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Rail Safety News
December 2018

Rail Safety News is produced by Rail Safety Victoria (RSV), a branch of Transport Safety Victoria (TSV), to help develop a strong safety culture in the tourist and heritage railway sector.

Twice a year (June and December), we write technical articles and source case studies – highlighting local and international expertise and experience – to help inform safe rail operations as required under rail safety legislation.

In this issue:

  • Director's update
  • Delaying bridge inspections puts everyone at risk
  • Accreditation – notification of change
  • Track inspection – beyond the basics
  • Summary of recent rail incidents
  • Volunteering and fatigue management
  • Personal profiles: Meet Mohan and Peter
Director's update

Dear subscriber,

In this edition of Rail Safety News I’d like to bring you up-to-date on:

  • Rail Safety Victoria’s key regulatory achievements
  • The Annual Rail Forum
  • The current situation with the local/Victorian rail legislation transition to national legislation, regulated by ONRSR.

Recently Rail Safety Victoria (RSV) published a report on our key regulatory achievements for local rail safety over the last two years, alongside those of the other branches of Transport Safety Victoria. 

The Annual Rail Forum held in Melbourne on 5 June 2018, was attended by over 38 representatives from both our national and local rail industry.

Results of a forum attendee survey were positive and indicated a need and willingness to continue this event in 2019.

The survey results indicated:

  • 80% of the forum topics were rated as very useful
  • Many survey respondents loved hearing about industry lessons from MTM and its experiences as a result of an incident at Laverton
  • 50% rated ONRSR industry updates as the most useful of the topics
  • More than 50% of respondents found value in the networking lunch and suggested it should be longer
  • Respondents see value in having more of their staff attend from their own organisations
  • Respondents would like to learn more about Office of the National Rail Safety Regulator (ONRSR) and the Melbourne office’s involvement in the national work.

Our next Rail Forum (Local and National operators) is scheduled for 25 June 2019, 9.30am -1.30pm in the Level 5 Theatrette, 121 Exhibition St, Melbourne. In response to popular request, operators will be able to bring other personnel from their organisations and we will extend the timing by an hour. If anyone would like to share any of their lessons as a presenter or would like a specific topic covered please let me know as soon as possible.

As many of you are no doubt aware, the Service Level Agreement (SLA) between TSV and ONRSR is still in place, and that in March 2018 the Victorian Government announced that a policy decision was made to remove the SLA and transition to a direct delivery model whereby all operators (including light rail) still accredited under Victorian legislation will come under Rail Safety National Law (RSNL). In effect, this will mean that all rail transport operators currently accredited under local/Victorian rail legislation will transition to national legislation, regulated by ONRSR.

In order for this to take effect, legislative amendments are required and these will be addressed as soon as possible. It is therefore, at this stage, not possible to set a date for the transition in 2019 and we will keep you informed of progress.

As with all previous transition from jurisdictions to ONRSR, information sessions will be held for those operators not previously regulated by ONRSR. A transition period will apply for transitioning operators to ensure they are compliant with any requirements under the national legislation that are not requirements under their current legislation. ONRSR’s guideline for Duty holders on transition to the RSNL contains useful information.

In the interim, we are here to answer any of your questions at any stage throughout the process.

Please contact your known representative, or reach out to RSV at:

T: 1800 223 022

I hope you enjoy this edition of Rail Safety News.

Happy holidays to you all, as we look forward to a safe 2019.

Jodie Talone
Director, Rail Safety

Delaying bridge inspections put everyone at risk

How important are timely inspections and maintenance of bridges? Sadly, we often don't think about this until a catastrophe occurs.

In Genoa, Italy, more than 40 people died and dozens were injured when the Ponte Morandi bridge collapsed in August. While some investigators might look at design deficiencies, some will look at inspection and maintenance matters.

Pictured: Kilcunda bridge

Read about bridge inspections

Kilcunda rail trestle bridge
Accreditation – notification of change

It is a condition of Rail Transport Operator (RTO) accreditation to provide written notification of certain things.

These include decisions, events or operational changes within the scope of the RTO’s operations, as per Rail Safety (Local Operations) (Accreditation and Safety) Regulations 2018 (Vic).

Typing on a keyboard

Notifications can be made in writing via the Rail Safety page on the TSV website by clicking the Notify of a change link.

RSV utilises these notifications to monitor risk and to track the extent of management of change within the RTO operations.

Read more about notification of change

Track inspection – beyond the basics

How does a rail operator effectively manage track infrastructure so that it: performs its operational, business and functional requirements; is fit for purpose; and is compliant with rail safety legislation?

Each rail operator has a different mix of operational requirements and a unique risk profile. 


When establishing that profile, a rail operator should consider the frequency of trains, the quality of track, the quality of the fastenings, the quality of the sleepers, whether the track has degraded, the overall track geometry, the track gradient – for starters.

Read more about track inspections

Summary of recent rail incidents

Of the seven recent rail incident investigations summarised in this issue, four involved light rail and three heavy rail.

The light rail incidents involve common themes of over speeding on curves, door entrapment and tram-to-tram collision.

Two heavy rail investigations relate to heritage trains operating on steep gradients and the need for particular care in such environments.

Tram speeding on a curve - Yorkshire, UK

On 19 July 2018, a tram on the Sheffield Supertram system in Yorkshire entered a tight curve at 37 km/h where the permitted speed was16 km/h.

The tram driver realised that he was going too fast just before the tram reached the curve and applied the emergency brake which brought the tram to a stand.

A Sheffiled tram

The sudden deceleration led to one passenger sustaining significant injury when she collided with one of the tram’s exterior doors. The impact caused a component in the door system to fail and the door to partially open.

Although the passenger remained within the tram, it is possible that she could have been ejected through the open door in slightly different circumstances.

This incident and a similar occurrence at Sandilands junction in 2016 led to UK tram operators, owners and infrastructure managers being required to:

  • Conduct a systematic review of operational risks and control measures associated with the design, maintenance and operation of tramways, including consideration of the factors that affect driver attention and alertness.
  • Develop measures to automatically reduce tram speeds if they approach high risk locations at speeds which could result in derailment or overturning.
  • Review signage, lighting and other visual information cues to assist drivers on the approaches to high risk locations such as tight curves. It also called for the consideration of in-cab warnings to tram drivers on the approach to high risk locations as an interim measure, ahead of the introduction of any future automatic tram speed interventions.
  • Improving the passenger containment provided by tram windows and doors.

Read more on the Rail Accident Investigation Branch website

Passenger trapped and dragged - Greater Manchester, UK

On 30 May 2018, a passenger was dragged after his hand became trapped in a pair of closed and locked doors in Bury, Greater Manchester. The tram was stopped by the driver after travelling about 15 m, reaching a maximum speed of 10 km/h.

This incident occurred because the driver believed that the illuminated ‘doors closed’ light meant nothing was trapped in the closed and locked doors, so the tram was safe to depart. The light actually means that no object has been detected between the closed doors by the door obstacle detection system.

The operator has briefed its drivers to undertake the final door visual check with the CCTV monitor in ‘split-screen’ mode showing the view of the tram doors obtained from an external camera mounted on the rear of the tram in addition to the front camera view used at the time of the incident. This practice has been embedded into its driver training programme.

Read more on the Rail Accident Investigation Branch website

Light-rail collisions - Pennsylvania, USA

On 21 February 2017 a Pennsylvania Transportation Authority (SEPTA) light-rail passenger train 57 struck stationary train 67. The collision and associated derailment caused train 67 to strike train 51 which was operating on an adjacent track. Four people were injured. The total estimated equipment damage was US$1.6 million.

The investigation by National Transportation Safety Board (NTSB) found that the driver of train 57 failed to control the speed of his train while approaching the stopped train 67. The probable cause was temporary loss of awareness.

The NTSB issued a recommendation to the Federal Transit Administration that it require the installation of crash- and fire-protected inward- and outward-facing audio and image recorders to verify crew actions and operating conditions.

Read the NTSB report

On 4 January 2017, SEPTA tram 9101 stopped to offload passengers. A trolley traveling on the same track struck it in the rear at an estimated impact speed of 18 km/h. First responders transported 40 passengers and both operators to local hospitals for treatment of minor injuries. The total estimated equipment damage was US$60,000.

The investigation found that the driver of the striking tram demonstrated degraded operating performance consistent with fatigue prior to the collision. The likely decline in performance was the result of a combination of fatigue from the effects of a recent illness, not sleeping well the five nights prior to the accident, and the sedating effects of over-the-counter medicine. This combination of factors negatively affected his medical fitness for duty.

The investigation by NTSB recommended the American Public Transportation Association develop performance standards for the use of forward collision avoidance systems technology for light-rail vehicles operating on an urban street environment.

Read the NTSB report

Derailment of a passenger train - Wales, UK

On 10 June 2018, a heritage passenger train in Wales, hauled by a ‘Garratt’ steam locomotive derailed the leading wheelset of the locomotive on a curve. No injuries were reported among the passengers or crew.

The accident was due to the failure of a suspension component (an equalising beam) on the locomotive, resulting in the complete unloading of the left leading wheel. The unloading allowed the flange of the left wheel to climb onto and across the left-hand rail into derailment.

This derailment demonstrates the importance of heritage railways ensuring that specific and appropriate inspections and checks are built into the vehicle maintenance and overhaul regimes. These help to monitor the integrity of all safety critical components which could cause derailment in the event of failure, and to ensure that such components are reassembled correctly after overhaul. This is particularly important on heritage railways with steep inclines.

Read more on the Rail Accident Investigation Branch website

Runaway coaches - South Gloucestershire, UK

On 25 July 2018, during shunting operations on the Avon Valley Railway, two empty coaches ran away for approximately 40m at Bitton station in South Gloucestershire.

The coaches ran towards a gated cycle and footpath crossing. Fortunately, they stopped when a wheel of the leading axle became stuck in the converging switch and stock rails of a set of points.

Avon Valley Railway coaches

At the same time, the leading coach collided with the level crossing gate.


This accident demonstrates the importance of the need for care when stabling vehicles and shunting on a running line in areas with significant gradients.

Read more on the Rail Accident Investigation Branch website

Collision at user-worked crossing - Kent, UK

On 23 October 2017, a passenger train collided with a parcel delivery van on a user-worked level crossing in Teynham, Kent. The train did not derail, and no-one on the train was hurt, but the train was damaged by the impact. The van driver suffered serious injuries and the van was severely damaged.

The investigation found that an underlying cause of the accident was that the requirement for authorised users to be responsible for briefing visitors about the safe way to use private crossings is unreasonable in present-day circumstances.

Read more on the Rail Accident Investigation Branch website

Volunteering and fatigue management

In our Western society we are increasingly "stealing time from the night”. That is, using it as a resource to free ourselves from the “time squeeze”: It makes sense to be so efficient but it comes at a cost.

Our biology requires us to function according to the rhythm of the Earth’s 24-hour cycle and there are consequences for stealing time.

Alarm clock

Fatigue is therefore, widely accepted as a safety issue across industries. Australian rail safety legislation imposes fatigue management obligations on both accredited rail operators and their rail safety workers (RSW). Volunteers working in tourist and heritage (T&H) operations are subject to the same obligations under the Rail Safety Act (2006) or the Rail Safety National Law (2012) as other RSW.

Read more about fatigue management

Personal profiles: Meet Mohan and Peter

Mohan Benberu

How long have you been with Transport Safety Victoria?
I started work as a Rail Safety Officer with Transport Safety Victoria in September.

Brief work background?
I’ve worked in different industries, mainly in project and quality management.

Mohan Benberu

Describe something about the rail regulator that operators may not be aware of.
The value a rail regulator brings to the safety equation by providing independent and constructive input to rail transport operators based on an analysis of national risk data.

What characteristic do you most admire in others?
Being themselves. “Be yourself; everyone else is already taken.” – Oscar Wilde

Read more about Mohan

Peter Martin

How long have you been with Transport Safety Victoria?
Since September.

Brief work background?
As a safety professional I have been involved in a variety of industries from engineering, rail and construction to pharmaceutical and social welfare.

Peter Martin

I am excited about the continuing developments in the rail industry, the co-regulatory approach and my role within this area.

Explain a typical work day.
After the usual morning rush around I walk to work which takes about 15 minutes and gives me a chance to clear my head and plan my day. During the day there are a number of activities with accreditation and Notifications of Change. I get to work with a great team that has depth and diversity in culture, personality and skill set. At the end of the day I walk home and look forward to spending some time with my family.

What do you see as some future challenges for rail operators?
The increasing population growth presenting substantial growth both in freight and passenger transport.

What characteristic do you most admire in others?
Empathy and compassion.

Read more about Peter

You’re a rail safety champion
Rail Safety Victoria recognises the essential and highly valued contribution of staff and volunteers to rail safety in almost every aspect of operations.
By reading this newsletter, we consider you a champion of safety in the tourist and heritage rail sector.
Please help to further champion safety by sharing Rail Safety News with others who can contribute to rail safety in the sector.


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Rail Safety News is distributed by Rail Safety Victoria, a branch of Transport Safety Victoria.