Lydiard Street gates: Final ATSB report released into train crash

The final investigation report from the Australian Transport Safety Bureau, released on Friday, states the train's sanding system was "ineffective" as it approached Ballarat station.

According to the report, the train was "unable to stop", and collided with the gates, despite the driver making braking maneuvers at 5.1 kilometres and at 2.6km out.

"Slippery rail conditions existed for at least the final 2.5 km of the approach to Ballarat Railway Station and probably the final 5 km," transport safety chief investigator Mark Smallwood said in a statement.

"Light rain was the primary environmental factor in the development of the slippery conditions, and the very low levels of adhesion at the contact between the train's wheels and the rail head substantially reduced the train's braking performance."

The train's sanding system, which is designed to "improve adhesion" to the tracks and slow down the train in slippery conditions, automatically activated, but there was "vegetation contamination" in one sander box, and "a lack of sand" in the other.

"There were missed opportunities to identify weaknesses in the sander configuration, while maintenance of the sander units did not test for discharge flow rates, and train preparation processes did not ensure a required minimum amount of sand in the sand boxes," Mr Smallwood said.

However, since the incident, V/Line has added new safety measures "to improve sander performance", including adding more sanders to the middle cars of the three-train sets.

The investigation also found that safety controls were ineffective in mitigating against a train arriving at Ballarat Railway Station travelling at excessive speed and being unable to stop before colliding with the crossing gates.

"It was concluded that there were insufficient risk controls in place to mitigate against a train arriving at Ballarat Railway Station travelling at excessive speed and being unable to stop before impacting the Lydiard Street North level crossing gates," the report states.

"The configuration of the crossing protection that used swing gates introduced additional hazards compared to boom barrier style crossing protection and risk controls were not in place to manage the unique risks that existed at the crossing."

To enhance management of this risk, V/Line has introduced a number of interim measures including reducing the permitted train speed on the approaches to Ballarat Station from 160 to 80 km/h, and installing overspeed-triggered operation of the Lydiard Street North level crossing protection.

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"This occurrence has highlighted the importance of rail operators having risk controls in place to prevent collisions because of slippery rail conditions," Mr Smallwood said.

One set of the heritage-style swing gates were completely destroyed in the incident, and one of the two people on board were taken to hospital.

The intersection remained closed to traffic for almost 18 months, when the state government installed $10 million worth of boom gates and other signalling upgrades.

It's understood a conservation management plan study is under way to work out how to incorporate the heritage-style gates into the precinct.

The full ATSB report into the incident is available online.

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