March 30, 2020 | Susan Napier-Sewell

Insufficient Brake Application Contributes to Slow-Speed Collision

Photo source: ONRSR

Insufficient Brake Application Contributes to Slow-Speed Collision

The slow-speed collision of an empty passenger train into a buffer stop on February 25, 2019, highlights the importance of train safety systems to protect against driver error and incapacitation, as the final report of the Australian Transport Safety Bureau (ATSB) investigation notes

What happened to cause the slow-speed collision?

After its passengers had disembarked, Metro Trains Melbourne train TD 6591 departed Newport Station for a siding where it was to be stabled (parked and secured). As the train approached the stabling location, the brakes were not applied in sufficient time to stop the train, and it collided with the buffer stop.

The collision resulted in substantial damage to the front of the train and the buffer stop, and the driver was hospitalized with minor injuries.

In subsequent interviews, the driver reported losing consciousness for a period of time prior to the collision, recalling entering the siding but having no other recollections until after impact. Also, subsequently, the medical examination found the driver may have fainted due to dehydration and lack of nutrition.

Analysis of data from the driver cabin’s Vigilance Control Event Recorder System (VICERS) showed that a brake application consistent with emergency braking was made about 1.5 seconds before impact, but that was after passing the required stopping point.

“Train safety systems are an important protection against driver error and incapacitation”

“The driver may have been incapacitated immediately prior to the accident and therefore temporarily lost awareness, leading to the train not stopping at the designated stopping point as the driver did not apply the brakes in sufficient time,” said ATSB Director Transport Safety Dr Stuart Godley.

“However, due to limited and conflicting evidence the cause, duration, and presence of incapacitation could not be determined.”

The train safety system did not activate during the incident

While the train was equipped with a safety system, comprising a pilot valve as part of the master controller, that was designed to apply the brakes in situations such as driver incapacitation, it did not activate in this incident. The recorded data indicated that sufficient pressure was maintained on the master controller. Therefore, the only aspect of the train safety system that could have activated and applied the brakes to protect against driver incapacitation was not triggered.

Additionally, the post-accident testing of the train’s braking system and the master controller hand pilot valve found no faults that would have contributed to a failure to stop.

“Train safety systems are an important protection against driver error and incapacitation,” Dr Godley noted.

“In addition, drivers are reminded to maintain their health and fitness for work to reduce the likelihood of incapacitation, including maintaining adequate levels of nutrition and hydration as well as consideration of the potential impact of fatigue,” Dr Godley said.

Learn more about the human factor of fatigue and its causal effect

Dig deeper into the very real human performance factor of fatigue on the ATSB website.

Read the ATSB report RO-2019-006: Collision of passenger train TD 6591 with buffer stop, Newport siding Victoria, on February 25, 2019.

The best solution foundation for safely transporting people and cargo from Point A to Point B

Transportation companies that move cargo or people by air, sea, road, pipeline, or rail, need improved safety, quality of service, and schedule performance. How do they get it? By finding and fixing the causes of problems through applying TapRooT® root cause analysis.

Corporations around the world do it reactively by using TapRooT® Root Cause Analysis to find and fix the causes of accidents and near-misses.

From small companies to large global industries—they do it proactively by using TapRooT® Root Cause Analysis for effective audits, assessments, and observations, and fixing root causes before accidents happen.

How to STOP repeat failures using Equifactor® Equipment Troubleshooting

Read the article by Mark Paradies, Co-Creator of TapRooT® Root Cause Analysis Training System and President/CEO of System Improvements Inc. Learn more about Equifactor® Equipment Troubleshooting and enroll in an Equifactor® course.

Founded in 1988, the TapRooT® Root Cause Analysis System solves hurdles every investigator faces

TapRooT® Root Cause Analysis Training System takes an investigator beyond his or her knowledge to think outside the box. Backed with extensive research in human performance, incident investigation, and root cause analysis, TapRooT® is a global leader in improved investigation effectiveness and productivity, stopping finger-pointing and blame, improving equipment reliability, and fixing operating problems.

System Improvements, the creator of the TapRooT® System, has a team of investigators and instructors with years of extensive training ready to offer assistance worldwide. We also offer ongoing support to our clients through free newsletters and root cause tip videos, the root cause analysis blog, and our annual Global TapRooT® Summit.

Register for a TapRooT® Root Cause Analysis Training Course

NOTE: Because of current corporate and governmental travel restrictions, social distancing policies, governmental regulations, and overall concern of the virus, we are CANCELLING all courses in North America through the end of May, and some into the early summer months. We hope this will allow enough time for the virus to subside and our clients to recover.

Of course, our staff and technical support team are working during this time. Feel free to connect by phone (MAIN: 865.539.2139; SUPPORT: 865.357.0080) or EMAIL.

We look forward to teaching COURSES as soon as possible. In the meantime, we also offer ongoing support to our clients through free NEWSLETTERS, root cause tip VIDEOS, and the Root Cause Analysis BLOG on our WEBSITE.

Please see our Covid-19 full STATEMENT.

TapRooT® Root Cause Analysis Training courses are taught all over the world. If you are interested in learning how to stop repeat incidents, find a 2-DAY or 5-DAY course.  We are available to train you and your staff on-site at your workplace; CONTACT US to discuss your needs. You may also call us at 865.539.2139 for any questions you may have.

Keep in Touch to Improve Your Problem-Solving Skills

We’re continually training, helping you improve your professional root cause analysis skills. Stay current with your TapRooT® Root Cause Analysis skills and training by:


Accident, Human Performance, Investigations
Show Comments

Leave a Reply

Your email address will not be published. Required fields are marked *