Investigators at the crash site in 2020.

By Grace Frost

The final investigation into the derailment of a passenger train at Wallan East in 2020 found the experienced driver of the train was unlikely to have understood a change to the service’s usual route, resulting in his own and one other death.

NSW Trainlink XTP passenger train ST23 was travelling from Sydney to Melbourne on February 20, 2020, when it derailed at Wallan East.

The driver and an accompanying qualified worker, who were both in the train’s leading car, died in the accident. 

Photo: Australian Transport Safety Bureau

Eight passengers were admitted to hospital with serious injuries, while a reported 53 passengers and the five passenger service crew sustained minor injuries.

The Australian Transport Safety Bureau, ATSB, released its final report into the incident on Wednesday, finding ‘a breakdown in risk management processes’ contributed to the derailment.

What happened?

A fire in a signalling hut at Wallan East two weeks prior to the derailment resulted in damage to the signalling system on the train line between Kilmore East and Donnybrook.

The Australian Rail Track Corporation, ARTC, slowed the speed limits between the stations where signals were down, resulting in major delays.

ARTC decided trains would operate at higher speeds once again from February 6 while signalling remained down.

Passenger trains were permitted to travel at 130 km/h.

An accompanying qualified worker, AQW, was also required to travel in the cab with the driver between Kilmore East and Donnybrook as a precaution.

The driver of the train that derailed had driven through Wallan eight times in the 12 days prior to the accident, with speed limits remaining at 130 km/h. 

On February 20, a deviation to the regular route through Wallan was made to prepare for testing the signalling system and to clean contamination off the track’s railhead.

Trains travelling through Wallan were to be routed through the Wallan Loop – a short section of railway that deviates from the straight track.

Source: Pass Assets, annotated by the Transport Safety chief investigator.

The train’s driver received a paper copy of the train notice advising of the changes at Wallan Loop from the AQW when they boarded at Kilmore East.

The paper specified a speed limit of 15 km/h for entry into the loop and a limit of 35 km/h when exiting the loop.

Photo: Australian Transport Safety Bureau

The network protocol did not require the network control officer to read the content of the documents to the driver.

The ATSB found there was no communication between the controller and driver regarding the maximum speed of 15 km/h for entering the Wallan Loop.

ATSB chief commissioner Angus Mitchell said investigations suggested the train driver likely expected to remain on the straight track, where the speed limit was 130 km/h.

“There was no protocol in place to confirm the driver’s understanding of the revised instruction, with no requirement for the driver to read back or confirm the instructions to the network control officer,” he said.

The train approached the Wallan Loop at about  7.43pm at a speed of between 114 and 127 km/h when the maximum permitted speed to enter the loop was 15 km/h.

Aerial view of the derailment of a passenger train in Wallan in 2020, which killed two people. Photo: Australian Transport Safety Bureau

An emergency brake application was made, which slowed the train a small amount but was not able to stop the train from derailing.

The driver had been associated with the rail industry for about 40 years, employed in a range of roles including driving, training, and management. 

Emergency services attend the scene in 2020.

Safety findings

The final report details 37 findings including 15 safety issues regarding the derailment.

Findings included that ARTC did not specify the qualification and knowledge requirements of persons who were to perform the safety-critical role of an AQW.

The investigations also found working arrangements to manage traffic while the signalling system was not functioning deviated from ARTC network rules.

“We identified that several safety factors increased safety risk including weaknesses in ARTC risk management, the train working arrangements, risk controls including a reliance on manual processes, and stakeholder engagement,” Transport Safety chief investigator Mark Smallwood said.

Photo: Australian Transport Safety Bureau

The investigation also highlighted the design of the XPT driver’s cab contributed to the fatal outcome for the driver and accompanying qualified worker.

“This investigation highlights the importance of effective risk management for managing planned and unplanned track and infrastructure works, such as in this instance the loss of signalling through Wallan,” Mr Smallwood said.

To view the full 130-page report, people can visit


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