Violet Town collision of 1969

 
  petan Chief Commissioner

Location: Waiting to see a zebra using a zebra crossing!
My grandfather is the fireman that jumped off the goods train. Arnfreid Brendecke. Still alive and well. Massive family up here in far North Queensland.
t_schreiber88
Thanks for the personal family update as eventually someone with investigative expertise will get to the bottom of this 1969 event. I suggest modern similar events would be examined in a more detailed way as our ability to engage in forensic analysis has greatly improved since 1969. If the eventual result is similar to the original coroner's report ok but at least this 1969 events needs to be rechecked by someone with the modern skill set to do so.

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  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
Given the current investigative arrangements we would probably be still waiting for their report.
My understanding is that the driver was dead which led to criticism of VR medicals. We have since gone overboard with this where potential drivers are now required to do push ups for example how this helps current long time personnel eludes me.
The main cause did wonders for the driver only principle.Sad
  Valvegear Dr Beeching

Location: Norda Fittazroy
As I write, I have beside me the Victorian Railways Report into this collision.
Please note; this is not to be confused with the Coroner's Report which was received after the VR Report had been written.

Paragraph 5.3.2:  "In Victoria, all main line diesel-electric locomotives are fitted with a Vigilance Control System. The system was designed by a Victorian Railways engineer who took out patents . . . It is pneumatically operated and is manufactured by Westinghouse Brake ( Australasia) Pty Ltd"
"Whilst the locomotive is in motion, the Fireman must operate the Vigilance Control System but, before pressing the button, he must satisfy himself that the Driver is alert."

Paragraph 7.3.8: In summary, Fireman Coulthard saw both the Distant signal at yellow, and the Up Home Arrival Signal at red over red. At about the time of sighting the Signal at Danger, he pressed the V.C button, and went into the nose of the locomotive to fill the kettle. Asked why he had disobeyed Regulations about ensuring the alertness of the Driver, and remaining at his post approaching signals, his reply to both points was, "I don't know."( There is approximately a page and a half of fine print about Coulthard's evidence.)

Paragraph 7.3.9: Guard Wyer's journal was shown to be at variance with actual times of arrival and/or departure at various locations, and completely omitted a 12-minute stop at Wodonga Loop.

Paragraph 10.7: Fireman Coulthard has five separate derelictions of duty listed: Guard Wyer has three.

Paragraph 10.13: " There were three men on the train, the Driver, Fireman and Guard, each of whom was responsible for the observance of signals and for taking action to stop the train in an emergency. The accident was caused by the failure of both Fireman Coulthard and Guard Wyer to carry out their duties when Driver Bowden did not respond to the indications displayed by the signals."

This may help to answer some of the question which posters have asked. If anyone wants to ask any more, feel free to do so, and I can try to find the answers within this Report.
  GrahamH Chief Commissioner

Location: At a terminal on the www.
Snip

Prior to this happening at Violet Town, I would be very surprised if any Diesel Loco's in NSW were fitted with any sort of Vigilance control.
The only such control as I remember was the "Dead Man' handle fitted to electric Suburban and Interurban  passenger trains.
gordon_s1942
There vigilance buttons in the 44 cls I had cab rides in in the second half of the 60s. 46 cl electrics didn't have up to the last time I rode one in 1972.
  Valvegear Dr Beeching

Location: Norda Fittazroy
Thanks for the personal family update as eventually someone with investigative expertise will get to the bottom of this 1969 event. I suggest modern similar events would be examined in a more detailed way as our ability to engage in forensic analysis has greatly improved since 1969. If the eventual result is similar to the original coroner's report ok but at least this 1969 events needs to be rechecked by someone with the modern skill set to do so.
"petan"
The event has been minutely examined, a very comprehensive VR report published ( see above), and "getting to the bottom" of it has been done. There is no need for any recheck. I'm not sure why you have any doubts about it.
  kuldalai Chief Commissioner

As a result of the Violet Town  Southern Aurora / Goods  head on collision modifications were made to the VC system on all VR locomotives.

It took a further incident (some years later ) again on the sg North East where an up Goods in heavy fog ran into the back of the Up  Spirit of Progress in heavy fog demolishing totally the trailing VHN  brakevan , till train to base radio was finally installed in all cabs on Victorian locomotives .
  petan Chief Commissioner

Location: Waiting to see a zebra using a zebra crossing!
The event has been minutely examined, a very comprehensive VR report published ( see above), and "getting to the bottom" of it has been done. There is no need for any recheck. I'm not sure why you have any doubts about it.
Valvegear
I refer to the general forensic principle of re-examining  major transport smashes in general and not only that 1969 one in particular. I earlier wrote... I suggest modern similar events would be examined in a more detailed way as our ability to engage in forensic analysis has greatly improved since 1969. I highlight the fact that the present day skill set of the Australian Transport Safety Bureau is certainly very much improved when compared to the investigative skills from the Southern Aurora smash era http://www.atsb.gov.au/about_atsb.aspx

It is not about doubting the earlier investigative personal as I expect the earlier investigators would have loved to have the present day forensic tools.
  Valvegear Dr Beeching

Location: Norda Fittazroy
I refer to the general forensic principle of re-examining  major transport smashes in general and not only that 1969 one in particular. I earlier wrote... I suggest modern similar events would be examined in a more detailed way as our ability to engage in forensic analysis has greatly improved since 1969. I highlight the fact that the present day skill set of the Australian Transport Safety Bureau is certainly very much improved when compared to the investigative skills from the Southern Aurora smash era http://www.atsb.gov.au/about_atsb.aspx
It is not about doubting the earlier investigative personal as I expect the earlier investigators would have loved to have the present day forensic tools.
"petan"


Your earlier post was quite specific about this crash in particular; I quote,"Thanks for the personal family update as eventually someone with investigative expertise will get to the bottom of this 1969 event." (my italics).

I cannot see what else anyone could possibly find with modern forensic tools. The facts are quite clear. Driver Bowden died at the controls. His death was due to "cardiac failure following coronary atherosclerosis and myocardial degeneration from scarring" (Dr J H McNamara, Senior Government Pathologist ). Fireman Coulthard and Guard Wyer failed in their duty.
The condition and operation of all systems were thoroughly checked, and all were found to have operated correctly.

What do you believe could be achieved by re-examining this crash?
We know precisely what happened, and we know precisely why it happened.

We have, in fact, been "to the bottom of this 1969 event" since 4th July 1969, when the Victorian Railways Report was handed to the then Minister of Transport, Vernon Wilcox MP.
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
Your earlier post was quite specific about this crash in particular; I quote,"Thanks for the personal family update as eventually someone with investigative expertise will get to the bottom of this 1969 event." (my italics).

I cannot see what else anyone could possibly find with modern forensic tools. The facts are quite clear. Driver Bowden died at the controls. His death was due to "cardiac failure following coronary atherosclerosis and myocardial degeneration from scarring" (Dr J H McNamara, Senior Government Pathologist ). Fireman Coulthard and Guard Wyer failed in their duty.
The condition and operation of all systems were thoroughly checked, and all were found to have operated correctly.

What do you believe could be achieved by re-examining this crash?
We know precisely what happened, and we know precisely why it happened.

We have, in fact, been "to the bottom of this 1969 event" since 4th July 1969, when the Victorian Railways Report was handed to the then Minister of Transport, Vernon Wilcox MP.
Valvegear
I have to agree. This accident was caused by the combination of factors that are so often seen in the case of rail (and other) accidents.

  1. The death of the driver
  2. The actions and/or the inactions of the fireman
  3. The actions and/or the inactions of the guard


Had any one of the above been different the collision would not have occurred.

In reality this was an accident caused by a relatively simple sequence of events that did not require an amount of 'forensic analysis'. The driver was dead and the rest of the team were inadequate.
  UpperQuad Locomotive Fireman

Location: 184.8 miles to Sydney
A modern investigative team revisiting evidence gathered over 40 years ago, clouded by railway folklore and myth, would have little hope of making accurate findings.
  Valvegear Dr Beeching

Location: Norda Fittazroy
A modern investigative team revisiting evidence gathered over 40 years ago, clouded by railway folklore and myth, would have little hope of making accurate findings.
UpperQuad
Judging by some of the early postings in this thread, there is a good deal of myth surrounding the incident. For example, people's ideas of was / wasn't Vigilance Control fitted.
The VR Report, completed 3 months after the crash, is detailed, comprehensive, wide ranging and conclusive. I agree that any new investigation would be hampered just as UpperQuad suggests. It would be a complete waste of time, money and effort.
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
Years ago (and I am not suggesting that it applied at Violet Town) there were stories of instances where the Vigilance Control had been disabled by (some) crews somehow. This led to trains being stopped mid-section for checking for a while.
Vigilance Control, of course, has come a long way since then.
  Valvegear Dr Beeching

Location: Norda Fittazroy
Any Victorian crew who attempted to disable the V.C would not have lasted long. The Hasler Speed Recorder made a record on a chart, and recorded speed, time of day, time travelled and at stop, and distance travelled.

VR report, para 5.3.1: " There is provision on the chart for other readings, and in Victoria this is used for recording the operation of the Vigilance Control System."

VR Report, Section 9, "DISCUSSION", has details of when the V.C. was pressed, and at what distance ( in miles and chains) from Melbourne. The final actuation was at 105 miles, 20 chains, which was within the Violet Town Loop.

"There was a time interval of some 54 seconds from when Fireman Coulthard first saw the Home Departure Signal at Stop to the point of collision, a distance of approximately 1 mile and 5 chains."

"The tests of Westinghouse Brake ( Australasia ) Pty Ltd showed that this train could have been stopped in 48 chains if an emergency brake application had been made from the locomotive, and it is difficult to understand why Fireman Coulthard did not take this action."
  awsgc24 Minister for Railways

Location: Sydney
If the British Rail AWS (Automatic Warning System) been fitted in Victoria, could/should/would the Violet Town SPAD and collision been prevented?

AWS is an 1956 electro-magnetic update of an earlier 1906 GWR semi-mechanical ATC (Automatic Train Control).

Victoria has more recently (c1990??) installed the more advanced TPWS on some lines. Does this include the North East Standard Gauge line? The NESG line opened in 1961.

See: https://en.wikipedia.org/wiki/Automatic_Warning_System

See: https://en.wikipedia.org/wiki/Train_Protection_%26_Warning_System
  kuldalai Chief Commissioner

If the British Rail AWS (Automatic Warning System) been fitted in Victoria, could/should/would the Violet Town SPAD and collision been prevented?

AWS is an 1956 electro-magnetic update of an earlier 1906 GWR semi-mechanical ATC (Automatic Train Control).

Victoria has more recently (c1990??) installed the more advanced TPWS on some lines. Does this include the North East Standard Gauge line? The NESG line opened in 1961.

See: https://en.wikipedia.org/wiki/Automatic_Warning_System

See: https://en.wikipedia.org/wiki/Train_Protection_%26_Warning_System
awsgc24
TPWS is installed only on the RFR  160 kmh lines to Geelong, Ballarat, Bendigo and  Traralgon .
  Gman_86 Chief Commissioner

Location: Melton, where the sparks dare not roam!
TPWS was introduced in 2005 on the Geelong line (between Werribee and Geelong), Ballarat line (between Sunshine and Ballarat), Bendigo line (between Sydenham/ Watergardens and Bendigo), Gippsland Line (between Pakenham and Traralgon). It is also on the Regional Rail Link (RRL) due to open in April 2015.
  KRviator Moderator

Location: Up the front
If the British Rail AWS (Automatic Warning System) been fitted in Victoria, could/should/would the Violet Town SPAD and collision been prevented?
awsgc24
No. AWS requires an acknowledgement on approach to a restrictive signal or it will start braking. If you acknowledge the alert, you'll quite happily sail past the signal if you don't manually slow the train. Given the VC was acknowledged shortly before the collision, AWS wouldn't have made a difference. ATP and IIRC, TPWS are the only systems currently in use that will stop you short of a signal.
  Lockspike Deputy Commissioner

Valvegear,
I believe you were on the right track when you stated "it is difficult to understand why Fireman Coultard did not take this action" It was established that Coultard was fit to work as loco crew as (amongst other factors) his cognitive abilities were satisfactory in that he was able to recognise and correctly interpret railway signals, I believe a key factor in this case. Even when Coultard realised (according to his stated evidence) a collision was imminent he did not engage in positive safety seeking behaviour (i.e. apply the brakes, something he had been trained in, and had a duty to do in an emergency). Subsequent brake testing revealed that even at this stage, a collision could have been averted. Instead, Coultard retreated into the engine room, clearly unreasonable behaviour.

The big question is why. What could have induced Coultard to only take this course of action.

After analytical reading of both the VR and Coroner's reports and giving them considerable thought, I came to what I consider a reasonable conclusion.
Carry out your own desktop analysis and see what conclusions you come to.
  Valvegear Dr Beeching

Location: Norda Fittazroy
Lockspike,

Thanks for your post.

First, anything which I posted in inverted commas was a direct quotation from the VR Report, e.g.  "it is difficult to understand why Fireman Coultard did not take this action".

Next, carrying out a desktop analysis of human behaviour is something for which I am eminently unqualified.

I can surmise that Coulthard was in denial that something quite out of the ordinary, something that had never happened in his experience, was actually taking place, and that somehow his brain just refused to accept it and therefore he did not act correctly. I don't think I can call that idea an analysis; it's a semi-educated guess.

I suspect that you may be engaged in an appropriate field to make such an analysis and I would be interested to read it.
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
Given that the Southern Aurora was probably the biggest 'big wheel' job what was this bloke's work history or had seniority gone out by then and all one had to do was keep the seat warm?
  Valvegear Dr Beeching

Location: Norda Fittazroy
Given that the Southern Aurora was probably the biggest 'big wheel' job what was this bloke's work history or had seniority gone out by then and all one had to do was keep the seat warm?
:YM-Mundrabilla"

V R Report, para. 4.2; " Driver John Bowden was 53 years of age, and he had been employed in the Railway Department for 31 years. He was appointed a Driver in 1951 and a Senior Driver in 1959. Since then, his duties involved driving express passenger and goods trains between Albury and Melbourne."

One surprising thing is the use of the words "Railway Department" - something I never heard or read anywhere else.
  YM-Mundrabilla Minister for Railways

Location: Mundrabilla but I'd rather be in Narvik
V R Report, para. 4.2; " Driver John Bowden was 53 years of age, and he had been employed in the Railway Department for 31 years. He was appointed a Driver in 1951 and a Senior Driver in 1959. Since then, his duties involved driving express passenger and goods trains between Albury and Melbourne."

One surprising thing is the use of the words "Railway Department" - something I never heard or read anywhere else.
Valvegear
Sorry Valvegear I was referring to the fireman rather than the driver.
  M636C Minister for Railways

Lockspike,

Thanks for your post.

First, anything which I posted in inverted commas was a direct quotation from the VR Report, e.g.  "it is difficult to understand why Fireman Coultard did not take this action".

Next, carrying out a desktop analysis of human behaviour is something for which I am eminently unqualified.

I can surmise that Coulthard was in denial that something quite out of the ordinary, something that had never happened in his experience, was actually taking place, and that somehow his brain just refused to accept it and therefore he did not act correctly. I don't think I can call that idea an analysis; it's a semi-educated guess.

I suspect that you may be engaged in an appropriate field to make such an analysis and I would be interested to read it.
Valvegear
Aircraft Pilots have a term "situational awareness". In several accidents, pilots have caused crashes by concentrating on one aspect (an incorrect instrument reading) to the exclusion of other visible information.

Coulthard had presumably never had to seriously contradict actions of his driver. It is possible that he never realised that the driver was incapacitated or dead until after the accident.

Had the driver fallen to the floor, he would have understood the situation, but the driver remained in his seat (much as the Waterfall accident driver remained in his seat operating the dead man pedal) and the actual situation took an unacceptably long time to register.

While he could operate the brakes, the driver appeared to still be in control and he couldn't reach the brakes without reaching across the driver to the brake stand.
So he took cover, possibly thinking the driver was still in control.

M636C
  Valvegear Dr Beeching

Location: Norda Fittazroy
Sorry Valvegear I was referring to the fireman rather than the driver.
"YM-Mundrabilla"

V R Report, para 4.2; " Fireman Mervyn George Coulthard is 30 years of age, and has been employed in the Department for eight years. In 1965 he qualified as a Fireman and, since January 1968, he has been regular Fireman to Driver Bowden on express passenger and goods trains. He passed a practical examination in the procedure to be followed in the event of his Driver becoming incapacitated. He was last examined by the Railway Medical Officer in November 1964, and passed fit."

I think that one problem is highlighted in that very paragraph - "regular fireman to Driver Bowden.", and that is familiarity. Everything's the same on every trip. Nothing goes wrong. Then, when the unexpected happens, confusion reigns and proper procedure is forgotten.
Airline Captains do not have regular First Officers, which ensures that everything is done by the book all the time. A good idea, I think.
  Lockspike Deputy Commissioner

Coulthard, in not attempting to stop the train, clearly did not behave reasonably. With the evidence available, it cannot be determined at which stage of the journey that Coulthard’s behaviour may have become unreasonable. Pascoe (Coroner) determined that Bowden died or was “in a coma at least 6 miles on the down side of the site of the crash”. During this time Coulthard cannot have had any communication with Bowden, nor seen Bowden make any movements, not even make throttle adjustments, in that six miles. It seems incredulous that Coulthard did not notice “the lack of reactions … in accordance with the skill and reputation of a man like Driver Bowden” (Pascoe), a man that Coulthard had worked closely with for thirteen months.

In attempting to make sense of Coulthard’s actions, we can look at what we know about him. We know he was 30 years old at the time of the crash and had been a railway employee for 8 years, half of which he had been a fireman. He joined the railways when he was 22, so one can assume he regarded it as a job, rather than a passion. If it were a passion it is more likely he would have joined upon leaving school.

He and Bowden had been a regular team for 13 months and the fact that Bowden picked him up on the way to work indicates that while they may not have socialised together, they were at least “workmates”.

Coulthard had had at least 6 hours sleep after a day off, prior to coming to work, so fatigue can be minimised as a factor.

We know that Coulthard enjoyed a drink, as on his day off he went to a hotel for lunch, a lunch that took 3 hours during which he consumed “about six 7-oz. glasses” of [presumedly] beer.

Coulthard did not challenge Bowden when it became blatantly obvious that Bowden was not slowing the train. Firemen were subordinate to Drivers; a driver’s decision was absolute, and it took a brave fireman to challenge a driver’s action. Even so, considering that the two men had been working together for 13 months and that they were on friendly terms, it is difficult to see why Coulthard did not ‘remind’ Bowden while there was still time to stop the train.

Coulthard had been working with Bowden for 13 months and we know that Bowden kept Anginine close at hand; it is unlikely that Coulthard cannot have known of Bowden’s heart condition.  

It is known that Coulthard faced at least three inquiries: - the investigation of the Victoria Police, the official Victorian Railways inquiry, and the Melbourne City Coroner’s court. When asked why he took no action when he was aware that the driver had not obeyed the signals he said, “I don’t know”. When Coulthard was asked why he did not close the throttle and apply the air brake he replied, “panicked, I suppose, that’s all”. When asked again why he made no attempt to stop the train his reply was, “I thought the brakes had applied”.

Coulthard’s self preservation instinct had diminished to the point that his problem solving skills were severely degraded. His judgement of what to do next had been so impaired that he was incapable of functioning in the appropriate manner.

The question is why, what could have caused such degradation?

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