Microsoft PowerPoint - Copy of -- OCI Presentation to the Select

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					        Legislative Council
Select Committee on Train Services

              Ian McCallum
            Chief Investigator
Transport and Marine Safety Investigations
Statutory position established 1 August 2006
Principal Function
   To investigate public transport and marine safety
   matters and report results to the Minister for Public
   Transport and/or Minister for Roads and Ports
Primary Focus
   Investigate to determine causal factors rather than
   apportion blame or liability
   Identify issues that may require review, monitoring or
   further consideration
Chief Investigator
   Is independent of transport operators, the industry,
   regulators and the Department of Transport
   Not subject to direction or control by Ministers
How we decide what to investigate:
  Potential for system safety improvement (safety value)
  that may be gained by investigating
  Fatal/serious injury to passengers or other people
  Extent of property damage
  Public profile of event
  Significance of failure of safety system
  Environmental impact of incident
  Part of a identifiable trend
  Rail investigation undertaken involving metro
  and V/Line trains since August 2006
Date          Event                                       Location      Status
12 Oct 2006   V/Line train derailment                     Traralgon    Complete

12 Nov 2006   V/Line level crossing collision             Winchelsea   Complete

18 Feb 2007   Connex Siemens platform overrun             Springvale   Complete

3 May 2007    Connex train derailment                     Oakleigh     Complete

4 Jun 2007    V/Line derailment                           Seymour      Complete

5 Jun 2007    V/Line train level crossing collision       Kerang       Complete

22 Aug 2007   Connex (loco) level crossing collision      Somerville   Complete

16 Nov 2007   V/Line train collision in Spencer St Yard   Melbourne    Complete
       Rail investigation undertaken involving metro
       and V/Line trains since August 2006 cont…
Date           Event                                         Location            Status
22 Feb 2008    Connex train overrun baulks at end of line    Sandringham       Complete
6 Mar 2008     V/Line pedestrian level crossing collision    Ardeer            Complete
27 Sep 2008    V/Line train struck pedestrian at station     Springvale        Complete
9 Jan 2009     Connex train overrun platform                 Cranbourne        Complete
Feb-Mar 2009   Connex Siemens train overruns at Noble        Various       Under Investigation
               Park, Ormond, Yarraman, Murrumbeena,
1 Jun 2009     PN train derailed on Connex line              ABB Siding    Under Investigation
15 Jul 2009    Connex train level crossing collision         Edithvale     Under Investigation
12 Sep 2009    V/Line derailed after collision with a tree   Stonyford     Under Investigation
20 Oct 2009    Connex train drags passenger along            Melbourne     Under Investigation
               platform                                      Central
Oaks Day 6 November 2008
What happened:
   Infrastructure failures result is passengers detrain onto
   operating rail lines
Main Findings
   Several critical infrastructure failures occurred causing the
   stoppage and delay of trains
   The stopping of a train at a signal resulted in the ‘burn-
   through’ of the overhead wire and loss of power to portions
   of the Craigieburn corridor
   Several of the infrastructure faults that occurred on Oaks
   Day were known to have occurred previously
   Connex staff did not declare an emergency
   Some train control processes, including communications,
   were inadequate
Contributing factors - Summary
  Position of the ‘air gap’ relative to Home signal № 23
  The failure of some on-train Public Announcement systems
  and a lack of staff at some key locations left the passengers
  The ‘group call’ from Metrol to trains to lower pantographs
  was not specific enough as to whom it was directed
  The degraded condition of some impedance bonds
  The content and execution of Connex contingency planning
  for a disruptive event or emergency was inadequate
  Some signalbox activity and processes at Kensington were
  Authorised Officers were unable to be effectively mobilised
  and deployed to assist passengers as the event developed
Safety Actions taken since the event
  Review of open ‘air gap’ locations – 8 locations had ‘section
  insulators’ installed
  Connex reviewed use of portable radios for staff at large
  crowd events
  Connex has undertaken to review the Customer Service
  Department Business Plan
  Connex has undertaken to review radio resources and
  channel availability
Recommended Safety Actions - Summary
   Review ERP, specifically in the area of significant event handling
   Review process in Metrol; specifically emergency & disruption
   indentification, responsibilities for incident direction, management of
   authorised officers
   Review instruction around advising train drivers to lower pantographs
   Ensure that there are effective methods for informing and evacuating
   Review impedance bonds throughout the network to determine the extent of
   the problem and take appropriate remedial action
   Considers altering crowd management on Platform 1 at Flemington Station
   Review processes at Kensington Signalbox
Department of Transport
   Advance the proposed study to replace mechanical interlocking on the
   metro network
Thank you

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