Sharing investigations – lessons for industry

In its monthly column, the Rail Industry Safety and Standards Board discusses the Sharing Investigations Forums scheduled in March and September 2020.

One of the forums RISSB co-ordinates on behalf of the rail industry in Australia and New Zealand is the Sharing Investigations Forum. The aim of this forum is to share lessons from a deep dive into incidents involving rail transport operators.

The ATSB has attended part of each forum and provided an analysis of, and lessons from, a rail incident. Or at the most recent forum, from an aviation incident. Featuring high on the agenda has been a presentation from a university around incident investigation and systems thinking.

To date, two forums have been held – one in Melbourne in 2018 and the other in Brisbane in 2019. Both Sharing Investigations forums were fully booked, and feedback was phenomenal with two further forums planned for 2020 – Sydney on 30th March at John Holland, Pyrmont and the second in Perth, likely to be held in September 2020 at Fortescue Metals Group in Perth.

Organisations that have presented and discussed an incident and the ensuing investigation into that incident have included: MTM, TasRAIL, ARTC, QR, Arc Infrastructure and Aurizon.

While there were many lessons shared, there were several common but critical lessons for industry that emerged from the in-depth discussions.

These include:

  • The need for clear, accurate safety critical communication (including the need to proactively monitor and demonstrate this).
  • The need to support identification of local risks (where workers do not perceive the level of risk, or the changing risk profile over time on site).
  • The importance of leadership from senior management/senior executives (response to incident is to ensure safety before continuing operations).
  • The benefits of reinforcing positive behaviours (through providing a just and safe culture).
  • Clarity on each person’s role and responsibility (ambiguity leading to assumptions that something was done).

RISSB is gathering lessons from these forums and turning them into a series of key lessons for industry that will be presented at the 2020 RISSB Rail Safety Conference in Sydney on 31 March and 1 April 2020.

In relation to communications, RISSB has worked with industry
to develop and publish a Safety Critical Communications Guideline (January 2018) and has since developed and is offering a Safety Critical Communications Course.

For more information about RISSB’s 2020 Rail Safety Conference, please visit conference-2020/

To view RISSB’s 2020 training and events, please visit

V/Line driver’s near-miss with a train after failing to stop at signals

An Australian Transport Safety Bureau (ATSB) rail safety investigation found a V/Line driver ran through a level crossing before the boom gates were down at Marshall, Victoria.

On January 2nd 2018 at around 2pm, V/Line train 7750 travelling to Geelong and 1305 V/Line travelling to Warrnambool were heading towards each other on a single track in suburban Geelong.

The two trains were 940m apart from colliding when a control room worker in Melbourne issued an emergency call instructing the drivers to stop.

The ATSB found that the driver of train 7750 did not respond to the Stop indications of signals MSL10 and MSL8 at Marshall.

The driver of train 7750 entered the single line section between Marshall and South Geelong and then into the Marshalltown level crossing before the crossing booms had lowered.

At approximately the same time, The 1305 V/Line Melbourne to Warrnambool service with two crew and 166 passengers on board had departed Geelong and was headed towards Marshall on the same single line section.

The trains were scheduled to cross using the loop track at Marshall.

The investigation report stated that in preparation for the cross of the two trains at Marshall, the train controller “was observing the signalling control and CCTV VDU when he saw train 7750 go through Marshall platform travelling too fast to stop at MSL10,”

“Realising that train 7750 would not be able to stop, the train controller made a fleet radio transmission to all trains in the area to ‘Red Light’ (Stop), the CCTV also allowed the train controller to confirm that train 7750 had stopped beyond the Marshalltown Road level crossing.”

The investigation concluded that the driver of V/Line train 7750 was most likely influenced by symptoms associated with nicotine withdrawal, having not applied a nicotine patch on that day.

“Following this incident, the driver of train 7750 tested positive for an inactive metabolite of cannabis, with levels suggesting use within the previous 7 days,” the report stated.

It could not be determined whether that had affected the driver’s performance at the time of the incident.

Report authors say attempts by V/Line safety critical workers to stop smoking should be managed under medical supervision.

As a result of the incident, V/Line has installed a train protection system at Marshalltown Road level crossing to stop a train that has passed a signal at Danger, which has over-speed sensors to prevent a train entering the crossing when unprotected.

V/Line has continued with planning for the provision of three-position signalling for this section as part of other infrastructure projects.

The driver of train 7750 no longer works for V/Line.

Inquiry launched into Wellington train derailment

New Zealand’s Transport Accident Investigation Commission (TAIC) has opened an inquiry over a July 2 freight train derailment that occurred in Wellington.

The TAIC has opened the inquiry to investigate whether or not the incident poses significant implications for transport safety. The TAIC will then make “findings or recommendations to help improve transport safety” based on the outcome of the inquiry.

The derailment occurred on July 2 at around 7:40pm NZ time at a junction between yard and North Island Main Trunk line. Four container wagons were derailed in the incident.

While no injuries were reported as a result of the incident, it did cause significant disruption for Wellington’s network, with all train services save the Johnsonville line temporarily cancelled while repairs and removal works were carried out by workers from KiwiRail. More than 20,000 commuters were reported to have been affected by the issues yesterday.

Night works are set to continue over the course of the week to fully restore the network, which suffered damage to eight sets of points and other sections of track. Metlink Wellington announced that late notice bus replacements for Hutt Valley line will be in operation tonight to compensate for the works.