Lessons Learned: Opposing Trains Enter Same Section of Track

Multiple factors allowed opposing trains to enter same section of Melbourne track.

Rail operators are advised to ensure consistent application of procedures, and that checks reduce the likelihood of single‑person errors, after two Melbourne opposing 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 (Australia) under a collaboration agreement with the ATSB (Australian Transport Safety Bureau), details the 25 February 2024 incident involving opposing trains.

A non-revenue (not passenger‑carrying) Metro Trains Melbourne train was traveling along a bidirectional, 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 toward 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 toward 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 signaling control circuitry to address issues identified in the investigation.

What the ATSB found

It was found that the station officer at Upper Ferntree Gully gave permission for train 3148 to enter the single line section in the belief that the track was clear of other rail traffic. They were unaware that train 7255 had departed Bayswater earlier than its scheduled departure time and had entered the section. Although the signal panel at Upper Ferntree Gully indicated that the section was occupied, they believed that the panel indication was due to a recurring track fault. The panel was of an older type and did not include train identification information. The investigation also found:

• Processes in place at Upper Ferntree Gully did not require validation by a second person of a station officer’s decision to issue permission to pass a signal at stop.
• The station officer at Upper Ferntree Gully did not receive a bell signal from Ringwood signal box for the early departure of train 7255 from Bayswater. Over time, the application of several MTM administrative signaling procedures and practices had become inconsistently applied by signaling staff on the Belgrave line.
• An internal MTM audit was ineffective in addressing deviation from MTM train control processes on the Belgrave line.
• Departure signals at Bayswater and Ferntree Gully stations were set to fleeting which meant train 7255 could depart both stations without signaler intervention or awareness.

Read the final ATSB report: “Safeworking incident involving MTM trains 3148 and 7255, Ferntree Gully, Victoria, on 25 February 2024,” publication date: 6/20/2025.