RO-2000-123

At about 1150 on Thursday 28 December 2000, a diesel multiple unit Train 3134 collided head on with another diesel multiple unit Train 3130 on the up main line between Penrose and Ellerslie. Train 3130 had become disabled at Ellerslie and with the assistance of a relief diesel multiple unit was setting back to Penrose in a wrong line running movement on the up main line. Through a series of miscommunications the train controller unknowingly authorised the wrong line running, which resulted in Train 3134 and Train 3130 assisted by the coupled relief DMU, being in the same section of track while moving in opposing directions.

Two crew members and seven passengers suffered minor injuries.

The safety issues identified included:

• the inadequacy of verbal procedures to provide defences against human error
• the training and certification of new entrant train controllers on additional train control desks soon after their initial certification
• insufficient opportunity offered to train control trainees to view the various operating systems in use during their training
• the lack of a structured process for area familiarisation prior to or during certification on a train control desk
• the routine involvement of train controllers in (non-operational) work created by incidents
• the absence of clear communication between the locomotive engineers, maintenance staff and the train controller resulting in not everyone sharing the same concept of the plan to restore the train network
• the unreliable radio communications existing between the train controller and locomotive engineers at the time of the incident.