Rail operators are advised to ensure consistent application of procedures, and that checks reduce the likelihood of single‑person errors, after two Melbourne trains entered the same section of single track from opposite directions.
A final report from Victoria's Office of the Chief Investigator (OCI), which investigates rail occurrences in Victoria under a collaboration agreement with the ATSB, details the 25 February 2024 incident.
A non-revenue (not passenger‑carrying) Metro Trains Melbourne train was travelling along a bi‑directional, single line section of track between Ferntree Gully and Upper Ferntree Gully stations, east of Melbourne, when it came to a stop at a red signal.
Another MTM train, a passenger service operating in the opposite direction, was at Upper Ferntree Gully station and scheduled to enter the single line section towards Ferntree Gully.
"The station officer at Upper Ferntree Gully believed the section between Ferntree Gully and Upper Ferntree Gully stations was clear and gave the passenger train permission to proceed into the single line section under a 'caution order'," Chief Investigator Mark Smallwood said.
The passenger service then proceeded into the single line section under the caution order (at below 25 km/h), and began to travel towards Ferntree Gully station, and towards the non‑revenue service which was still stopped midway along the section.
"Fortunately, the driver of the moving passenger train sighted the stationary non‑revenue train a short time later," Mr Smallwood said.
"They brought their train to a stop about 300 m away from the stationary train."
The OCI concluded that the station officer at Upper Ferntree Gully believed a recurring track fault was incorrectly holding the passenger train at the station, and that the single section between the two stations was clear. The non‑revenue service had arrived in the section from Ferntree Gully ahead of schedule and was not expected by the station officer.
"The investigation found that at Upper Ferntree Gully (and some other parts of the MTM network), the issuing of a caution order did not require validation by a second person," Mr Smallwood observed.
"Checks on safety‑critical decisions should be incorporated into procedural systems to reduce the likelihood of single‑person errors.
"In addition, procedures associated with managing trains between Bayswater and Upper Ferntree Gully on the Belgrave line were inconsistently applied, and gaps in protocols and record‑keeping probably impacted the effectiveness of the systems."
In response, operator Metro Trains Melbourne has reviewed relevant procedures and commissioned changes to signalling control circuitry to address issues identified in the investigation.
You can find here the final report: Safeworking incident involving MTM trains 3148 and 7255, Ferntree Gully, Victoria, on 25 February 2024
