Preliminary report released 19 September 2022
This preliminary report details factual information established in the investigation’s early evidence collection phase, and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.
The occurrence
Prior to the incident
On 13 July 2022 at about 0716, V/Line passenger train 8070 departed Echuca on a scheduled service to Southern Cross Station in Melbourne via Bendigo (Figure 1). The three-car VLocity Diesel Multiple Unit (DMU) was operating on the regional broad gauge line. Onboard were the driver, conductor and 40 passengers.
Figure 1: Broad gauge rail route from Echuca to Bendigo
Source: e-way street directory, Melway 2017, annotated by Chief Investigator, Transport Safety (Victoria)
That same morning, a property owner (farmer) north of Bendigo and near Goornong was expecting a truck to collect and transport a load of hay. The farmer had engaged a local transport company and arrangements were made for the truck to use the Holmes Road level crossing that was near the farm. Use of this crossing provided a route between the Midland Highway and Railway Road on which the farm was located.
The Holmes Road level crossing was a gated, passive level crossing that was not available for normal public access. The gates on both sides of the crossing were fitted with locks, and keys had been provided to authorised property owners.
The farmer reported attending the Holmes Road level crossing shortly before the expected arrival of the truck, unlocking and opening the gates and then returning to the hay shed on their property.
The incident
The truck driver had been instructed to proceed to the farm to load hay for delivery to Mansfield. They travelled north along the Midland Highway from a nearby transport depot and turned left at the access road to the Holmes Road level crossing. Arriving at the level crossing, they found the gates open, and proceeded onto the crossing.
Train 8070 was scheduled to arrive at Goornong Railway Station at 0808. The train driver reported that, on approaching the level crossing, they could see the truck turning off the Midland Highway towards the crossing. With the train travelling at about 70 km/h, the train driver sounded the horn and expected the truck to stop. When it did not, the train driver made an emergency brake application and was in the process of turning their seat away, when the train impacted the truck.
The impact resulted in the derailment of both bogies on the leading car of the train. The lead rail car and the track infrastructure were extensively damaged. The train driver sustained minor injuries. There were no injuries to the passengers on the train.
The truck driver was seriously injured in the collision. The truck was severely damaged, with the semi-trailer separating from the prime mover (Figure 2).
Figure 2: Rear of train, prime mover and semi-trailer of truck after collision
Source: Chief Investigator, Transport Safety (Victoria)
Context
Location
Goornong is about 28 km north of the city of Bendigo in Victoria and the Holmes Road level crossing is about 5 rail-km north of the Goornong Railway Station (Figure 1).
Level crossing
The Holmes Road level crossing connected the Midland Highway and an unsealed local road named Railway Road that ran parallel to the rail track on its western side. Although Holmes Road was about 950 metres north of the level crossing and did not intersect the rail track or the Midland Highway, the crossing was designated the Holmes Road level crossing for V/Line identification purposes.
The Holmes Road level crossing was located about 2.4 km from the transport depot and about 700 m from the hay shed access road that was on the opposite side of the railway (Figure 3).
Figure 3: Location of Holmes Road level crossing
Source: Google maps, annotated by Chief Investigator, Transport Safety (Victoria)
Crossing protection
In 2013, V/Line equipped the level crossing with lockable gates. To provide limited access to the level crossing, V/Line had a formal agreement with local property owners. The agreement provided authorised users access to the level crossing under conditions set out in the agreement, and keys to the gates of the crossing were provided to those authorised users.
The crossing road was about 6 m wide and a single swing gate was installed across the road on either side of the railway. The gates were fitted with signage that included a notice with a telephone number to call before transferring livestock or heavy machinery, a reference number for the level crossing and to advise train control when the crossing was clear.
The level crossing was also fitted with signage typical of a passive (give way) level crossing. The Australian Standard 1742.7[1] specified the signage requirements. W7-12[2] and RX-8[3] signs were located on the Midland Highway before the turn-off to the level crossing (Figure 4).
Figure 4: Signage on approach to and at the level crossing
Source: AS1742.7:2016, annotated by Chief Investigator, Transport Safety (Victoria)
On either side of the crossing, R6-25,[4] R1-2[5] and RX-9[6] signs were installed (Figures 5 and 6).
Figure 5: Holmes Road level crossing access from east of the rail track
Holmes Road level crossing shown from the east side, the approach side of the truck. At the time of incident, the gate was open.
R6-25, R1-2 and RX-9 assemblies to the left of the road were knocked to the ground during the collision.
Source: Chief Investigator, Transport Safety (Victoria)
19 September 2022
Holmes Road level crossing shown from the west side with all signage intact.
Source: Chief Investigator, Transport Safety (Victoria)
Train 8070
Train 8070 was a three-car VLocity set numbered 3VL35, consisting of car 1135 (DMD), 1335 (TM), and 1235 (DM).[7]
In addition to its derailment, the impact with the truck caused damage to the front of the leading car. The laminated safety glass of the windscreen and side windows were shattered, but all windows remained within their frames (Figure 7). The driver’s cab floor was pushed up and the underside of the control desk was deformed.
Figure 7: Damage to the front of the train
Source: Chief Investigator, Transport Safety (Victoria)
The truck
The truck consisted of a 2013 Kenworth T909 prime mover, coupled to a 45-ft drop-deck semi-trailer (Figure 8).
Figure 8: Drop-deck semi-trailer
Source: Chief Investigator, Transport Safety (Victoria)
Further investigation
To date, the ATSB has:
- inspected the location of the occurrence
- examined train operational information
- examined truck operational information
- interviewed a number of parties
- commenced collection of other relevant information
The investigation is continuing and will include review and examination of:
- the arrangements for the use of the Holmes Road level crossing
- the use of the level crossing by property owners
- the operation of the truck and train
- the configuration of the level crossing
Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.
A final report will be released at the conclusion of the investigation.
About the ATSB
The ATSB is an independent Commonwealth Government statutory agency. It is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers.
The ATSB’s purpose is to improve the safety of, and public confidence in, aviation, rail and marine transport through:
- independent investigation of transport accidents and other safety occurrences
- safety data recording, analysis and research
- fostering safety awareness, knowledge and action.
The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia, as well as participating in overseas investigations involving Australian-registered aircraft and ships. It prioritises investigations that have the potential to deliver the greatest public benefit through improvements to transport safety.
The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 and Regulations and, where applicable, international agreements.
Rail safety investigations in Victoria
Most transport safety investigations into rail accidents and incidents in Victoria and New South Wales (NSW) are conducted in accordance with the Collaboration Agreement for Rail Safety Investigations and Other Matters between the Commonwealth Government of Australia, the State Government of Victoria, and the State Government of New South Wales. Under the Collaboration Agreement, rail safety investigations are conducted and resourced in Victoria by the Chief Investigator, Transport Safety (CITS) and in New South Wales by the Office of Transport Safety Investigations (OTSI), on behalf of the ATSB, under the provisions of the Transport Safety Investigation Act 2003.
The Chief Investigator, Transport Safety (CITS) is a statutory position established in 2006 to conduct independent, no-blame investigation of transport safety matters in Victoria. CITS has a broad safety remit that includes the investigation of rail (including tram), marine and bus incidents.
Purpose of safety investigations
The objective of a safety investigation is to enhance transport safety. This is done through:
- identifying safety issues and facilitating safety action to address those issues
- providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available on the ATSB website. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
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- AS1742.7:2016, Manual of uniform traffic control devices, Part 7: Railway crossings.
- Railway Crossing on Side Road.
- Railway Gate on Side Road.
- Railway Crossing.
- Give Way.
- Railway Crossing width marker assembly.
- DMD - Driving Motor (Disability toilet), TM - Trailing Motor, DM - Driving Motor