Page:ATSB RO-2018-004 - Collision of passenger train A42 with buffer stop.pdf/20

ATSB – RO-2018-004

On Monday 22 January 2018, train A42 approached Richmond Station with a train crew comprising a driver and a guard and with 24 passengers on board. The train entered the platform under the posted speed limit of 50 km/h but did not slow as expected and collided with the buffer at an estimated speed of 26 km/h. The evidence obtained from the train’s event recorders confirm that the driver did not have any input to the controls for the period of 22 seconds from 0951:06 to 0951:28.

The buffer stop collision was the result of a lack of braking input by the driver as the train approached the buffer stop on Platform 2 at Richmond Station. The analysis section of this report explores the human factors surrounding the driver’s performance and likely reasons for his lack of braking input.

The buffer stop withstood the impact of the collision and prevented the train from continuing into the street. The two hydro-pneumatic rams positioned on the front of the buffer stop were not aligned with any structural element on the front of the train, this meant they had little or no effect in the absorption of energy from the collision.

Other elements discussed in the analysis section include:
 * driver safety systems
 * buffer stops
 * crashworthiness and crash energy management systems (CEMS)
 * emergency response management
 * management of safety risks.

The following elements were excluded from further analysis:
 * the train’s braking and control system
 * track adhesion and track-related issues
 * signalling and train control issues
 * the actions of the guard.

There is a risk with the operation of any vehicle that the operator may perform in a sub-optimal way. On passenger trains, there are many procedural and engineering defences put in place to mitigate this risk. These defences include: training, rostering, vigilance devices, operator enable (deadman) systems, train stop/trip gear systems, and the guard. The introduction of technology such as Automatic Train Protection in future will provide an additional defence.

The driver of A42 was interviewed by the ATSB on two occasions and was questioned closely about the events of that day, his previous shifts, and any aspect that may have potentially affected his behaviour on the day of the collision. The driver stated that he was feeling well and everything was normal leading up to, and during, the shift. He said he was well-rested, had slept well before his shift, had eaten normally, was hydrated and was feeling comfortable in the cab of the train. The driver had just had a break at Blacktown station less than an hour before the incident.

The driver was certified as medically fit in accordance with the National Standard for Health Assessment of Rail Safety Workers (Health Assessment). Under this standard, rail safety workers such as the driver must have a valid certificate of fitness to perform rail safety work. The driver last had his category 1 medical assessment in February 2014. He was passed as ‘Fit for Duty – unconditional’. This certificate was valid until April 2019. In addition to this compulsory medical, › 16 ‹