Overspeed into Wallan Loop

 
  historian Deputy Commissioner

The ATSB has released a report into an incident where the V/Line N on N set went into the loop at Wallan at 97 km/h.

https://www.atsb.gov.au/publications/investigation_reports/2015/rair/ro-2015-011/

The design speed of the turnout is 40 km/h. The usual rule of thumb is that at roughly twice the design speed the inner wheels will unload on the points, leading to a derailment on the following reverse curve. This was well above twice the design speed. I guess the N and the N set have a low centre of gravity and stiff springs. Lucky.

The signalling was working as designed, with the Home signal showing low speed caution, and the auto in the rear showing normal speed warning (i.e. next signal is at stop). This was the original NE SG CTC arrangement. Moves into the loop were signalled using a low speed aspect as there was essentially no overlap at beyond the departure home signals.

The driver had never been signalled into the loop at Wallan before, and, in interview, said that he expected a medium speed aspect into the loop. The report notes that the driver didn't respond at all to the automatic at yellow.

The overspeed variant of TPWS would have prevented this incident, and is installed on the V/Line RFR lines for this reason. It is not installed, however, on the ARTC lines.

The ATSB report focuses on the reporting of the incident. The buffet attendant reported the overspeed, because they had injured passengers.

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  KRviator Moderator

Location: Up the front
I am astounded the Drover managed that, but then compounded his screw up by not calling for emergency services when it became obvious he had injured passengers on board. Sure, he was fearful of a Pineapple, but that does not absolve your responsibility to your crew and your passengers, and furthermore it exposes your company to a multi-million dollar lawsuit if they die due to your inaction. At least the Connie was on the ball.

The Distant is at Caution. Basic safeworking means "The next signal could be at Stop" but what does this turkey do? Barrel along at track speed, not even beginning to brake until he's within sight of the points, nearly 3.5km from the Distant! Too bad if the Home signal was being held at stop because the main & loop were occupied, he'd have caused a bigger pileup than Violet Town.

The report states he was being performance managed for (multiple) SPADs and failing to stop at platforms on several occasions, yet he was still on the road. To me, I have to wonder just how rigorous V/Line's safety culture is given they allowed a Drover to keep his job despite having several at-fault incidents. Either way, this is the result. Hopefully other operators will take it on board, and perhaps introduce a 3-strikes policy or similar.

The report also notes that V/Line was unable to obtain his disciplinary record from Metro due to privacy complaints. This is an ongoing issue in the Rail industry in Australia at present, whereby if you screw up enough with your current employer, you are able to move on with no repercussions. Test positive for drugs at work? No worries, you're allowed to resign and go work for another operator. Multiple at-fault SPAD's? Here's the resignation paperwork, we'd 'encourage' you to fill that out. All that does is pass our problem-child onto another operator, in turn putting other crews, passengers and staff at risk, and personally, it is my single biggest gripe with the industry at present. If you screwup enough, clearly you don't belong up the noisy end of a train. Maybe you should try pottery or something.

The usual rule of thumb is that at roughly twice the design speed the inner wheels will unload on the points, leading to a derailment on the following reverse curve
Historian
I didn't know that! Another tidbit to file away. Razz
  woodford Chief Commissioner

What an interesting report to read, WELL worth reading the whole thing. Sadly to a good extent it DOES show VLine does not always know what its doing, something we have all suspected.

What can one say about this particular drivers perfromance, talking about being way to casual..................................... He is a blight on the good performance of nearly every other driver.

Man, though, do they build the switchs and rolling stock like battle ships.......................................................

woodford
  shutterbug Station Staff

Location: Melbourne
Wow - what an interesting, and frightening, report to read.
  Madjikthise Deputy Commissioner

"said that he expected a medium speed aspect into the loop"

Did they follow up by asking him his definition of medium speed?
  DalyWaters Chief Commissioner

The report also notes that V/Line was unable to obtain his disciplinary record from Metro due to privacy complaints. This is an ongoing issue in the Rail industry in Australia at present, whereby if you screw up enough with your current employer, you are able to move on with no repercussions.
KRviator
This is a major problem with dire ramifications bound to result one day.

When the Office of the National Rail Safety Regulator was set up, there should have been a National Rail Qualifications Register set up and maintained at the same time.  All qualifications and disciplinary actions should be recorded in one place.

There have been known instances since privatisation of at least one person conning an employer into believing they were qualified to drive trains and being let loose at the controls when , in fact, they were not qualified to drive trains at all.
  BrentonGolding Chief Commissioner

Location: Maldon Junction
And I bet the Vline Inform message would have gone along the lines of '11 July 2015, the 8625 Melbourne to Albury service is delayed approximately 60 minutes due to an ill passenger'  
Or if there had been a derailment 'the 8625 Melbourne to Albury service will terminate at Wallan due to a track fault" Very Happy

BG
  Daryl Junior Train Controller

Location: Carrum Downs
gross incompetence!
  billjohnston Station Master

The ATSB report is also deficient in defining speed. It reports yellow over red on the automatic signal leading up to Wallan loop as medium speed warning when in fact it is normal speed warning. Perhaps the Victorian regulator bears some responsibility as it refused ARTC having red over yellow with an 80 indication on the passing loops so now trains regularly pass red over yellow over 80 k points so I suspect some drivers don't get right down to 40 k when entering the passing loops, leading to some complacency which is fine until you get sent into Wallan or the other short loops. If I recall correctly the Wallan points are actually 65 k points hence the train did not derail. Perhaps the database has not been updated when these points were replaced .
Bill Johnston
  Boss Chief Commissioner

Location: Caulfield Line
As KRViator said:

The report states he was being performance managed for (multiple) SPADs and failing to stop at platforms on several occasions,


Even blind Freddie should have been able to see that he lacked the necessary concentration to drive anything - train, car or bike.
  awsgc24 Minister for Railways

Location: Sydney
Moves into the loop were signalled using a low speed aspect as there was essentially no overlap at beyond the departure home signals.
historian

The low speed (small yellow in Vic) into the loop may also mean that track circuits are occupied by something such as a train.

In NSW low speed (small green) guarantees that track circuits in loop are clear.

In NSW shunt (small yellow), if provided, could mean that track circuits are occupied.
  kuldalai Chief Commissioner

Two other observations here not commented on by  ATSB  Investigation  :

1.  A Geelong bound PM Peak period V/Locity derailed and rerailed some years ago on the Down track passing over the then existant Maryibrnong  River  Goods points.  The train paused at Newport after passengers reported a rough ride over the points, but after some time the train proceeded to Geelong at normal speed .  The  investigation was critical that no inspection of the train was carried out before the train was allowed to proceed to Geelong at normal speed .

Here in this North East case we have a recurrence of an incident where rollingstock could have been damaged, and yet the train was allowed to proceed at normal speed .

2. The multitude of different colour light signalling aspects on the regional network itself requires intense concentration by drivers, as a SPAD incident at Marshall around 2 years ago with two aspect colour light signals resulted in a finding that having a mix of 2 and 3 position colour light signals on the same line had the potential to be confusing to operational staff .

3. These days standard Victorian country practice is for a loop cross in 3 position territory to have a Reduce to Medium Speed aspect, followed by a Medium Speed aspect into the loop  (and in most cases with speed proving) .  Here on the North East sg we have Normal Speed Warning followed by a Low Speed aspect into the loop .  Not very consistent and makes it harder for drivers .
  Galron Chief Commissioner

Location: Werribee, Vic
A point also to note is how well the the track seemed to stand up to a basicaly full speed verge through a set of points with a design limit less than half that speed. While not something to take for granted, its good to show these where at least maintained well enough to stand up to this, and that the track kept hold of the loco well enough to keep it on track.
  mikesyd Chief Commissioner

Location: Lurking
No mention of the fate of the driver, can we assume he is no longer driving trains, and not in any safeworking position?
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
No mention of the fate of the driver, can we assume he is no longer driving trains, and not in any safeworking position?
mikesyd
I would not bet on it. Bear also in mind that these one man N class passenger trains mix it with sparks at close intervals in the Metrop.

Was there not a case a few years ago where Vlocity drivers were not even trained to stop the train on the airbrake alone in an emergency?

What exactly are the role, responsibilities and powers of the Rail Safety Regulator in cases of this nature?
  woodford Chief Commissioner

The ATSB report is also deficient in defining speed. It reports yellow over red on the automatic signal leading up to Wallan loop as medium speed warning when in fact it is normal speed warning. Perhaps the Victorian regulator bears some responsibility as it refused ARTC having red over yellow with an 80 indication on the passing loops so now trains regularly pass red over yellow over 80 k points so I suspect some drivers don't get right down to 40 k when entering the passing loops, leading to some complacency which is fine until you get sent into Wallan or the other short loops. If I recall correctly the Wallan points are actually 65 k points hence the train did not derail. Perhaps the database has not been updated when these points were replaced .
Bill Johnston
billjohnston
The report does say the aproach signal ES1475 was yellow over red (Normal speed warning) but the signal WLN/2, the signal immediately protecting the switching was red over red over yellow, low speed caution. No matter what way one looks at it that means 15kph at the points NOT 97kph. The report says there was no siting line issues. Now I will be the first to admit I know little about signaling and safeworking, but in this case a driver ran through a "low speed caution" signal at line speed, as far as I can see there can not possibly be any justification of lack of line knowledge or a complacence issue here, particularly as he had a past record of SPADS. It would seem he is an accident waiting to happen.

Important point: The ATSB is PURELY about finding out WHY something occured, they NEVER have allocated blame ITS NOT WHY THEY ARE THERE, the task is to find out what happened SO IT CAN BE PREVENTED, although I believe the actually have no power to enforce there findings.

woodford
  woodford Chief Commissioner

Woodford asks a question....................

Are we going to have to have a head on collision between two trains with the possibility of scores of deaths before Australia generally adopts some modern signalling system that can stop trains if required.

The apparent lack of concern from the authorities after reading the report makes one REALLY wonder............................

woodford
  woodford Chief Commissioner

Woodford asks a question....................

Are we going to have to have a head on collision between two trains with the possibility of scores of deaths before Australia generally adopts some modern signalling system that can stop trains if required.

The apparent lack of concern from the authorities after reading the report makes one REALLY wonder............................

woodford
woodford
PS, the Harrow and Wealdstone rail crash in Britain in 1952 finally convinced rail authorities in Britain that good training was simply not enough and that SOME kind of automatic warning system was required. Are We going to have to suffer something like this before any action is taken.

woodford
  DalyWaters Chief Commissioner



Important point: The ATSB is PURELY about finding out WHY something occured, they NEVER have allocated blame ITS NOT WHY THEY ARE THERE, the task is to find out what happened SO IT CAN BE PREVENTED, although I believe the actually have no power to enforce there findings.

woodford
woodford
Can anyone see anything from this ATSB report which helps to show a way of preventing this event from occurring again?

V/Lne are requiring drivers to do a one day course in "Just Culture".  Other than that, it is business as usual.

I have been critical of findings of the ATSB for quite a while.  Whilst disciplinary actions are best left to the Operator with (hopefully) a close eye being kept on it by the Rail Safety Regulator, it is important that ATSB have competent people who can direct positive change to prevent incident recurrence.

The major incident at Craigieburn with the Spark hitting the rear of the Apex freight should have seen better action than it did.  It resulted in drivers being required to phone and talk to an answering machine before passing a red automatic signal.  It was deemed unnecessary to require a conversation with a real person as that would mean needing to hire another staff member in train control.  A sad compromise.

In aviation, the ATSB also released a finding regarding the Qantas and Virgin planes that both nearly ran out of fuel landing in serious fog at Mildura Airport.  In its report, ATSB went to great lengths to paint the picture of why these planes had to land in conditions they were not equipped for.  Unfortunately, they did not find that aircraft should carry enough fuel to be able to divert to a different capital to be sure of leaving the bad climate system.  Nor did they criticise Australia's woeful third world infrastructure that has Melbourne Tullamarine as the only airport with fog landing equipment (with Perth soon to be equipped).
  woodford Chief Commissioner

More thoughts from woodford,

While this incedent as it stands is quite serious, a point is drivers are only human and all people make mistakes. The driver that had the SPAD the caused the  Harrow and Wealdstone accident was VERY highly thought of, in fact long after the event people at his depot were saying the investigation was flawed as he simple would not have missed a signal at red. What I think this shows as that even the best can make mistakes and in this sort of case anyway a reliable technology DOES exist to over come this sort of error and make it almost inconsequential and it SHOULD be fitted.

woodford
  woodford Chief Commissioner



Important point: The ATSB is PURELY about finding out WHY something occured, they NEVER have allocated blame ITS NOT WHY THEY ARE THERE, the task is to find out what happened SO IT CAN BE PREVENTED, although I believe the actually have no power to enforce there findings.

woodford
woodford
Can anyone see anything from this ATSB report which helps to show a way of preventing this event from occurring again?

V/Lne are requiring drivers to do a one day course in "Just Culture".  Other than that, it is business as usual.

I have been critical of findings of the ATSB for quite a while.  Whilst disciplinary actions are best left to the Operator with (hopefully) a close eye being kept on it by the Rail Safety Regulator, it is important that ATSB have competent people who can direct positive change to prevent incident recurrence.

.
"DalyWaters"


Its not the ATSB's job to implement change, its there  to point out the immediate circumstances that caused the incedent. The NTSB in the USA is the same, I think you will find it the same the world over. A problem all accident investiagtion bodies face is that there recomendations may go against what big business and govenments wish for, thats almost certainly why they can ONLY recommend changes.

The findings on the causes and what is being done for the wallan incedent are on pages 16 and 17 of the report.

woodford
  kitchgp Chief Commissioner

The report raises a few questions:
As the brakes weren't applied until 5 secs after the train had traversed the points, if the points were set for the main line, and hence there would have been no jolting to gain the driver's attention, would he have continued on his merry way past the departure home signal (WLN/6)?
Was the driver distracted, eg non-operational electronic device?
Why did Metro Trains elect not to provide information about any disciplinary action and the ATSB not recommend that organisations be required to exchange such information in the future?

For someone who might know:
Does the ARTC Network Control Officer advise a driver by radio that the train is to be held at a crossing loop or does the driver just "pick it up" from the signal aspects? There is nothing in the report to say the driver was ever aware of what was going on, until he was jolted by the points and probably saw "red over red" at the departure home signal (WLN/U6).
  HardWorkingMan Chief Commissioner

Location: Echuca
There seems to be an increase in 'distraction issues' in all forms of transport.  Texts now "need to" be responded too instantly not when it's convenient. People are playing games on their smartphones while driving, cycling, driving vehicles (including public transport) etc.  Hopefully this wasn't a case of a new level in Candy Crush or a nearby Pokémon!
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
The report raises a few questions:
As the brakes weren't applied until 5 secs after the train had traversed the points, if the points were set for the main line, and hence there would have been no jolting to gain the driver's attention, would he have continued on his merry way past the departure home signal (WLN/6)?
Was the driver distracted, eg non-operational electronic device?
Why did Metro Trains elect not to provide information about any disciplinary action and the ATSB not recommend that organisations be required to exchange such information in the future?

For someone who might know:
Does the ARTC Network Control Officer advise a driver by radio that the train is to be held at a crossing loop or does the driver just "pick it up" from the signal aspects? There is nothing in the report to say the driver was ever aware of what was going on, until he was jolted by the points and probably saw "red over red" at the departure home signal (WLN/U6).
kitchgp
Regardless of whether ARTC or 'the man outside Hoyts' rings him/her up to say 'do up your shoe laces' a Driver is responsible for obeying the signals as well as driving to whatever conditions he may encounter at all times. End of story.
  Valvegear Oliver Bullied, CME

Location: Richmond Vic
or 'the man outside Hoyts'
"YM-Mundrabilla"
Now you're showing your age !

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