there is no evidence that it is effective in this regard. There is no record that the Driver of train 2020 had informed his employer of the medication he was taking.
To be consistent with CTM standards the Driver of train 2020 needed to wear glasses while driving, At the time of the incident he was not wearing his glasses. Procedures did not provide for this requirement to be made known to his supervisors.
Final Report Page 32 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 4.7 Driver Training
4.7.1 General
With the introduction (see Section 3.8) of single person operated trains (SPOT) in the Melbourne metropolitan area, suburban train guards were given the option to be trained as suburban electric train drivers. To be considered for acceptance as a trainee driver, MET guards were required to undergo a specialised selection process (Appendix 2). In excess of 600 guards applied for training. Sixty-two (62) were selected. The Driver of train 2020 was one of the selected group. Successful applicants were transferred to the Driver Training Centre at South Dynon to undertake the conversion course which was designed to be competency-based following an analysis of guard/driver tasks and responsibilities.
The conversion training program for Met guards who met selection requirements consisted of Stages 1, 5, 6, 7, 8, 9 and 10 of the approved driver-training program. Recognised prior learning to qualify as a guard exempted them from Stages 2, 3 and 4 which provided background in rail operations, train dynamics, train management, shunting, track and signals and safeworking.
Stage 1 of the conversion training program required the selected trainees to undergo aptitude, psychological and medical assessment followed by a one day theory examination in signals, safeworking and train operational procedures. On satisfactory completion of Stage One trainees received theory instruction in safeworking practices, signalling aspects and rules and regulations not previously necessary for guards. The former guards were required to demonstrate recognition of prior learning through written assessment with successful outcomes.
Stages 5, 6 and 8 were predominantly classroom and simulator-based training staged over a seven week period. Stages 7 and 9 consisted of rostered on-the-job training (OJT) and assessment over a 21 week period. Stage 10 allowed for revision and examination in the final week.
Taking into consideration recognition of prior learning for safeworking and route knowledge, the major variance between the 1991 and 1997 driver training programs and the guard-to-driver conversion training program is the amount of time given to OJT and assessment. The 1991 program allowed for 46 weeks of OJT, the 1997 program 42 weeks with the guard-to-driver conversion program providing 21 weeks of OJT.
The investigation noted that scheduled practical assessment of passing three position automatic signals at danger is not included in continuation training conducted by CTM.
Subsequent to consultation with the driver training provider (RTI), the investigation was unable to verify that Victorian driver training standards are being applied uniformly across the industry. It would appear that the training syllabus within the Victorian training program is being modified by individual operators to meet their own perception of requirements.
Final Report Page 33 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 There is some risk that this could result in fragmentation of the approved driver training standards. Accordingly there is a need to establish minimum standards and guidelines for the training, assessment and on-going accreditation of drivers for universal application across the industry.
4.7.2 Driver - Train 2020
Analysis of records of Continuous Training and Driver Safety Audit (see Section 3.8.2) indicates that most non-complying incidents occurred, as could be expected, when the driver was undergoing training. Incidents relating to speed and signalling which occurred subsequent to qualifying as a driver should be noted.
The periods between continuation training undertaken by the Driver of train 2020 range from four to eight months with an average of 6.33 months between each training period. Training documents (Stage 5 Continuation Training Lesson Paper) supplied by CTM indicate that part of his continuation training on 20 July 2000 included identifying and dealing with signal irregularities associated with an illuminated letter ‘A’ on home signals. At interview on 7 August 2000 he was unable to re-call when he was last tested on procedures for passing signals at stop.
4.8 Analysis of Crew Operating Procedures (Rules)
Rule 1, Section 13 of the Rule Book is designed to protect trains stopped by accident, failure, obstruction or from any other cause in a track section. Protection is not required if a train has arrived at a home signal or is within the protection of a home signal at an intermediate location. The procedure in part requires a driver of a train stopped for any of these reasons to immediately advise the Train Controller of the circumstances by train radio. The Train Controller of a train stopped for any of these reasons is required to take immediate action ‘to stop any following train’.
The safeworking rule for the protection of trains in the 1987 State Transport Authority Rules and Regulations (Regulation 239) which preceded the Rule Book and single person operated train procedures reads as follows:
Trains Stopped by Accident, Failure, Obstruction or from any Cause
(a) Except where instructions are issued to the contrary, when a train is stopped in a Section by accident, failure, obstruction or other exceptional cause (unless it has arrived at the Home Signal, or is within protection of a Home Signal at an intermediate location) the Driver must (where train to Base Radio communication is available) immediately advise the Train Controller of the circumstances. The Train Controller must take steps to have any following train stopped, also to prevent any train approaching on any parallel line that may also be obstructed.
The PTC Supplementary Amendments to the Rules and Regulations for the operation of locomotive hauled driver - only passenger trains (issued 1992) also refers to …. other exceptional cause. The current Driver Training Booklet supplied by the RTI Training Centre (MB94L1H.DOC) details how protection is to be provided for trains stopped by accident, failure, obstruction, or by any other exceptional cause. The Rule Book refers to …. any other cause.
Final Report Page 34 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 The investigation was unable to ascertain the reason for the deletion of the word exceptional from the Rule Book.
CTM internal procedure (HTOP11IMO-05) requires a driver to inform the Train Controller at Metrol (via train radio) where any irregularities or delays occur which cause a single delay of three (3) minutes or more or where minor delays accumulate to the extent that the train is running three (3) minutes or more late. This internal procedure appears to be in conflict with Rule 1, Section 13 in the Rule Book which requires the driver to immediately advise the Train Controller of the circumstances if the train is stopped by accident, failure, obstruction or from any other cause.
The investigation sought professional opinions within the rail industry as to train driver responsibilities to advise Train Control when trains are delayed through failure and the intent and application of Rule 1 Section 13. Opinions on the intent and application of Rule 1 Section 13 varied from the importance it places on immediate advice to Train Control of any failure or delay to the view that the Rule is intended to provide protection only for trains which are unable to run forward ie disabled trains or track obstruction. The latter view is that the automatic block signalling system will provide protection for trains delayed on route.
Nevertheless, once a driver exercises train brake tripping procedures to pass an automatic signal at stop, the safety of the line relies on human intervention and the driver concerned following correct procedures. As was the case in previous incidents reviewed in the investigation, an error of judgement occurred which resulted in the collision at Holmesglen.
It was a case where the engineering control was over-ridden by a subjective administrative control under which responsibility rests solely with the driver. When a reliable engineering system is capable of being superseded by an administrative control subject to interpretation by humans involved the potential is created for incidents of this nature to occur.
CTM trains are fitted with a radio system which enables a train driver to communicate with Train Control, Signallers and other Drivers, train crew allocation officers and CTM internal telephone numbers. Communication with other train drivers and signallers may be via an open radio channel, the specific radio number or the internal telephone exchange.
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.
The door failure on train 2018 at Holmesglen prevented it from going forward. The investigation is of the opinion that the Rules and Procedures for management of train irregularities and delays and train protection are unclear and require review as a matter of priority.
Final Report Page 35 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 4.9 Other Similar Incidents
All four reports on similar incidents had a common element of reduced visibility due to inclement weather. A further element common to the incident at Holmesglen and incidents at Aircraft and South Dynon is that the Driver in each case believed that the signal was at danger for reasons other than the section ahead was occupied by another train.
While in each case there were no serious injuries to personnel or passengers, the reports (although not fully detailing damage to rolling stock) provided sufficient information for it to be established that the damage loss would have been in the order of $50M in current value for the five incidents including Holmesglen.
Final Report Page 36 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 4.10 Rules in Other Organisations
An analysis of rules applied by other railway organisations for passing Automatic Signals at stop has been carried out and the following observations are made:
In Queensland a form SW10 - Authority to Pass Signals at Stop - must be issued by a Train Controller or Signaller before a train is permitted to proceed. The only exceptions are where a verbal authority may be issued by a Signaller for shunting yard movements and a train driver authority issued by a Signaller for signals fitted with SP plates at level crossings and cane railway intersections. When a train has been authorised to pass a signal at danger the first train over the section must proceed at a speed not exceeding 50 km/h when there is a track circuit indication of unknown cause or at 25 km/h when passing a position light signal or at normal speed expecting the next signal will be at stop if either of the above do not apply.
In New Zealand the locomotive engineer may, at a stop and stay signal equipped with an ‘A’ light, move the train forward cautiously to the next signal on observing that the line is clear. For intermediate stop and stay signals the locomotive engineer must communicate with Train Control. If satisfied that the track section ahead is not occupied Train Control may authorise the train to pass the signal at stop.
In the United Kingdom a driver is not permitted to pass a signal at danger without the authority of a Signaller. The authority must include a limitation on the extent of the movement being authorised. RailTrack has the capacity to identify the location of trains in automatically signalled sections. The Melbourne system does not have this capacity beyond Metrol coverage. Drivers of London Underground trains can pass automatic signals at danger under their own authority after waiting at the signal for two minutes. The speed of the train is limited (to 5 mph) by application of interlocking equipment.
The investigation has considered the Final Report of the Special Commission of Inquiry into the Glenbrook Rail Accident on 2 December 2000. In the section of track where the accident occurred the movement of trains was controlled by automatic signals.
In completing its Holmesglen report the investigation has had particular regard to recommendations made by the Special Commission of Inquiry in the areas of training for safety critical staff, competency of train drivers and train communications.
Final Report Page 37 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 5. Conclusions
5.1 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.
The extent of damage to the carriages and couplings of both trains and the distance that train 2018 was pushed forward indicated an impact speed in excess of 44.5 Km/h.
As a result of the collision twelve (12) people including the two drivers were transferred to hospital for attention. None were found to have critical injuries.
5.2 Contributing Factors
· the Driver of train 2020 did not comply with Rule 1 Section 3 of the Book of Rules and Operating Procedures 1994 in that he did not proceed with extreme caution after exercising train brake tripping procedures at signal DG484.
· the procedure in place for proceeding past three position automatic signals at danger is open to non-compliance through human error and CTM could not demonstrate that adequate measures were in place to ensure compliance with the procedures.
· there was no evidence discovered which indicated that the competency of the Driver of train 2020 to comply with Rule 1 Section 3 of the Book of Rules and Operating Procedures 1994 had been audited in the field; such an omission could have contributed to the incident.
· the Driver of train 2018 did not inform Train Control that he was further delayed due to a failure of the car door locking system on his train. Had the Driver of train 2020 been aware that train 2018 was delayed at Holmesglen Station he would in all probability have driven his train more cautiously thereby avoiding the collision. The procedure for a driver to inform Train Control when delayed for such a failure is open to interpretation.
· vegetation on the approach to Holmesglen Station limited the ability of the Driver of train 2020 to sight train 2018 earlier in the sequence of events leading to the incident.
Final Report Page 38 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 · while there was no direct evidence to suggest that the following factors contributed directly to the incident the investigation found that they were matters of concern needing to be addressed:
· the train crew rostering system which allowed the Driver of train 2020 to be exposed to potential levels of work related fatigue
· measures to capture and record the use of medication which could affect performance by operating staff
· procedures to ensure that drivers wear glasses when prescribed to do so for train operating purposes; and
· the fact that the Driver of train 2020 required remedial training for excess speed in particular circumstances shortly after qualifying indicates a possible shortcoming in training received or in assessment of his competency to qualify as Driver; subsequent Continuation Training and Driver Safety Audits did not prevent a ‘signal passed at danger’ incident on 19 October 1997.
Final Report Page 39 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 6. Recommendations
Safety actions recommended for implementation by CTM are that:
(i) Training of Drivers
(a) CTM review the competency of each current driver who qualified through Conversion Training for Metropolitan Guards and that any remedial training required be identified and implemented.
(b) Given possible consequences if Rule 1 Section 3 it is not correctly applied that CTM:
i) undertake practical assessments of the competency of all current drivers in exercising train brake tripping procedures to pass three position automatic signals at danger; and
ii) schedule future assessments of competency in this regard into OJT Continuation Training and Driver Safety Audits
(c) The effectiveness of Continuation Training for drivers and procedures for re- assessing drivers who do not meet elements of Continuation Training requirements be assessed.
(d) The effectiveness of remedial training given to individual drivers to correct identified non- conforming practice be assessed
(ii) Driver Safety Audits
(a) Driver Safety Audit records be designed to indicate when it is necessary for a driver to wear glasses for train operating purposes and that practical sight tests be included in the Driver Safety Audit Checklist for application by instructor drivers.
(iii) Medical
(a) Effective processes be implemented to ensure that; i) requirements for drivers to wear glasses for train operating purposes; and ii) the potential impact of prescribed medication on a driver’s ability
are known to relevant driver managers.
(iv) Driver Shift Patterns
(a) Available research on the effect of shift patterns on work related fatigue be analysed and applied to the design of train driver rosters; and
(b) Resourcing and rostering issues identified at Section 4.5 in this report be addressed
Final Report Page 40 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 (v) Local Factors
(a) Programs for containing trackside vegetation impacting on driver ‘line of sight’ be implemented.
(vi) Technology
(a) The benefits and practicality of installing i) equipment to limit the speed of trains after passing signals at danger; and
ii) data loggers
on suburban electric trains be assessed.
(vii) Train and Signal Maintenance
(a) Recommended Actions listed in Appendix 7 and concerns identified in Appendix 9 be addressed.
Safety actions recommended for implementation by Department of Infrastructure are that:
(viii) Compliance Rules
(a) Rule 1 Section 3 in the Book of Rules and Operating Procedures 1994 as applied by all operators be amended to include a mandatory maximum speed
(b) Rule 1 Section 13 in the Book of Rules and Operating Procedures 1994 as applied by all operators be reviewed to remove any uncertainty as to the responsibilities of both drivers and Train Controllers to protect trains stopped by accident, failure, obstruction or from any cause
(ix) The Department of Infrastructure and the Public Transport Corporation (PTC) transfer file records of all Victorian rail accidents/major incidents to an accessible database for the purposes of ensuring that recommended actions are completed and that such data is available for future analysis and research purposes.
(x) The Department of Infrastructure manage the impact of Recommendations i, ii, iii, iv, v and vi on other train operating companies and organisations accessing the Victorian rail network.
(xi) The Department of Infrastructure establish minimum standards for the training, assessment and continuing competence of drivers and ensure their adoption by all train operating companies and organisations in Victoria.
(xii) The Department of Infrastructure review procedures for trains passing signals at danger given variations in on-train equipment, signalling systems and traffic densities to assess their effectiveness
Final Report Page 41 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 (xiii) The Department of Infrastructure agree consultation arrangements with all train operators, track access providers and the Rail Tram and Bus Union (RTBU) for implementation of the recommendations contained in this report and for the on-going management of train operating safety
Final Report Page 42 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 References
Australian Transport Safety Bureau (2000). Collision between Freight Train 9784 and ballast Train 9795. Rail Investigation Report R1/2000
Dawson, D. and Reid, K (1997) Fatigue, alcohol and performance impairment. Nature, 388:235
Final Report of the Special Commission of Inquiry into the Glenbrook Rail Accident April 2001
Marquie J.C. and Foret J. (1999) Sleep, age, and shiftwork experience. Journal of Sleep Research, 8, 297-304 (1999)
Reason. J. (1992) Human Error. Cambridge University Press. Cambridge
Reason. J. (1994) REVIEW, Vol I. Management Overview. British Railways Board, London
Final Report Page 43 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Glossary
Automatic Block Signalling – A signalling system whereby two or more trains travelling in the same direction are spaced a track section apart. Each track section is governed by signal indications that operate automatically for the passage of the train. It may also include locations where certain types of signals may be locally or remotely controlled.
Broad Gauge – The gauge is the distance between the running faces of the two rails, measured a nominal distance below the tops of the railheads. In Victoria, there are two types of network gauges – Broad Gauge and Standard Gauge. The distance between the two rails on the broad gauge network is 1600 mm, while the standard gauge network is 1435 mm; hence the term broad referring to the wider gauge between the networks.
Diesel Ticket - A Certificate issued to certify competency to drive diesel locomotives following successful assessment and examination.
Draw Gear Assembly - The term used to describe the coupling and cushioning assembly that connects adjacent carriages.
LHB Bogies – The term LHB refers to the make of the particular type of bogie fitted to the trains involved in the collision. Each bogie type has slightly differing train braking characteristics.
Rheostatic Braking – A system of braking that uses the traction motor system to provide retardation by dissipating the electrical energy generated by retardation through electrical elements.
Rolling Stock Examinations Drivers Preparation - Conducted daily to check the functionality of driver equipment, brake system, brake equipment and pantograph equipment.
A Exam - conducted weekly to examine the security of undercar equipment, adjustment and repair of brake rigging/cylinders and renewal of any brake blocks/parts.
B Exam - conducted each 8 weeks to examine the condition of car equipment such as seats, lighting, handgrips and drivers cab equipment such as windscreen wiper/washer.
C Exam - conducted at defined intervals (25,000 km for Comeng Train) at a depot to examine wheels, bogies, traction and other electrical motors, coupling gear, trip mechanism and camshaft control mechanism.
D Exam - conducted at defined intervals (50,000 km for Comeng Train) at a depot and includes ‘C exam’ plus traction control equipment and other system function checks.
Final Report Page 44 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 E Exam - conducted at defined intervals (360,000 km for Comeng Tread Braked and 440,000 km Comeng Disc Braked) at a depot and includes ‘D’ exam plus bogie overhaul.
MET Driver Training Syllabus - is the document identifying all tasks required to be undertaken by a train driver to reach certification as a qualified driver (Locomotive Single Person Operation Metropolitan). It includes the proficiency level required to be achieved for each task and the Report records the level achieved by the trainee at task assessment.
Slip/Slide Sensing Units - The device fitted to some axles of carriages in the train which sense if the wheels are spinning or slipping on the rail while the car is powering or sliding under braking and which provides control to correct the condition.
Track Section - A section of track between two fixed signals
Tripping past signal – Rail industry terminology for a train (suburban passenger) passing a signal at the Stop position. When passing the signal at Stop, the train’s air brake is automatically applied when the trains trip lever comes into contact with the raised train stop arm.
Tripcock – The portion of the trip mechanism that controls the flow of air from the train brake piping system
Trip Mechanism – The device fitted to suburban train driving cars, that when a driving car is leading, engages with the raised train stop arm to release air from the train brake pipe and cause the brake to be applied.
Train Stop – A device located at most signals in the metropolitan electrified area and is positioned between the outside left-hand rail of the track and the signal. The device includes a pivoted arm that when the signal is at the Stop position the arm is elevated. When the signal is at Proceed the arm is lowered.
Final Report Page 45 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 Appendices
Appendix 1 Analysis of Speed of Impact
Appendix 2 Conversion Driving Training Course
Appendix 3 Driver Of Train 2020 - Continuation Training History
Appendix 4 Drivers’ Recent Shift History
Appendix 5 Analysis of Shift Patterns
Appendix 6 Report on Recent Defects of Cars 612M and 569M
Appendix 7 Verification of the Train Braking System
Appendix 8 Signal Equipment History
Appendix 9 Verification of Signalling System
Final Report Page 46 of 46 Investigation into the Collision Between Connex Passenger Trains at Holmesglen Station on 26 July 2000 APPENDIX 1 APPENDIX 1 - ANALYSIS OF SPEED OF IMPACT
1. Data
Mass of train 2020 (m1): the approximate disc car weights are: MOTOR CAR = 46330 kg TRAILER CAR = 30080 kg
The weight of train and driver is assumed to be 229300 kg = m1.
Mass of train 2018 (m2):
It is assumed that there were 100 passengers on board with an average weight of 60 kg. The total weight of the train and passengers would be 235300 kg = m2..
It is assumed that after impact both trains were sliding. This is based on the track marks, the condition of the track, the weather conditions and the reports given by the Driver of train 2020.
At the point of impact train 2020 was moving with speed v1 and had mass m1. After impact both trains (m1+m2) were moving at speed v’ a distance of approximately 38 metres.
2. Calculation
From the conservation of momentum:
m1 v1 = (m1+m2)v’
v1 = (1+m2/m1)v’ = 2.026 v’ The coefficient of friction µ varies according to the conditions of the surfaces in contact between approximately 0.05 and 0.2. For this analysis, considering the track was wet a value of 0.05 will be used. The energy needed to overcome sliding friction is: 2 E1 = (m1+m2) x g x µ x distance moved (x) = ½ (m1+m2) (v’ ) 2 From this E1 = 8659679 = ½ (m1+m2) (v’ ) (v’2) = 37.278 v’ = 6.106
and from v1 = (1+m2/m1)v’ = 2.026 v’, v1 = 12.37 m/s = 44.5 km/h
However, a significant amount of energy would have been absorbed by the deformation of the carriages and couplers. From advice, the deformation of the couplers would have absorbed approximately 20 km/h of the impact. Therefore a more likely speed of train 2020 at the moment of impact is approximately 65 km/h.
Appendix 1 Page 1 of 1 Analysis of Speed of Impact APPENDIX 2 CONVERSION DRIVER TRAINING COURSE
PUBLIC TRANSPORT CORPORATION
CONVERSION TRAINING
MET GUARDS TO DRIVERS
SUBJECT: Conversion Training REVISION: 3 AUTHORISED BY: Signed W. Uren SECTION: DATE / ISSUED / REVISED: dated 27/7/94 PAGE 1 OF 8
Bill Uren MANAGER TRAIN CREW OPERATIONS
Appendix 2 Page 1 of 8 Conversion Driver Training Course INTRODUCTION
This report outlines the progress made to date on the design, development and implementation procedures of the conversion course for Guards to Electric Train Drivers
OBJECTIVE
The objective of the Driver Training, Centre Development Team is to implement a conversion course for Guards and maintain the skills and quality of driver standards.
CONCEPT OVERVIEW
The concept of the Conversion Scheme provides for 4 Blocks, divided into 6 Stages of training. The term of the course is to be a maximum of (6) six months. The following sections outline the conversion course on a stage by stage basis.
STAGE 1 - ENTRANCE AND SELECTION
Stage 1 provides for the selection of Guards, with selection of applicants proceeding in accordance with a specialised selection process developed for the original Driver Training Scheme by a predetermined selection profile from driver assessment and interviews identifying work preferences and perceptions associated with Drivers .who are working, on Metropolitan/Suburban Trains. A medical examination as determined by the medical section for recruitment as Drivers. On completion and acceptance he/she would progress to a one day theory exam on their knowledge of Signals, Safeworking and Train operational procedures as a current suburban Guard
1 day entrance examination.
Appendix 2 Page 2 of 8 Conversion Driver Training Course STAGES M- SAFEWORKING AND SIGNALS
On satisfactory completion of Stage 1 the conversion Guard will receive theory instructions in Safeworking practices not previously taught and any changed practices as is necessary to do the Driver's tasks in the Signals and Rules and Regulations
This component will provide theory training (Driver tasks) in subjects from the current Trainee Driver Courseware Stage 5 and 7, leading into examination and assessment by an instructor Driver Special Class.
This stage is a minimum of..
Theory 4 days Instructor ratio one to eight Examination 1 day Instructor ratio one to eight
Appendix 2 Page 3 of 8 Conversion Driver Training Course STAGE 6 AND 7
On satisfactory completion of Stage 5M the trainee will proceed to Stage W for Classroom theory and practical instruction in Driver's knowledge on the simulator in the following
(a) Fundamental of Electricity (b) The 1500 Volt D.C. supply reticulation system through power sources from sub-stations to the trains. (c) Identification and functions of the Master Controller, Pantograph, Motor Alternator, Compressor, Brake Equipment and other components. (d) Safety apparatus (e) Structure and component layout of the Hitachi and Comeng trains. (f) Air Brake (g) Brake test for Electric Motor and Trailer Cars (h) Train consist make up
This stage is a minimum of.
Theory 7days Instructor ratio one to eight Simulator 1 day Instructor ratio one to one *Examination 1 day Instructor ratio one to eight *TP0 1 day TPO orientation Trainee issued with roster books, relevant keys, locker etc and instructed on the fundamental operation of the ERD environment.
Appendix 2 Page 4 of 8 Conversion Driver Training Course STAGE 7 OJT
During this stage the Trainee will be rostered for a specific period of general rostered work. 7he purpose of this stage is to consolidate previously taught specified knowledge and transform this knowledge into practice. To ensure the Trainee is attaining sufficient skills elements, an Instructor Driver Special Class will conduct a stage 7 assessment in the 3rd and 5th week to monitor the Trainee's progress.
Maximum of 5 weeks with On Job Trainers.
O.J.T. Ratio: one to one
STAGE 8 TRAIN MANAGEMENT(Including SIMULATOR Training)
Familiarisation and fault finding, through theory classes and practical instruction, Trainees will receive a Drivers knowledge of the definition and functions of equipment on Hitachi and Comeng electric train consists, and familiarisation of components and fault sequences.
Electric train characteristics the trainee will receive theory training to a drivers level in the following:-
a) Brake procedures and their effects
b) Management of trains through undulating grades
b) Management of trains in short block sections
d) Management of trains through high density suburban interlocking
e) Management of trains and reaction to unscheduled events
f) Train characteristics
Appendix 2 Page 5 of 8 Conversion Driver Training Course Trainee Driver will proceed to the simulator to progress with his driving skills. This component will provide for theory and practical instruction on a one to one basis on the Met Suburban simulator. (If the Simulator is not available a non-revenue service train will be used for approximately five days). This component will be uniquely geared for the specific requirements of Met operations The Simulator will be used to graphically demonstrate train handling practices, including the effects of poor train handling practices and aspects of train dynamics.
By means of the Simulator the Trainee will be given practical instruction in driving and managing Electric Train consists under all operating conditions, including their characteristics in fault finding and rectification.
This stage is a minimum of
Theory 5 days Instructor ratio one to eight Examination 1 day Instructor ratio one to eight Simulator 4 days Instructor ratio one to one
Appendix 2 Page 6 of 8 Conversion Driver Training Course STAGE 9 - GENERAL ROSTER WORK (ON JOB TRAINING)
The trainee will be rostered for a specific period of general rostered work, (specific period trainee must drive over each track at least three times (Demo, Guided. Unguided practice) together with an On Job Trainer.
The purpose of this stage is to consolidate previous training received both as a Guard (driving train when Driver is incapacitated) and as a trainee Driver. It will also provide scope for the trainee Driver to gain additional working experience and Train Management skills associated with the Met system
Included in this stage will be periodic monitoring and assessments by Met Special Class Instructor Drivers to ensure any unwanted or improper techniques are detected and corrected with the aid of specified training. (ie. simulator sessions).
Maximum of 16 weeks with On Job Trainers.
O.J.T. Ratio: one to one
It is in this stage, that during assessments and O.J.T progress reports that the duration of on job training for each trainee will be individualised. If the trainee is found to be competent to drive, (alone without supervision) he would progress to the final stage. Assessments and O.JT. progress reports will be carried out at 2 week intervals during O.J.T component to ascertain their competence to drive alone.
A Trainee Driver who is not competent and fails three assessments, after remedial tuition and specified simulator sessions to correct deficiencies will be removed from the Trainee Driver Grade.
Appendix 2 Page 7 of 8 Conversion Driver Training Course STAGE 10 FINAL EXAMINATION
Final examination will be administered by the instructor Driver special class to ensure the certification of trainee Drivers meet the operational requirements of the Met.
2 days revision
1 days drivers Examination CONDUCTED ON THE COMPUTER BASED TRAINING SYSTEM
1 day S.C.I.D. Assessment
1 day T.P.O. Validation
Appendix 2 Page 8 of 8 Conversion Driver Training Course APPENDIX 3 DRIVER OF TRAIN 2020 - CONTINUATION TRAINING HISTORY
Met Continuation Training Lesson Summary July 1996 to October 1997
Date Block Details
July 1996 13 Train Equipment and Preparation
November 1996 14 Train defects, Overhead components and procedures, electro hydraulic point machines and dual control point machines
May 1997 15 Couple/Uncouple Comeng trains, dangerous goods, skidding wheels, Train Authority Working and identification of and dealing with signal irregularities
October 1997 16 Train Authority Working – train disabled / derailed, Nth Melbourne Wash Plant and PA System Operation
Analysis of Continuation Training Lessons Stages 1 to 5 – May 1998 to July 2000
Date Stage Crew Route Train SW SW - Customer Train Meals / Exam Total Manager Knowledge Equipment/ Other Signals Service Stabling Breaks Talk Faults (Hours & Includes minutes) Travel and SIS lesson papers
May 98 1 1.10 3.20 0.55 1.15 0.50 0.25 7.55 Jan 99 2 1.00 3.15 1.00 0.30 0.30 0.45 0.55 7.55 Jul 99 3 0.30 2.00 1.20 0.30 2.25 0.30 0.45 8.00 Nov 99 4 1.30 2.40 1.00 0.30 0.30 0.50 1.00 8.00 Jul 00 5 0.30 1.00 1.50 1.10 1.35 1.10 0.45 8.00 Total 280 735 255 170 130 125 220 245 230 2390 (minutes) % 11.7 30.8 10.7 7.1 5.4 5.2 9.2 10.3 9.6 100
Appendix 3 Page 1 of 1 Driver of Train 2020 - Continuation Training History APPENDIX 4 DRIVERS’ RECENT SHIFT HISTORY
Driver of train 2018 Driver of train 2020 Date Sign on Sign Hours Date Sign Sign Hours off Worked on off Worked 11.7.00 A/L 11.7.00 B/O 12.7.00 A/L 12.7.00 B/O 13.7.00 A/L 13.7.00 16.58 00.51 7.53 14.7.00 A/L 14.7.00 16.20 00.26 8.06 15.7.00 B/O 15.7.00 16.39 00.25 7.46 16.7.00 B/O 16.7.00 B/O 17.7.00 A/L 17.7.00 06.45 14.39 7.54 18.7.00 A/L 18.7.00 06.19 12.54 6.35 19.7.00 A/L 19.7.00 05.37 13.39 8.02 20.7.00 A/L 20.7.00 15.54 15.24 9.30 21.7.00 A/L 21.7.00 05.37 13.39 8.02 22.7.00 B/O 22.7.00 04.21 12.47 8.26 23.7.00 11.30 18.50 7.20 23.7.00 06.28 14.47 8.19 24.7.00 14.09 21.43 7.34 24.7.00 04.26 10.09 5.34 25.7.00 11.24 19.14 7.50 25.7.00 04.29 10.09 5.40 26.7.00 12.03 19.42* 7.39 26.7.00 13.47 19.33* 5.46
*shift of collision
A/L On Annual Leave
B/O Booked Off ( Rostered Day Off )
Appendix 4 Page 1 of 1 Drivers’ Recent Shift History 1 APPENDIX 5 ANALYSIS OF SHIFT PATTERNS
Extract from report from Centre of Sleep Research University of South Australia
Re Fatigue Analysis of driver shifts
The Centre of Sleep Research has developed a software tool for evaluating work related fatigue by examining the time of day and the duration of work and rest periods. The attached document “computerised management of work related fatigue” explains its derivation and application. Suffice to say here that any shift with a fatigue index “score” of more than 80 should be examined from a risk management perspective.
Attached also you will find the results of the fatigue model examination of the work of the two drivers you forwarded to us. We were unable to model the work of driver A as the model requires at least 7 days of prior work history to provide a definitive result for a particular day. However from our experience we may say that work related fatigue would not have been significant with Driver A at the time in question, primarily due to the time of day of his recovery periods (generally 2200 – 1100 which is ideal), and full recovery between shifts could be expected.
For driver B, from the information provided, we can conclude that:
· There was an occurrence on the 10th consecutive shift · Fatigue levels had been rising steadily throughout the working of these shifts due to the preponderance of early morning starts. These starting times cause an interruption to REM sleep periods, which are important for mental alertness. · On the two shifts prior to the incident fatigue levels were of an order to cause concern · However due to the later starting time of the shift on the day of the incident (allowing some recovery of the sleep debt incurred on the previous shifts) work related fatigue was at an insignificant level.
Note the emphasis on work related fatigue above. The model can only deal with the known facts about working time. There may well have been significant non work related matters (sick children, noisy environment, social activities etc.) that meant that driver B did not get a good recovery sleep on the night before his shift on 26/7. Fatigue management is a shared responsibility requiring both the employer (through rostering work with sufficient recovery periods) and the employee (using non work time responsibly) to act in accordance with OH&S principles
Regards,
(Signed) Professor Drew Dawson
Appendix 5 Page 1 of 1 Analysis of Shift Patterns APPENDIX 6 REPORT ON RECENT DEFECTS OF CARS 569 AND 612
Train 2018 - Car 569M
Date Fault description Rectified description 7/6/99 Doors slow to close, door 1 tied Tested ok. closed 28/6/99 Door close button indication flashing No fault found, tested ok. continuously 5/7/00 Door 3 tied closed (inoperative) Door piston replaced. 30/7/99 Wheel slip light permanently on Tested ok. 2/8/99 Rheostatic brake inoperative Traction control replaced 11/8/99 Vertical shock absorbers and other Vertical shock absorber replaced equipment on suspension leaking 13/8/00 Lateral shock absorber leaking on Shock absorber replaced bogie 1 19/8/99 Tail lights (red) inoperative Blown, replaced 21/8/99 Marker light (white) inoperative Blown, replaced 23/8/99 Hand pilot valve hard to hold down Internal shaft lubricated, tested ok. 26/8/99 D exam Completed 26/8/99 Brakes leaking off Fault cleared in running no fault found. 31/8/99 B exam Completed 8/9/99 B exam Completed 9/9/00 B exam Completed 23/9/00 Sticking brakes Fault cleared in running no fault found. 27/9/99 Marker lights (white) inoperative Blown / replaced 27/9/99 Tail lights (Red) inoperative Blown / replaced 10/11/99 Wheel slip fault light permanently on No fault found, tested ok. 29/11/99 Brakes worn, multiple wheels Checked, within specification, tested ok. 3/12/99 Trip modifications Tested ok. 8/12/99 EP brake not releasing, isolated 7 step relay inoperative, replaced 9/12/99 Brake cylinder not releasing, 7 step relay inoperative, replaced multiple wheels 2/2/00 Doors close button indication Doors tested ok. continuously flashing 4/2/00 Flashing door control light Rectified in running, no fault found 8/2/00 Doors self releasing, A side, train No fault found, tested ok. running 10/2/00 Doors close button must be held DR1 contactor – wires 1948 loose down to drive, intermittent fault in terminal. Contactor replaced . 16/2/00 Doors self releasing, B side B side contactor replaced 24/2/00 B exam Completed 1/3/00 Drivers brake valve handle damaged Replaced 17/3/00 Rheostatic brake inoperative Earth fault relay reset
Appendix 6 Page 1 of 3 Report on Recent Defects of Cars 569 and 612 Date Fault description Rectified description 22/3/00 Disc cracked Replaced 3/4/00 A exam Completed 23/4/00 Lateral shock absorber broken Replaced 4/5/00 Brake pipe, slow to charge Drivers brake valve replaced 8/5/00 Wheel slip fault light permanently on Security of sensor cable checked 17/5/00 B exam Completed 7/7/00 Wheel slip light permanently on Tested ok 14/7/00 B exam Completed
Train 2020 - Car 612M
Date Fault description Rectified description 1/6/99 Trip arm damaged, trip not operating Sticking, lubricated 2/6/99 Trip and other equipment – would Trip inoperative, repaired not trip 7/6/99 Trip and other equipment – wont trip Trip jammed, freed or operate at all 26/8/99 E exam Completed 27/8/99 Trip wont reset Trip lubricated 24/9/99 B exam Completed 13/10/99 Trip, tripping, Normal trip Trip inoperative, replaced 15/10/99 Trip wont raise, yellow cock not Trip inoperative, lubricated isolated 15/10/99 Trip wont raise, yellow cock isolated Trip cable, damaged, replaced 20/11/99 Automatic brake erratic, very soft No fault found tested ok. intermittently 3/12/99 Loose trip Secured 9/12/99 B exam Completed 3/1/00 Tail lights (red) inoperative Blown, replaced 5/1/00 C exam Completed 20/1/00 Rheostatic brake inoperative Wheel spin slide unit fuse blow, replaced 21/1/00 Trip, wont raise, Yellow cock Trip jammed, freed isolated 22/1/00 Rheostatic brake inoperative No fault found, tested ok. 2/2/00 Trip wont raise, yellow cock isolated Trip raise/lower switch inoperative, lubricated 5/2/00 Trip wont raise, yellow cock isolated Back jammed, repaired, lubricated and tested ok. 9/2/00 Trip wont raise, yellow cock isolated Piston jammed, freed, tested ok. 22/3/00 Trip wont raise, yellow cock not Raise/lower trip inoperative, isolated replaced 26/3/00 Rheostatic brake inoperative Traction control relay armature plate stop missing, replaced 27/3/00 Trip cable damaged Nuts loose, secured 29/3/00 Trip wont raise, yellow cock isolated Trip jammed, lubricated 29/3/00 Trip wont raise, yellow cock isolated Cylinder not in line with cable, repositioned, adjusted
Appendix 6 Page 2 of 3 Report on Recent Defects of Cars 569 and 612 Date Fault description Rectified description 30/3/00 Bogies, wheels, scaled, wheel 6 31/3/00 Trip wont raise, yellow cock isolated No fault found, lubricated 4/4/00 Trip wont raise, yellow cock isolated Jammed, lubricated 4/4/00 Ride indicator (height), missing, bogie 1, B side 6/7 wheel 5/4/00 Trip wont raise, yellow cock isolated Jammed, replaced 23/4/00 Drivers brake valve, brake controller, Replaced, tested ok. blow of air, minimal 23/4/00 Speedo inaccurate Replaced 1/5/00 Ride indicator (height) missing, Nil stock bogie 1 B side 21/5/00 Rheostatic brake inoperative Plugs secured, tested ok. 16/6/00 Blow of air from electrical cabinet Trip raise/lower switch leaking, repaired 6/7/00 Ride indicator (height) missing 13/7/00 Holding air pressure when brakes are 7 step relay replaced off 20/7/00 Vertical shocker rubbers worn, to be replaced
Appendix 6 Page 3 of 3 Report on Recent Defects of Cars 569 and 612 APPENDIX 7 VERIFICATION OF THE TRAIN BRAKING SYSTEM
1. Introduction
At the request of Mr. K. Butler, Manager, Accreditation Audit Systems, Safety and Technical Services Branch of the Department of Infrastructure, an engineering investigation was conducted on the “Aggressor” train involved in the collision at Holmesglen on the 26th July 2000.
The purpose of the investigation was to determine the integrity and operating condition of the brake systems and individual items of brake equipment fitted to the train.
2. Background
On the 26 July 2000, a 6 car “Comeng” disc brake train (612M-1156T-661M, 563M- 1132T-564M) collided with the rear of a 6-car “Comeng” train (647M-1174T-590M, 570M-1135T-569M) which was stationary at the UP Holmesglen platform.
The lead vehicle of the Aggressor train was 612M, and the car, which took the initial impact on the “Receiver” train, was 569M.
Following the incident, the two, worst damaged 3-car units, (612M-1156T-661M and 569M-1135T-570M) were removed from the tracks and stored beside the down line on the city side of Holmesglen station. The leading unit of the receiver train (647M- 1174T-590M) was despatched to Epping Depot and the trailing unit of the aggressor train was taken back and placed in the stabling sidings at Glen Waverley.
Prior to any further movement, the trailing aggressor unit required a roadworthiness examination, where it was appropriate to determine the condition of the brake systems.
Similarly, prior to any further movement or disturbance of the brake systems of the stored aggressor cars, it was required that the continuity of the brake air systems be tested.
3. Trailing Unit: 563M-1132T-564M ( Glen Waverley sidings)
3.1 Inspection
On Saturday 29 July 2000, I attended Glen Waverley stabling sidings with Mr. A. Robinson, Project engineer, Alstom Aust., and two Alstom Train Maintenance staff, where the trailing unit of the aggressor train (563-1132-564) was stabled.
The 3-car unit was a disc-braked train with the lead car 563M at the city end of the unit.
Appendix 7 Page 1 of 6 Verification of the Train Braking System The cars were initially inspected to determine the physical condition with regard to safety prior to connecting air or power.
3.1.1 563M
The front of the car 563M had suffered significant damage to the front fibreglass panels, deformation of the stainless steel front structure and destruction of the Scharfenberg coupler. The coupler (which houses the electrical and pneumatic inter- car connections), had been damaged in the collision and had been removed. The electrical cables, which are hard-wired between the car body and the coupler had been roughly severed rendering electrical inter-car testing impractical.
Internally, the driving compartment had some minor damage due to dislocation of equipment from the impact-damaged external structure.
A check was made to ensure the Main Reservoir pipe and Brake Pipe isolating cocks from the coupler to the car-body were operable and in the closed position.
Inspection below the car revealed that the compressor mounts were severely distorted from the impact. Some equipment case latches had been dislodged or damaged.
It can be logically expected that other heavy equipment mounts will have been similarly affected.
Brake equipment was inspected and appeared to be undisturbed.
The Scharfenberg semi-permanent couplings on both the 563M-car and 1132T-car had suffered irreversible distortion to their deformation tubes but electrical and pneumatic connections were not damaged.
3.1.2 1132T
The trailer car damage was limited to the deformation tubes at each end of the car.
Brake equipment appeared undisturbed and undamaged.
3.1.3 564M
The car appeared to be undamaged other than some distortion of the compressor mounts. A check of more remote equipment was recommended.
3.2 Test Procedure
As all air had been lost from the Main Reservoir, air connection was made by extension hose to an adjacent Hitachi train from which the test train was fully charged.
Prior to raising pantographs on the train to be tested, an inspection was carried out to identify any air leaks. The train appeared to be in reasonable condition with no significant leaks. The temporary hoses were disconnected and the pantographs were raised individually to check the integrity of each Motor-Alternator circuitry. Some difficulty was encountered with the MA from 563M however, it was considered that
Appendix 7 Page 2 of 6 Verification of the Train Braking System the severed inter-car coupling cables and the result of the impact would have contributed to the problem.
From the cab of car 564M the Main reservoir pipe was observed to charge to the standard 700kPa. The air brake was then cut in at the driver’s brake valve isolating cock.
The brake pipe charged up to the correct pressure of 550 kPa.
The air brake system was then tested, first in Automatic Air mode, stepping the handle from the off to the full service position, then moving the handle to emergency. The Automatic Air and Emergency brakes performed in accordance with normal operating parameters.
The Electro-Pneumatic (EP) brake was switched in and tested in each step applying and releasing. The brake performed correctly.
For each brake mode, the train brake-cylinders were inspected to ensure each car responded correctly.
The brake systems were tested to ensure that change-over from one mode to another occurred correctly.
The train was then powered from that car and responded correctly.
The rheostatic brake could not be tested in the stationary position, however the Earth Fault Relay was inspected and had not tripped.
The brake was applied and isolated in preparation for testing from car 563M.
The above procedure was repeated in car 563M. The brake equipment responded correctly.
Damage to the cabling and dislocation of the Master Controller had produced a powering fault and it was not possible to power the train from the cab without further fault finding and repair work.
The tests conducted were in accordance with the specified brake maintenance test procedures. The brake systems operated in accordance with the specified performance limits set for normal train operation.
Following the inspection the train was declared acceptable to be transferred to Epping train maintenance depot.
4. Leading unit: 612M-1156T-661M (Holmesglen)
On the 3 August, in the company of Mr. Robinson, I attended the site at Holmesglen where the damaged cars were stored.
The purpose of the inspection was (if excessive damage had not occurred) to establish the continuity of the Main Reservoir pipe and Brake Pipe throughout the length of the 3-car unit.
Appendix 7 Page 3 of 6 Verification of the Train Braking System 4.1 Continuity Test
The procedure involved connection of a portable air supply to each car in turn, to pressurise each pipe and ensure that air-flow was evident at the other end of each pipe being tested. In addition any leakage was examined to ensure the leak had occurred following the incident.
Each car was examined and it was determined that connection could be made to the threaded outlet of each isolating cock.
A significant leak was found on the main reservoir pipe on the trailing bogie of 612M. This leak was from a bogie air bag supply pipe which had obviously been damaged either in the collision or when the cars were subsequently moved off the track.
Each car was tested in this manner and all cars were identified as having clear and continuous Main Reservoir and Brake pipes.
5. COMPONENT TESTS: (Ballarat Workshops)
Following discussions with Mr. Robinson, it was agreed that the following components should be removed from the cars, as indicated below, to be tested on the appropriate brake equipment test racks at the Alstom Workshops at Ballarat:-
Car 612M; Driver’s Brake Valve Trip valve Triple Valves Electro-Pneumatic Brake Relay Valve (7-step Relay)
Cars 661M and 1156T, Triple valve EP Valve (7-step Relay valve)
On 24 August, Mr. Robinson and I travelled to the Alstom Ballarat Workshops to conduct the necessary tests.
The supervisor of the Brake shop, provided staff as required to conduct the acceptance test procedures on each of the components.
5.1 Trip Valve: 612M
The trip valve from the leading car in the collision, 612M, was mounted on the test bench and a pressure of 550 kPa. applied. The trip lever was struck and the valve commenced to discharge.
However, instead of allowing a rapid discharge of air down to approx. 100 kPa. or less, the valve reset at 450 kPa. This represented a failure under test. If operated slowly the valve could occasionally be made to operate as specified, but on most occasions it reset immediately.
Appendix 7 Page 4 of 6 Verification of the Train Braking System The valve was stripped and was found to have been lubricated with WD40 or a similar agent. Such spray lubricants should not be used on these valves as the carrier solvents leach the lubricant out the valve’s impregnated sintered spindle bushes.
It was reported that most valves received for overhaul have been treated in this manner, leading to incorrect performance and a reduction in service life.
Each component was examined and several new components were installed after which the valve was retested. The valve still continued to reset at too high a pressure.
It was therefore stripped and rebuilt with the original components.
Test results remained consistent with the valve resetting at high pressures.
To ensure production valves operate correctly in service, the specified test procedure is extremely sensitive, with very low volume airflow rates compared to the flow from a train brake pipe. The higher standard of operating limits required during these tests ensure that all overhauled valves will work satisfactorily in the more demanding rail operating environment.
It was therefore agreed that the valve would be refitted to a suburban train and tested at the normal train pressures and typical volume airflow rates. See Section 6.0 below
5.2 Driver’s Brake Valve: 612M
The Driver’s Brake Valve was mounted on the test rack base plate and connected both electrically and pneumatically.
When the regulated shop air supply was introduced, an air leak became evident which built to a heavy discharge causing the brake pipe gauge to drop to 215kPa from its correct pressure of 550 kPa. The cover plate was removed from the Release Prevention Valve and the circlip, which retains the valve, fell out. In this condition the train would not have been capable of movement, hence it was considered that the circlip must have been dislodged, either as a result of the accident, or when the valve was removed and in transit. The circlip was restored and the air leak was not encountered again.
The brake valve was then tested in accordance with the Manufacturer’s test specification for both pneumatic operation and electric operation.
The valve complied with the normal brake bench test sequence for an acceptable standard valve.
5.3 Triple Valves
The triple valves from all 3 cars were tested in accordance with the Manufacturer’s test specification and all complied with the normal performance requirement.
Appendix 7 Page 5 of 6 Verification of the Train Braking System 5.4 Electro-Pneumatic Valves (7-step Relays ).
The Electro-Pneumatic (EP) Valves or 7-Step relay valves from all 3 cars were tested in accordance with the Manufacturer’s specification and all complied with the normal performance requirements.
6. TRIP VALVE 612M: (Train Test)
On 25 August, the suspect trip valve was fitted to a suburban train at Alstom, Epping Train Maintenance Depot and tested in the normal manner required when a driver is preparing his train and when the trip valve is tested during routine maintenance exams.
The trip was set and the brake pipe fully charged to 550 kPa.
The trip was then struck and the brake pipe fully exhausted until approximately 70-80 kPa at which point it reset. This is normal operation.
The test was repeated several times and the result was correct on each occasion.
Accordingly it can be stated that although the valve did not pass the stringent test requirement on the test bench, the valve was still in an acceptable operating condition and would have performed correctly during the Driver’s preparation checks and in operation.
7. CONCLUSION
The brake systems on train 2020 ved in the Holmesglen incident on 26 July 2000 were in an acceptable operating condition capable of meeting the standard brake performance requirements for a “Comeng” train. Brake pipe and Main reservoir continuity was found to be unimpaired after the accident and would have been proved by the driver prior to his moving the train on the day of the incident.
8. RECOMMENDED ACTIONS
The general condition of the equipment tested was acceptable, however the use of lubricant sprays such WD-40 was identified as contributing to the failure of the oil- impregnated sintered bushes in the Trip valve.
The solvent-based carrier of these spray lubricants dilutes and leaches out of the lubricant which is impregnated into the sintered bushes.
It is therefore recommended that the maintenance providers be made aware of the presence, location and suitable treatment of the sintered bushes.
It is recommended that appropriate instructions are issued to all maintenance staff to ensure that solvents are not used to free or clean sintered bushes.
Further, only a compatible light machine oil should be used to provide an initial assembly coating after bushes are cleaned and then all excess should be wiped away to avoid contamination with dust.
Appendix 7 Page 6 of 6 Verification of the Train Braking System APPENDIX 8 SIGNAL EQUIPMENT HISTORY
Equipment Date Fault / Action performed Signal DG484 21/2/00 Marker lamp out. Lamp replaced Signal DG484 18-21/12/00 Performed preventive maintenance Signal DG484 7-13/7/99 Performed preventive maintenance Signal DG484 30/3/99 Marker light not illuminated. Lamp replaced Signal DG484 30/12/98 Performed preventive maintenance Trainstop DG484 21-22/3/00 Performed preventive maintenance Trainstop DG484 18-21/1/00 Performed preventive maintenance Trainstop DG484 29/10/99 Performed preventive maintenance Trainstop DG484 19/5/99 Performed preventive maintenance Trainstop DG484 1/3/99 Performed preventive maintenance Trainstop DG484 30/12/98 Performed preventive maintenance Track Circuit ADG 24-25/5/99 Performed preventive maintenance 484T Track Circuit 24-25/5/99 Performed preventive maintenance DG484T Relay DG484 29/10/99 Performed preventive maintenance Enclosure DG484 29/10/99 Performed preventive maintenance
Equipment Date Fault / Action performed Signal DG526 18-21/2/00 Performed preventive maintenance Trainstop DG526 15-18/5/00 Performed preventive maintenance Trainstop DG526 21-22/3/00 Performed preventive maintenance Trainstop DG526 18-21/2/00 Performed preventive maintenance Trainstop DG526 29/10/99 Performed preventive maintenance Trainstop DG526 7-8/9/99 Performed preventive maintenance Track Circuit ADG 22-26/11/99 Performed preventive maintenance 526T Track Circuit 22-24/11/99 Performed preventive maintenance DG526T Relay DG526 21-22/3/00 Performed preventive maintenance Enclosure DG526GR 21-23/03/00 Performed preventive maintenance Enclosure DG526J 22-24/11/99 Performed preventive maintenance Enclosure DG526TF 22-24/11/99 Performed preventive maintenance
Appendix 8 Page 1 of 1 Signal Equipment History APPENDIX 9 VERIFICATION OF SIGNALLING SYSTEM
1. Maintenance Records
The signalling system does not have loggers or recorders installed in this area.
The signalling system in this area was commissioned on the 20 Feb 1964.
The Alstom maintenance records dated from January 1999 indicate the following:
· No major or wrong side faults reported on DG484 signal, trainstop, and track circuits (Note: A track circuit is the method used by the signalling system to detect the presence of the train.)
· No major or wrong side faults reported on DG460 signal, trainstop, and track circuits.
· DG484 and DG460 signal, trainstop, and track circuits have been maintained on a regular basis to set standards.
· Timber re-sleepering and ballast resurfacing was carried out in May 2000. To facilitate ballast-resurfacing DG484 trainstop was moved, replaced and tested. The Timber re-sleepering and ballast resurfacing operations caused damage to a variety of cables associated to track circuits and immediately repaired and tested. On the completion it appears that a final inspection was carried out with more cables being identified as substandard, renewed and tested prior to the 26 July 2000.
2. Inspections and tests immediately carried out after the incident.
Alstom records of inspections and tests carried out immediately after the incident indicated that the signalling system function in accordance with design at the time of the incident. Alstom made arrangements for more comprehensive tests to be carried out at a later date. The Trainstop trip arm (not the operating mechanism) was replaced and the original put into storage as evidence. Visual inspection of the trip arm face by Alstom personnel revealed fresh marks that may have been caused by a contact to the trains emergency breaking system. It must be noted that trainstop trip arm was not measured in accordance with maintenance instruction 0302-07 prior to the replacement of the trip arm. The last time this was measure, according to records, was 19/5/2000.
3. Comprehensive inspections and tests
The Alstom personnel carried out comprehensive inspections and tests, in my presence, on signalling system on the 1st August 2000. The inspection and tests where carried out in a professional manner. All data was recorded and analysed.
Appendix 9 Page 1 of 2 Verification of Signalling System The inspection and tests revealed the following:
· The searchlight relay in the DG484 signal was dated 24 July 1976. There was no evidence available to indicate the relay was serviced after that date. Visual inspection of the mechanism operating indicated that the searchlight relay was functional.
· The DG484 trainstop segment gear and pinion gear was not lubricated in accordance with documented standards. The standard requires oil and the gears were lubricated with light grease. Testing provided no evidence to suggest that this affected the safe performance of the trainstop.
· Evidence of rodents in both DG484GR and DG460GR equipment housings. Baits had been laid and there was no evidence of damage caused by rodents.
· The marker light lens was not firmly fixed to the housing.
· The trainstop adjustments were not in accordance with documented standards but were within safe limits.
In conclusion, it is my opinion that the system was functioning in accordance to its design requirements. I wish to highlight that the following concerns:
· There is no major train incident investigation procedure / instruction./ checklist for the railway signalling system. As such, some inspections and tests may have been overlooked in the initial investigation.
· The removed trip arm was not measured and compared to documented standards.
· On the given evidence, the searchlight signal mechanism has passed its service life.
Appendix 9 Page 2 of 2 Verification of Signalling System