safety Archives - Waking up in Geelong https://wongm.com/tag/safety/ Marcus Wong. Gunzel. Engineering geek. History nerd. Fri, 06 May 2022 08:06:37 +0000 en-AU hourly 1 https://wordpress.org/?v=6.7.1 23299142 Pilots confusing Essendon Airport for Melbourne Airport https://wongm.com/2021/11/wrong-runway-essendon-airport-confused-melbourne-airport/ https://wongm.com/2021/11/wrong-runway-essendon-airport-confused-melbourne-airport/#comments Mon, 08 Nov 2021 20:30:46 +0000 https://wongm.com/?p=18668 Over the years there have been many examples of pilots confusing one airport for another, and Melbourne has seen more than it’s fair share – thanks to Melbourne Tullamarine Airport being located near Essendon Airport. Google Earth 14 January 2014 Air India flight AI301 Boeing 787-8 VT-ANM Photo by byeangel from Tsingtao, China, via Wikimedia […]

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Over the years there have been many examples of pilots confusing one airport for another, and Melbourne has seen more than it’s fair share – thanks to Melbourne Tullamarine Airport being located near Essendon Airport.


Google Earth

14 January 2014
Air India flight AI301
Boeing 787-8 VT-ANM

From the Carry-on blog.

Operating AI301 from Sydney to Melbourne VT-ANM approached and crossed Melbourne from the east following usual tracking paths for aircraft inbound from the north-east to YMML’s active Runway 34.

The flight crew initiated a right turn to lining up for Essendon’s Runway 35 mistaking it for YMML’s Runway 34.

Sources in Airservices Australia confirm the flight crew discontinued the approach at roughly 1,050 ft after being notified by Melbourne Approach, made a left turn, climbed to 1,500 ft and re-established a second approach this time to Runway 34.

The missed approach is easy to see on the flight track.


FlightAware flight tracking log

31 March 1994
Australian Airlines
Boeing 737-300 VH-TJA

Note: not the same 737 as this incident

From the ATSB investigation.

At about 18 NM from Melbourne, the crew were requested by air traffic control to report when the Melbourne runway was in sight. The crew reported they had that runway in sight and were cleared to track to join final inside 8 NM from Melbourne.

The crew requested and were given further track shortening until they were instructed to make a visual approach for runway 34 and to call Melbourne Tower. The Approach Controller then diverted his attention to other duties for a short period.

On rechecking the progress of the aircraft it appeared, to him, to be on final for runway 35 at Essendon. The aircraft was at an altitude of approximately 1500 feet. The Approach Controller advised Melbourne Tower who instructed the aircraft to turn left for Melbourne. The aircraft subsequently landed without further incident.

The flight crew subsequently advised that when they were given the visual approach they believed they had the Melbourne Airport in sight and its position was confirmed by checking the map displayed on the aircraft flight management computer. However, they had not used any other aircraft navigational systems to confirm their position in relation to Melbourne.

24 February 1991
Lufthansa
Boeing 747-400 D-ABTC

From the ATSB investigation.

The aircraft, which was approaching Melbourne Airport from the west, was radar vectored onto base leg and descended to 3000 feet.

At 1704 hours Melbourne Approach Control advised the crew that their position was nine miles south-west of the field. They were asked to advise when they had the runway in sight and also to say when the runway 34 lead in strobe lights were sighted.

Shortly after, the crew responded that they had the runway and strobe lights in sight. Approach Control gave the crew their position as six miles south-west of the field, told them to make a visual approach and not to descend below one thousand five hundred feet until established on final.

At 1706 hours the controller told the crew they were approaching the runway extended centre line. The Approach Controller noted that the aircraft was passing through the extended centre line and had not turned to line up with runway 34. He promptly issued instructions to the aircraft to climb to 2000 feet. At about the same stage the crew realised that the runway they had been looking at was too short for their operations and also decided to go around. Further radar vectors were given and the aircraft subsequently landed normally on runway 34 at Melbourne without any other problems.

Runway 35 at Essendon Airport was the runway sighted by the pilots. It does not have lead in strobe lights. The crew indicated they must have seen reflections near Essendon which they mistook for strobe lights.

On the approach the crew had seen a runway from a long way out, which they thought was the north/south runway for Melbourne Airport, but was in fact runway 35 at Essendon Airport. In the lighting conditions at the time they did not see Melbourne Airport, until on the go around.

On the approach the minimum height descended to was just over 1000 feet above the elevation of Essendon Airport.

8 August 1987
Singapore Airlines flight SQ31A
Boeing 747-200, 9V-SQM

From the ATSB investigation.

On arrival in the Melbourne area the aircraft was vectored by Air Traffic Control (ATC) to a left base position for an approach to runway 34.

At a point 5 nautical miles (9.2 kilometres) south of the airport, and 1 mile (1.7 kilometres) to the left of the extended centreline of the runway, the aircraft was instructed to turn left to take up a north-easterly heading. The crew reported at this time that “we have the field visual.”

The aircraft was then instructed to make a visual approach, and to turn further left for a direct approach to the runway. The crew acknowledged this instruction, but the aircraft was observed to pass through the extended centreline. ATC advised the aircraft that it was now to the right of the centreline, and instructed it to turn left onto a north-westerly heading to intercept this line. The aircraft landed without further incident.

The Captain of the aircraft later advised that he was familiar with the Melbourne/Essendon area. Appropriate navigation aids had been selected to monitor the approach.

The Captain reported that he had initially mistaken Essendon for Melbourne, because the latter had been obscured by rain and low clouds. However, the crew became suspicious when the navigation aids did not confirm the visual indications. They were in the process of correcting the situation when ATC instructed the aircraft to turn to the left as it had passed the extended centreline. The crew had then sighted the Melbourne runway complex and had proceeded visually.

13 May 1987
Air New Zealand
Boeing 767-200ER, ZK-NBC

From the ATSB investigation.

The aircraft was radar-vectored for an approach to Melbourne (Tullamarine) Runway 34. The flight crew reported they were “visual” when at 2000 feet and about 17 kilometres (9 nautical miles [nm]) south east of Melbourne.

The Approach Controller advised the flight of its radar position in relation to Melbourne and requested confirmation that the crew had Runway 34 in sight. When this was acknowledged, instructions were given for the flight to take up a heading of 320 degrees; to intercept the extended centre line of Runway 34 from this heading; and to make a visual approach.

Shortly afterwards the Tower Controller at Essendon Airport (5 nm south east of Melbourne) called the Melbourne Approach Controller and reported that a heavy aircraft was on approach for (Runway 35) Essendon.

The Approach Controller called the aircraft, requested its present altitude and, on being advised it was “through fifteen hundred” (feet), instructed the flight to climb to 2000 feet and turn left onto a heading of 320 degrees. He also advised that the aircraft was 7 nm south east of Melbourne and still two miles to the right of the runway centre line.

Shortly afterwards, the flight crew reported they were at 2000 feet and had “Runway 34 Melbourne in sight”. The aircraft was then cleared for a straight in approach and for transfer to the tower frequency. The aircraft landed without further incident.

The flight crew have confirmed that they initially turned towards Essendon but detected their error at about the time the Approach Controller instructed them to turn (back) to 320 degrees and to climb.

30 December 1985
Qantas flight QF36
Boeing 767-200, VH-EAJ

From the ATSB investigation.

Air Traffic Control of the aircraft was being exercised by Melbourne Approach, which was directing the aircraft for a landing on Runway 27 at Tullamarine. The controller obtained approval from the Essendon controllers to vector QF36 through Essendon airspace.

The aircraft was progressively descended and when clearing the aircraft to descend to 2000 feet the controller advised the crew that the aircraft was 4 miles to the left of the runway extended centre line. The crew advised that they had visual contact with the ground and were then cleared to continue a visual approach.

Shortly afterwards, the crew sighted a runway and commenced a turn to the left, during which visibility reduced as the aircraft entered a rain shower.

On passing through the shower, the crew immediately realised that they had turned towards Essendon, and a right turn was carried out to continue tracking towards Tullamarine.

When the premature turn was commenced, it was observed on radar by the Approach controller and visually by both the Melbourne and Essendon Tower controllers. The Approach controller queried the aircraft intentions at about the same time as the crew commenced the turn back towards Tullamarine.

A normal landing was carried out about 3 minutes later.

19 June 1985
Garuda flight GA898
Boeing 747-200, PK-GSB

From the ATSB investigation.

Garuda Flight 898, was being radar vectored by Melbourne Air Traffic Control (ATC) for a landing on runway 34 at Tullamarine Airport. Shortly after the pilot acknowledged an instruction to call Melbourne Tower the aircraft was seen to turn and descend as though making an approach to runway 35 at Essendon Airport.

The Melbourne Tower controller instructed the aircraft to climb to 3000 feet above mean sea level (AMSL), and a few seconds later the aircraft was seen to be established in this climb. After further radar vectors were given, an uneventful landing was carried out at Melbourne.

It was subsequently determined that the aircraft had descended to a minimum height of approximately 350 feet above the level of Essendon Airport, and was about 1.5 kilometres from the runway threshold before the climb was commenced.

So why is it confusing?

Until the 1960s Essendon Airport was Melbourne’s main international gateway.

But today it is mainly used by business jets and light aircraft.

DC3 among parked planes at Essendon Airport

But mid-sized jets such as the Fokker F70 can also safely operate into the airport.

Light plane passes over parked Alliance Airlines Fokker F70 VH-QQR

From the 1,921 metre long east-west and 1,504 metre long north-south runways.


Google Earth

Which just so happen to be a similar orientation to the 2,286 metre long east-west and 3,657 metre long north-south runways at Melbourne Tullamarine.


Google Earth

This similarity has been noted by ATSB investigators.

There have been a number of instances where Essendon has been mistaken for Melbourne. The two airports are in close proximity and have similar runway configurations. In this instance the flight crew members were not very familiar with the Melbourne area or with the approach to Runway 34.

Who recommended the following back in 1987.

It is recommended that consideration be given to the following

– 1 Operators briefing the relevant flight crews on the real possibility of misidentifying the two airports.
– 2 Operators instructing flight crew to make full use of available radio aids on visual approaches to Melbourne.
– 3 The Department of Aviation providing visual and/or radio aids to assist ready identification of Runway 34, such as sequenced strobe lights leading to the threshold and/or an instrument approach facility to the south of the airport.

The largest aircraft ever to land at Essendon Airport were a handful of Boeing 707s back in the 1960s – I’d hate to see what would happen to a Boeing 747 that tried to do the same.

Spot the difference

One spotting feature is the different strobe lights pattern at each airport – Essendon Airport’s beacon flashes white every four seconds – Melbourne Airport’s beacon flashes alternate white/green.

While the aerodrome charts also feature a warning – “WARNING: Secondary airport (Essendon) 5NM south-east”.


Airservices Australia – Aerodrome Charts

And Melbourne Airport runway 34 now has a distinctive identifier – three sets of sequenced white strobe lights commencing 485 metres from the end of the runway, and aligned with runway 34 centreline.


Airservices Australia – Aerodrome Charts

Footnote: freeway confusion

A hazard for pilots landing at Essendon Airport at night is the freeways that surround the airport.

Tullamarine Freeway at English Street

An issue raised by the ATSB in a 2017 investigation.

The airport has two runways aligned 17/35 and 08/26, and it is bounded on two sides by freeways with substantial amber lighting and well-lit residential areas. At night, the lights around the airport present a complex picture. The published aerodrome chart had a caution note describing that amber freeway lighting may confuse flight crews when attempting to identify runway 08/26 lighting.

Computer confusion too

On 10 March 2015 an AirAsia flight from Sydney to Malaysia ended up having to divert to Melbourne when the pilot entered the wrong initial coordinates into the inertial navigation system.

And some unsourced stories

I found this story online referring a supposed incident around 1996.

About 5 years ago I was flying in the circuit in a little PA-28 at Moorabbin. It appeared to me that there was a B747 on long final. My flight instructor flicked the freq to Melbourne International, and sure enough, Alitalia 747 was lined up on the Moorabbin runway (which is less than 1.6 km long!) and complaining that he had visual but his navaids were all wrong. Melbourne Airport cleared him for a visual landing but then cancelled the clearance when they saw where he was on radar!

And this one from the 1970s.

They were also aware of anecdotal accounts of a DC-10 lining up to land on the Essendon runway sometime in the 70s, and being warned off at the last minute.

Further reading

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So you’ve dropped something onto the tracks https://wongm.com/2020/03/dropped-stuff-on-the-railway-tracks/ https://wongm.com/2020/03/dropped-stuff-on-the-railway-tracks/#comments Mon, 16 Mar 2020 20:30:00 +0000 https://wongm.com/?p=13847 So you’ve dropped something onto the railway tracks – your hat perhaps? Umbrella? Footy scarf? Bottle of Passion Pop? ‘Caution wet floor’ sign? ‘P’ trap? Collection of Formplex weatherboard samples? Well – don’t run across the tracks. Chase down station staff. They’ve got a long grabby arm. Ready to fish it back up. Footnote I […]

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So you’ve dropped something onto the railway tracks – your hat perhaps?

Someone lost their hat on the tracks at North Melbourne

Umbrella?

Broken umbrella discarded on the railway tracks

Footy scarf?

Some Melbourne fan dropped their footy scarf onto the tracks at North Melbourne

Bottle of Passion Pop?

Bottle of Passion Pop on the tracks

‘Caution wet floor’ sign?

'Caution wet floor' sign on the tracks at Flinders Street Station

‘P’ trap?

Someone lost their 'P' trap on the tracks at Seddon station

Collection of Formplex weatherboard samples?

Pile of Formplex weatherboard samples discarded on the tracks

Well – don’t run across the tracks.

Chase down station staff.

V/Line staff at Footscray also looking onto the tracks for a missing item

They’ve got a long grabby arm.

Metro staff at Footscray looking onto the tracks for a missing item

Ready to fish it back up.

Metro Trains staff retrieve a mobile phone from the tracks with a long pickup claw

Footnote

I remember a few years ago a railfan attaching their GoPro camera to the side of a steam train doing the rounds of suburban Melbourne, only for it to fall off and land on the tracks. Presumably they found the camera, because they were able to share the footage. 😛

A2 986 passes through Hawksburn station with an up shuttle from Caulfield

Another unlucky railfan had a similar experience on a tram tour around Melbourne – holding their mobile phone out the window recording video along the St Kilda light rail the tram brushed past a lineside tree, knocking it out of their grasp and down onto the ballast below.

Photostop at South Melbourne loop on route 12

Moral of the story – use a camera strap!

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Melbourne trains moving with open doors https://wongm.com/2019/05/melbourne-trains-moving-with-open-doors/ https://wongm.com/2019/05/melbourne-trains-moving-with-open-doors/#comments Mon, 13 May 2019 21:30:00 +0000 https://wongm.com/?p=12580 Last week The Age published article titled Long delays for justice over teen’s train death – detailing with the aftermath of a 2014 fatality at Heyington station. Initially much has been made of the gap between the train and the sharply curved platform at Heyington. But the real cause was something far more concerning. Moving […]

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Last week The Age published article titled Long delays for justice over teen’s train death – detailing with the aftermath of a 2014 fatality at Heyington station.

X'Trapolis on a citybound service arrives at Heyington station

Initially much has been made of the gap between the train and the sharply curved platform at Heyington.

Rubber platform edge at Heyington station

But the real cause was something far more concerning.

Moving a train while the doors are open

The Australian Transport Safety Bureau released their final report into the Heyington fatality in April 2016, and detailed how the train moved while the doors are open:

The train was equipped with a traction interlocking device to prevent the train from moving while its carriage doors were open. The device, as designed, deactivated after a period of time and allowed the train to depart with the doors held open.

The report explains the normal operation of the train doors by the driver.

The driving cab at each end of the EMU contains the equipment and devices to enable the driver to operate and monitor the train doors. Located on the driver’s control console are two yellow pushbuttons that open the left and right hand side doors respectively and a blue pushbutton that closes doors on both sides.

To close the doors, the driver presses the blue pushbutton on the console. An intermittent beep sounds at each door for three seconds to warn passengers of imminent door closure. The yellow pushbutton lamp at the control console is extinguished and the doors close while emitting an intermittent beep at the doors. When the doors are successfully closed, the beep ceases and the pushbutton lamp on the door is extinguished. The blue pushbutton lamp on the console illuminates and flashes continuously until the doors are detected closed and then displays a steady blue light.

As well as how the train driver is prevented from moving the train while the doors are open.

Pressing the blue pushbutton at the console initiates door closing and a 60 second time delay for traction authorisation. Detection of all doors closed and locked before the 60 seconds elapse, activates traction authorisation.

And something concerning – a safety feature that automatically disengages itself.

Should the doors fail to close and lock after 60 seconds, the system is designed such that traction is authorised, despite the possibility that the doors have not closed. Once traction is authorised and applied the train will move.

Which led to the incident at Heyington.

The driver activated the door close command at 23:51:24 and shortly after made two attempts to apply traction. The train did not move as the traction interlock system had detected the open door and inhibited the application of power to the motors.

The end doors of the fourth car and the doors on all the other cars had closed, but the centre doors of the fourth car were held open by the two youths. After a short delay, the driver made an announcement for passengers to keep the doors clear. During this period, as designed, the doors attempted to close several times, but were held open.

The driver then applied traction again at about 23:53:30 and the train commenced moving along the platform with the doors held open, as the traction interlock system had timed out as designed.

Enter human factors

The ATSB argued that the design of the X’Trapolis train’s traction interlock system was flawed.

Where the design of a safety system such as a traction interlock times out automatically, it would be prudent to have additional indications/alarms to warn a driver of a change of state in the vehicle controls, particularly during passenger boarding at a station. Further, formally documenting the operation of the traction interlock override systems in the MTM training manuals would increase driver awareness of the risks associated with these systems.

And that other rail operators are much safer.

Traction override systems on passenger rolling stock managed by other operators also required drivers to intervene and operate a switch if they are required to override a traction interlock. In most cases, procedures require the use of the override when there is a failure of the door closed detection equipment or electrical circuitry. Prior to operating the manual override, drivers are required to follow procedures to ensure doors are closed and locked, and to verify this action by seeking authority from a train control centre.

But in Melbourne, we don’t do that.

MTM operates Comeng, X’Trapolis and Siemens trains on its network. The traction interlocking systems on the Comeng and X’Trapolis trains in Melbourne are designed such that the interlocking system is deactivated automatically after a period of time. MTM advised that the train’s traction interlock system was designed to deactivate to enable trains to be moved in case of door faults.

Except on one kind of train.

The traction interlocking system on the Siemens type trains, also operated in the MTM fleet, would not allow the train to move with the doors open without driver intervention to override the interlock.

Their brakes might not work, but at least Siemens got something right!

Siemens 783M arrives into Flinders Street Station

So time to fix the problem?

In April 2016 the ATSB raised a safety issue with Metro Trains Melbourne.

As designed, the traction interlock automatically deactivated after a period of time. This allowed traction to be applied and the train to depart with the carriage doors open.

Who initially responded:

MTM advised the ATSB that subsequent to the incident MTM has made no changes to the traction interlock system on the rolling stock, but has commenced a risk review of the traction interlock timing.

The ATSB wasn’t happy, so in July 2016 they recommended Metro Trains modify the traction interlock override system to incorporate additional risk mitigations, which they accepted:

MTM has now completed a risk review of the traction interlock timing. It is considering proposals to modify the interlock override system on both X’Trapolis and Comeng Fleets which have the same functional design.

The proposed steps are to undertake circuit modifications and install a key operated override switch. When implemented, these measures will allow a train to gain traction control in circumstances where a door appears to be open, but will differ from the arrangement at the time of the incident in that they require an additional manual intervention from the driver.

Circuit modifications will necessitate the removal of the existing timer relay circuit that provides for the functionality to be restored after a 60 second delay. Therefore if a ‘door open’ condition is detected following the initiation of the ‘door close’ command, the circuit will inhibit traction without time limitation, until the key switch is operated to reinstate traction.

During the running of a train, MTM’s systems will be such that the key can only be operated by a driver properly authorised and having the appropriate operating key. It should be noted that this is a similar configuration currently on the Siemens fleet.

In December 2016 tests of the modified traction interlock system had commenced on a single Comeng train, with a warning sign in the cab informing drivers of the modification, while Metro Trains gave the following timeline of implementation:

For Comeng trains within the MTM fleet, the installation of the proposed solution is being undertaken as part of the Comeng Life Extension program and is planned to commence by December 2016.

The Comeng Life Extension program is currently halfway complete, with the new override key switches appearing in each cab.

'Detrain passengers when door loop bypass switch is isolated' notice onboard a Comeng train

But for the X’Trapolis trains, money and technical difficulties got in the way.

For X’Trapolis trains, the implementation works are scheduled to commence after circuit validation by the train designer ALSTOM. For a number of reasons, MTM cannot proceed to make these alterations without ALSTOM approval.

In discussion with DEDJTR (Department of Economic Development, Jobs, Transport and Resources) it is proposed that new X’Trapolis trains being ordered would be the first fitted, with changes to other X’Trapolis trains being the subject of further review of funding options.

But it looks like the X’Trapolis fix is now on the way.

T385 pushes the train into the GEB siding at Sunshine, with T386 shunted clear into a siding

The 2017 Metro Trains Melbourne franchise extension included the ‘Indef. Traction Interlock XT Fleet Project’ as a line item, and since late-2018 dozens of X’Trapolis trains have passed through the Alstom Ballarat workshops for upgrades – hopefully a fix to the traction interlocking was one of the changes.

Footnote: everything old is new again

Way back in November 2008 then rail operator Connex Melbourne undertook an investigation into the problem of Comeng trains moving away from stations with doors still open.

Between 3 July and 23 September 2008, there were 17 confirmed incidents relating to Comeng trains moving with at least one passenger saloon door open.

The report recommended six actions, one of which was:

That a review of the operation of the Comeng door system be undertaken to determine its suitability in the current (2008) operating conditions. This review to consider the adequacy of the 15-second traction delay as provided.

Metro Trains took over from Connex in 2009 and implemented a fix for the problem.

MTM advise that this review has been completed. The 15-second traction delay has been increased to 60 seconds, and by June 2010 approximately 70 per cent of the fleet has received the modification.

The Heyington fatality in 2014 suggests that wasn’t enough – but thankfully the current works should fix it for good.

Sources

And a housekeeping note

I recently launched a page on Patreon where you can help support my work. Next week’s blog post is “Southern Cross Station – what could have been” – and if you sign up over at https://www.patreon.com/wongm you’ll get a sneak peak!

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Dodgy doors on Melbourne’s Comeng trains https://wongm.com/2014/03/melbourne-comeng-train-door-issues/ https://wongm.com/2014/03/melbourne-comeng-train-door-issues/#comments Mon, 24 Mar 2014 20:30:13 +0000 http://wongm.com/?p=4560 Last week the doors of Melbourne's Comeng trains received another mention in the news, when it was revealed that a 17-year-old boy had jumped out of moving train at Watergardens station after forcing the doors open. So how long have the doors had this vulnerability?

Article on Comeng train doors: The Age, March 15, 2014

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Last week the doors of Melbourne’s Comeng trains received another mention in the news, when it was revealed that a 17-year-old boy had jumped out of moving train at Watergardens station after forcing the doors open.

Article on Comeng train doors: The Age, March 15, 2014

Some history

Melbourne’s Comeng trains are currently the oldest in the suburban fleet as well as the most numerous. Having entered service between 1981 and 1988, they received their current interior look and feel during a mid-life refurbishment program completed between 2000 and 2003.

On first entering service the Comeng trains were operated by a two-person crew – a driver up front to make the train stop and go, and a guard at the rear to watch the doors and tell the driver when to depart – but the second person was removed during the Kennett-era reforms of the 1990s, when single person operation of suburban trains was introduced.

Since entering service, very little has changed with the Comeng train doors: on arriving at a station they are released by the driver and manually opened by passengers as required, then prior to departure the door close button is pushed, triggering the pneumatic actuators that hold the doors closed, which then illuminates a light once all the doors have been detected as closed.

Melbourne’s newer trains follow the same general process, but with one important difference – once the doors close a locking mechanism holds them shut, with the only way to unlocking being to use the door open button, or to engage the emergency release lever.

By comparison the Comeng train doors have two flaws: they can be forced open by applying as little as 20.5 kilograms of force applied to the handle,[1] and as soon as the train loses power, the doors become unlocked. This causes many problems – at the Craigieburn depot they had to retrofit their brand new train wash so that Comeng train doors don’t get pushed opened by the cleaning brushes, and if your train loses power in the middle of peak hour atop a bridge, there is nothing to stop you falling out.

The start of safety concerns

In October 2009 a fatality occurred at Melbourne Central station, when a passenger forced the doors open and leapt from a departing Comeng train.

The Office of the Chief Investigator investigated the incident, releasing their final report in January 2011. They found the following factors contributed to the incident:

  • The victim forced open a powered door and attempted to alight from the moving train.
  • Due to a faulty component preventing the correct operation of a safety circuit, the train driver was unaware of a door having been forced open.
  • Although the existence of this fault condition on any train would not be evident to any casual observation, the train operator was aware that these trains were susceptible to developing this defect. There was no daily pre-service procedure to check for such a fault condition.

The ‘faulty component’ was incredibly small – a simple electrical connection between the two 3-carriage units of the train had shorted out, resulting in the ‘door closed’ lamp in the cab giving a false indication to the drivers, even though the doors in the rear half of the train had been forced open.

As a result Metro changed their procedures to ensure that the integrity of the door monitoring system is checked every time a new driver takes over a train.

However this was not the end of concerns around Comeng train doors, with Transport Safety Victoria issuing a safety notice to the Department of Transport in September 2011 regarding them:

Regulator concerned about train door safety
22 September 2011

Transport Safety Victoria (TSV) has issued a safety notice to the Department of Transport in relation to its concerns about the safety of passenger doors on Comeng trains.

TSV’s Safety Director, Alan Osborne, says the doors of these trains do not comply with modern passenger train design standards and have been associated with a number of incidents.

“Unlike other Victorian trains, the passenger doors of Comeng trains are able to be forced open,” said Mr Osborne.

“Being able to force the doors open of a moving train, or a train stopped between stations, increases the risk of fatal accidents occurring. Passengers should never do this, but the fact is they can because of the way the Comeng train doors are designed.”

A fatal accident occurred at Melbourne Central station in 2009, when a passenger forced open the doors of a train in motion. The passenger attempted to jump to a platform, but was caught and dragged by the moving train.

Mr Osborne has confirmed that the safety notice has been issued to require the Department of Transport to address the safety issues associated with the Comeng doors.

“There has been extensive consultation with the Department and Metro Trains about this issue and we still do not have any committed plans to address the safety risks,” said Mr Osborne.

“It is time to begin planning to address the risks of being able to force the train doors open, particularly as the Comeng trains could remain in operation for the next decade or two.’

In addition to recommending that the planning process start, the notice is intended to ensure statutory safety obligations are met.

Some of the actions referenced in the notice include removing the external and internal passenger door handles, installing a more sensitive door closing control on the doors, and installing a traction interlock system to prevent trains from departing stations until all doors are confirmed locked.

Mr Osborne has asked that these actions are undertaken at the next major overhaul of the fleet, in order to reduce the disruption to passenger services.

The actions will bring the Comeng trains to a similar standard of other passenger train door design standards currently in place on X’trapolis and Siemens trains, which are used on the metropolitan rail system.

The notice requires the Department of Transport to provide a response to the proposed actions once it has formally considered the issues. Part of this formal consideration requires the Director of Public Transport to consult with the Victorian Treasurer and Premier.

At the time of the notice being issued, Alan Osborne from Transport Safety Victoria said that the rectification works should only cost $10 million, but:

“I’m not getting good noises from the Department of Transport that this is going to be funded in the next major overhaul,” he said.

“I’m not saying there’s a massive risk that has to be dealt with right now, but what I do want to see is some committed plans put in place for the future so that we know that these things are going to get upgraded at the next major overhaul of the Comeng fleet.”

Transport minister Terry Mulder had the following to say:

“It’s a concern. We face that situation and we’re going to deal with it,” he said.

I’ll have further discussions with Metro. As I say, these trains are due for a mid-life overhaul and throughout the course of that, we may well be able to do that work.”

As with anything that politicians can’t cut the ribbon on, the issue of the Comeng train doors stayed on the backburner. Transport Safety Victoria complained again in October 2012, but upped the ante:

Transport Safety Victoria has placed a condition on train operator Metro’s accreditation: repair the doors on 96 Comeng trains from 2017 when the first train reaches the 35-year life expectancy or replace them.

It comes after TSV issued a safety notice to the Transport Department in September last year requiring the doors be fixed as they can be opened while the train is moving.

TSV acting director rail safety Andrew Doery said the regulator wanted a “funded, committed plan” to fix the problem, estimated by Metro to cost $12.9 million. “We’ve seen no program to rectify the doors,” Mr Doery said.

We now arrive at March 2014, three years out from the supposed retirement of the Comeng fleet, when Metro finally decides to pull their finger out and started trialling changes recommended all the way back in September 2011.

Deceptively simple, the modification has only been made to a single Comeng carriage (numbered 1097T) and consists of a new style of door handle, which is presumably harder for scrotes to force open with their foot.

New style of door handle on trial on Comeng carriage 1097T

Unfortunately the new design also makes it harder for people with frail hands to open the doors – instead of pushing at an exposed handle, one now needs to grip the insides of it with one’s fingers.

I can't see how people with frail hands will cope with these trial door handles on the Comeng trains

So why don’t we just retrofit the Comeng trains with power operated doors, identical to the newer trains in the Melbourne suburban fleet?

Turns out penny pinching was to blame – 7000 new door handles only cost $400,000 while retrofitted a new automatic door system would have cost $10 million.

Adelaide leads the way

Turns out Adelaide had exactly the same problem as Melbourne with their 3000 class diesel railcars. Built in Victoria between 1987 and 1996, these trains used the same body shells and doors as Melbourne’s Comeng trains, just with a diesel engine underneath the floor for propulsion instead of electric motors powered from overhead wires.

Pair of 3000 class head for the city at Marino, passing a few small boats out on the water

In 2009 TransAdelaide commenced a mid-life refurbishment program for their fleet of trains, which include the following features:

  • Emergency call buttons next to doors to allow passengers to speak to the drivers.
  • New passenger information display panels at each end of the railcar and automated audio announcements.
  • Improved hand straps, seat grips and new bike stow areas with attachment rails.
  • A new digital public address system with better audio.

Nothing new there, except for this last item:

  • Push-button automated doors to prevent them being forced open while the train is in motion.

This is what the original doors on Adelaide’s 3000 class trains look like:

Exterior door detail of a non-refurbished 3000/3100 class railcar

And a refurbished train, retrofitted with push-button operated lockable doors.

Exterior door detail of a refurbished 3000/3100 class railcar

It makes you wonder – if Adelaide can do a job properly, why can’t we?

Further reading

Rail Safety Investigation Report No 2009/14 has more details of how the Comeng door mechanisms currently work.

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