Keperra Railway Station Fatality€¦ · passenger services within the Brisbane suburban area. Train 1732 was a six car suburban EMU, 144.8 m in length and weighed 235.6 tonnes. The

Transport and Main Roads

Connecting Queenslandwww.tmr.qld.gov.au

Keperra Investigation ReportKeperra Railway Station Fatality

Saturday 7 May 2011

Transport and Main Roads Keperra Investigation - Keperra Railway Station Fatality - Saturday 7 May 2011

Contact:Web http://www.tmr.qld.gov.auPhone 07 3253 4986Email [email protected] PO Box 673 Fortitude Valley Qld 4006

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Keperra Investigation ReportKeperra Railway Station FatalitySaturday 7 May 2011


Contents

Terms of reference ...........................................................................................................................3Investigative methodology ..............................................................................................................4Executive summary .........................................................................................................................5

1 Factual information .................................................................................................................... 6 1.1 Overview .................................................................................................................................... 6

1.2 The location ............................................................................................................................... 6 1.3 Rolling stock operator .................................................................................................................7 1.4 Rail infrastructure manager ........................................................................................................7 1.5 Train information ........................................................................................................................7 1.6 Rail traffic crew ...........................................................................................................................7 1.7 Mobility scooter information ...................................................................................................... 8 1.8 The mobility operator information ............................................................................................. 8 1.9 The occurrence .......................................................................................................................... 8 1.10 Post occurrence ........................................................................................................................10

1.10.1 Response .......................................................................................................................10 1.10.2 Injuries ..........................................................................................................................10 1.10.3 Loss and damage ...........................................................................................................10

1.11 Environmental conditions .........................................................................................................10

2 Analysis ....................................................................................................................................11 2.1 Keperra rail platform ................................................................................................................. 11 2.2 Train condition ..........................................................................................................................12 2.3 Scooter condition ......................................................................................................................12 2.6 Electromagnetic interference ..................................................................................................... 13 2.7 Scooter operator behaviour .......................................................................................................14

3 Findings ................................................................................................................................... 16

4 Safety actions .......................................................................................................................... 16

Transport and Main Roads Keperra Investigation - Keperra Railway Station Fatality - Saturday 7 May 2011 33

Terms of reference

As a Rail Safety Regulator, the Director-General, Transport and Main Roads, requested an investigation into the fatality at Keperra Railway Station in accordance with the terms and reference outlined below.

As Rail Safety Regulator pursuant to the Transport (Rail Safety) Act 2010 I hereby require you, a Rail Safety Officer, to conduct an investigation in accordance with Section 183 (2) of the Transport (Rail Safety) Act 2010 and report to me on the circumstances and causes of the fatality at Keperra Railway Station on Saturday 7 May 2011.

Your investigation will:• clearly establish the factual circumstances of the incident• conduct an analysis of the cause or causes of the incident• assess human factors and identify any underlying systemic issues:

– the interface and the actions of relevant parties which may have caused or contributed to the incident

• assess the adequacy and effectiveness of actions taken as a result of the incident paying particular attention to:

– response to the incident – recovery operations undertaken

• assess the adequacy and effectiveness of platform safety• if necessary, make appropriate recommendations designed to prevent a recurrence of any

failures.

The investigation team will be comprised of Rail Safety Officers from the Rail Safety Regulation Branch of the Department of Transport and Main Roads and other Rail Safety Officers appointed from external consultants.

David StewartDirector-GeneralTransport and Main Roads


To understand the factual circumstances, environment, standards and procedures of the railways operation, information was sought and obtained from a variety of sources including:• Queensland Rail Ltd• Queensland Police Service• Workplace Health and Safety Queensland, Department of Justice and Attorney General• Australian Bureau of Meteorology.

Information was also obtained from the following sources:

• collision scene site visit• interview with the daughters (the family) of the scooter operator• photographic evidence• CCTV footage• motorised scooter user manual • Therapeutic Drugs Administration, Commonwealth Department of Health and Aging• monitoring of Electromagnetic Interference at the scene. • interviews with the train driver and guard.

The information gathered was assembled to provide a sequence of events and to analyse and consider the issues and conditions that were involved. Findings and recommendations are based on the evidence available to the investigation panel at the time of this report.

Investigation methodology


At 12.01 pm 7 May 2011, an electric mobility scooter drove over the edge of a station platform at Keperra Station, and into the path of a moving passenger train. The passenger train impacted with the scooter. As a result of the collision, the operator of the scooter was fatally injured. No damage was caused to the train and the rail traffic crew were uninjured.

Transport and Main Roads conducted an independent investigation of the incident, that determined the immediate cause of the incident was that the scooter operator lost control of the scooter and failed to stop prior to the edge of the platform.

The report recommends that: • Queensland Rail considers a continuing education program as to the responsible use of mobility scooters

on station platforms. • Queensland Rail considers imposing a speed limit for mobility scooters on station platforms.

For the purposes of this report, the incident was a notifiable occurrence as defined in Schedule 3 of the Transport (Rail Safety) Act 2010. The reasons that it is considered a notifiable occurrence are:

• The operation or movement of rolling stock on a railway track is defined in Section 9 of the Transport (Rail Safety) Act 2010 as railway operations.

• Rolling stock as defined in Schedule 3 of the Transport (Rail Safety) Act 2010 was involved in this incident. The incident occurred on a railway as defined in Schedule 3 of the Transport (Rail Safety) Act 2010

• The incident caused death. • The operator of the rolling stock was accredited under the Transport (Rail Safety) Act 2010 at the time of the

incident. • The incident was an occurrence that was required to be reported by the railway operator and the railway

manager under the conditions of accreditations.

Executive summary


1. Factual information

1.1 OverviewAt 12.01 pm on 7 May 2010 an electric mobility scooter drove over the edge of a station platform at Keperra Station, and into the path of a moving passenger train. The passenger train impacted with the scooter. As a result of the collision, the operator of the scooter was fatally injured. No damage was caused to the train and the rail traffic crew were uninjured.

1.2 Location Keperra is a suburb of Brisbane located 12 km north west of the Brisbane CBD. The suburb is serviced by the Ferny Grove Line, a suburban railway line. The railway line runs from Brisbane to Ferny Grove a distance of 17.35 track km. The track speed limit at the location is 70 km/h.

BrisbaneBardon

Windsor Keperra

Bulimba

Woolloongabba

Stafford

FernyGrove

MountCoot-tha

Figure 1: Location of Keperra, Queensland


1.3 Rolling stock operatorThe train involved in the incident was operated by a rolling stock operator accredited under the Transport (Rail Safety) Act 2010. The rolling stock operator conducts train passenger services in the Brisbane suburban area.

1.4 Rail infrastructure managerThe rail infrastructure manager of the Ferny Grove Line is accredited under the Transport (Rail Safety) Act 2010. The rail infrastructure manager is responsible for the operation and maintenance of the railway line and associated infrastructure including the Keperra Train Station.

1.5 Train information (Train 1732)The rolling stock operator operates both three and six car configuration Interurban Multiple Units-(IMU), Suburban Multiple Units (SMU) and Electric Multiple Units (EMU) trains as part of its regular electric passenger services within the Brisbane suburban area. Train 1732 was a six car suburban EMU, 144.8 m in length and weighed 235.6 tonnes. The train was not fitted, nor required to be fitted with a data logger or front view camera.

The train was operating a scheduled service from Ferny Grove to Beenleigh, with stops at all stations in between. Keperra Station was therefore a scheduled stop.

1.6 Rail traffic crew The train was operated with a single driver occupying the leading cab, and a train guard occupying the fourth car in a six car configuration train.

The driver at the time of the collision had almost three years train driving experience, having worked generally with Queensland Rail since 2006. The train driver was qualified on the type of train involved in the collision and route competent for the Ferny Grove line including the section where the collision occurred.

On the day of the collision the driver had started work at 10.03 am and the day prior had completed his shift at 11.02 am. Fatigue was not considered to be a contributing factor to this incident.

The guard on the train had been qualified as a guard for in excess of 14 years and certified as competent for the Ferny Grove route.

On the date of the collision, the guard had started work at 10.03 am. On the day prior to the collision, he had completed work at 2.45 pm.

The railway operator uses the National Transport Commission National Standard for Health Assessment of Rail Safety Workers as a basis for health assessment of its ‘Safety Critical Workers’. The rail traffic crew were assessed as ‘Fit for Duty’ as prescribed in the National Health Standard at the time of the incident.

The qualifications and medical fitness of the rail traffic crew are not considered to have contributed to the incident.


1.7 Motorised scooter informationThe mobility scooter involved in the incident was a Heartway Mystere PF5, manufactured by Heartway Medical Products. The PF5 mobility scooter is propelled by a 700 watt electric motor powered by a 12 volt battery system. The mobility scooter has a maximum speed of 10 km/h. The mobility scooter size is 1.42 m in length, 63 cm wide and weighs 107 kg. The mobility scooter has a turning radius of 1.16 m.1

1.8 The mobility scooter operatorThe mobility scooter operator (the scooter operator) was a 63 year old female resident of Keperra. The scooter operator had a degenerative spinal condition and had complied with her doctor’s advice to stop driving a car.2

The operator purchased the scooter second hand in 2010 from a company in Brisbane. The scooter operator did not receive any particular training on how to operate the scooter, although she had previously owned another type of scooter.

1.9 The occurrenceAt approximately 12 pm Saturday 7 May 2011, the scooter operator drove the mobility scooter to Keperra Station with the intention to catch train 1732. The scooter operator entered onto Keperra Station from the station car park, located opposite the corner of Silvertop and Blackbutt Streets. Her actions were recorded on Closed Circuit Television (CCTV).

The scooter operator was in the process of swiping a go card at the western (Ferny Grove) end of the platform when the pedestrian warning lights began flashing and the audible warning tone sounded for the pedestrian maze. The pedestrian warning system had been activated by train 1732 approaching Keperra station from the west, en route from Ferny Grove Station.

1 Heartway PF5 specifications2 Information provided by the scooter operator's family

Figure 2: An approximate rendering of the Heartway PF5 mobility scooter


Figure 3: Overview of scooter operator's movements on the mobility scooter at Keperra Railway Station on Saturday 7 May 2011

The gates began to close behind the mobility scooter and the scooter operator drove the mobility scooter east along platform 1 until reaching a point between the main station building and seating on the western side of the main station building (refer figure 3).

Without stopping, the scooter operator turned the scooter right (toward platform 2) away from the edge of platform 1 and travelled in a tight arc before turning back to the left sharply, toward the Assisted Boarding Point (ABP) on platform 1.

The scooter was then driven over the ABP and off the northern platform edge of the number 1 platform.

The front of train 1732 collided with the left side of the scooter operator while she was still seated in the scooter. The scooter operator was thrown from the scooter, landing in the grass and clear of the railway line.

The train driver, upon seeing the scooter operator leave the platform, made an emergency brake application and stopped the train 50 m after the collision point.


1.10 Post occurrence

1.10.1 ResponseAt 12.02 pm the train driver contacted Network Control with an emergency broadcast and reported the incident. The network controller promptly advised emergency services. The driver and guard were relieved of duty after the collision. There was no indication of alcohol or drugs affecting their performance.

The Queensland Police Service attended the incident and is preparing a report for the Coroner. The incident was also investigated by the rail infrastructure manager.

Rail Safety Officers from the Rail Safety Regulation Branch were advised of the incident and commenced an investigation. At the time of the incident, Keperra Station was unmanned with several witnesses leaving the station prior to being interviewed.

At the time of the collision there were about 30 passengers on board the train, who were detrained. Alternative transport arrangements were made for the passengers to continue their journey.

1.10.2 InjuriesThe scooter operator was seriously injured and was conveyed from the scene at 12.52 pm by the Queensland Ambulance Service to the Royal Brisbane and Women’s Hospital. She passed away at approximately 2 pm. There were no reported injuries to train passengers or the rail traffic crew.

1.10.3 Loss and damageThere was no damage caused to the train as a result of the collision. The motorised scooter suffered moderate damage as a result of the collision.

1.11 Environmental conditionsThe following Bureau of Meteorology weather information was recorded from the Brisbane City and Brisbane Airport weather stations on 7 May 2011. The weather condition was fine with light winds. Environmental factors were not considered to be a contributing factor to the incident.

Date Day

TempsRain Evap Sun

Max wind gust

Min Max Dir Spd Time

o C o C mm mm hrs km/h local

7 Sat 12.3 25.0 0 4.0 10.0 W 13 12.05 pm

9 am 3 pm

Temp RH Cld Dir Spd MSLP Temp RH Cld Dir Spd MSLPo C % 8th km/h hPa o C % 8th km/h hPa

18.1 67 1 SW 6 1018.3 24.0 38 3 W 4 1014.3

Table 1 : Bureau of Meterology weather information for Saturday 7 May 2011


2. Analysis

2.1 Keperra rail platformThe rail platform at Keperra is an island platform situated between two railway tracks. Pedestrian access to the western end of the platform is by way of a rail line crossing with access controlled by lights and gates. Pedestrian access to the eastern end of the platform is by way of a ramp from Mooney Street. Disabled access is provided for at either end of the platform.

The platform is approximately 150 m in length and conforms to the construction standard of the rail infrastructure manager. The surface of the platform is bitumen.

The platform has one nominated ABP in either direction, located approximately 70 m along the platform and connecting with the last carriage of a three car unit or the third carriage of a six car unit. At the northern boarding point, where the scooter operator was intending to wait for the train and the point of impact, the width of the platform was approximately 10.4 m.

Using measurements taken by the Queensland Police, from the edge of the platform there is a 600 mm white line, then another 600 mm yellow line (the line which intending passengers are required to wait behind). Behind this yellow line is a blue square with a white painted wheelchair centred on it, which indicates an ABP for the platform. This painted square is 900 mm x 900 mm and from the edge of the platform to the outer point of the assisted board point is 2.1 m.

Inspection of the platform found no signage for instructing scooter users. Electric scooters in Queensland can travel up to 10 km/h. The platform was dry and clear of any debris when the incident occurred.

Figure 5: Keperra Railway Station platform

Assisted Boarding

Point

Direction of train travel

Figure 4: Example of an ABP Marker

Transport and Main Roads Moranbah Investigation - Fatal Collision 8 July 2010 - Final Report - TMR3584, September 201112

2.2 Train conditionThere were no train faults identified by the rail traffic crew prior to the incident and during the course of the Queensland Rail investigation.

Queensland Rail advised that the braking systems of train 1732 were tested post collision, the tests identified that the train’s brakes were functioning as designed.

2.3 Scooter conditionThe Queensland Police Service, with the assistance of a scooter technician rebuilt the damaged scooter and tested it mechanically. The following settings were found on the scooter.

The control settings of the scooter are limited from 1 to 10, with 10 being the highest setting. The following settings were applied at the time of the incident:

• Acceleration-3

• Deceleration-7

• Reverse-5

• Forward-9

• Variance-5

Headlight LED

Battery time LED

Left signal light LED Right signal

light LED

LCD display

Set buttonLCD control

buttons

Headlight switch button

Hazard light LED

Left signal light switch

button

Right signal light switch

button

Horn button

Figure 6: PF5 Scooter display board mounted on handlebars.


Transport and Main Roads Moranbah Investigation - Fatal Collision 8 July 2010 - Final Report - TMR3584, September 2011 1313

All controls of the scooter are operated by hand, with the speed of the scooter controlled by a finger lever control that is located on the handlebars at the side of the display panel. The further the finger lever is pushed the faster the scooter will go, up until the speed limit of 10 km/h is reached. To brake, the finger lever control is released into the neutral position, which will automatically apply the electromagnetic brakes. The scooter is also fitted with a ‘Rhino Controller’, which monitors the operation of the scooter, if there was a problem with the braking system or other system the operator should have been aware as an error indicator is displayed on the display panel.

During testing, the scooter performed well turning at full speed. The application of the brakes on the scooter can be counter intuitive as the operator releases the throttle rather than squeezes or depresses a brake pedal.

The brakes of the scooter were tested and it was found when driving at full speed, the average stopping distance was 2.55 m. Ten braking tests were conducted, with no braking failures. The Queensland Police Forensic Crash Investigation Unit did not locate any mechanical failure that would have contributed to the loss of control of the scooter.

As the stopping distance of the scooter is 2.55 m, to stop prior to the yellow line on the platform, the scooter operator would have had to release the accelerator, therefore engaging the braking system well prior to going on the blue ABP. Analysis of CCTV footage indicates that at the ABP the scooter operator had not reduced speed. It is estimated that at the time of the scooter operator leaving the edge of the platform, she was still operating at, or near, full speed.

Motorised scooters require registration with Transport and Main Roads. The operator is to supply to Transport and Main Roads a certificate issued by a medical practitioner, physiotherapist or occupational therapist to confirm that the person has a severe mobility impairment.

The scooter was not registered at the time of the incident. The organisation from which the scooter operator had purchased it from (now out of business) had informed her that they would register it on her behalf.

The mechanical condition of the motorised scooter is not considered as having contributed to the incident.

2.4 Electromagnetic Interference Electromagnetic Interference (EMI) is a disturbance that affects an electrical circuit due to either electronic induction or radiation emitted from an external power source. This can include items such as overhead power lines and train radios commonly found on station platforms.

The issue of EMI was raised in the investigation as a possible cause of the scooter operator losing control of the scooter and, in particular, the electromagnetic braking system as motorised scooters can be susceptible to EMI.

The scooter operator travelled parallel to the overhead lines and when approaching the platform edge, was within 10 m of the train. Both the overhead power lines and train radio would have been emitting EMI at the time of the incident.

The manual of the motorised scooter involved in the incident indicates that the scooter technology is capable of providing at least 20 V/m3 (volts per meter) of immunity. This immunity level4 is generally what is recommended for scooters on the current Australian market. International testing found that with an immunity level of 20 V/m no EMI reactions were found even with a transmitter within close proximity.

As a result of this concern and for completeness, engineering firm Compliance Engineering was engaged to test the collision scene for EMI measurements. The tests were undertaken in similar weather conditions as at the time of the collision and were conducted from 12 pm 13 July 2011 until 12.05 pm on 14 July 2011.


3 Electromagnetic Interference values expressed as V/m (volts per metre).4 Witters D, Medical Devices and EMI: The FDA Perspective, U.S. Food and Drug Administration,

www.fda.gov/ MedicalDevices/Device RegulationandGuidanceDocuments(Medical Devices and Radiationon Emitting Products.

Transport and Main Roads Moranbah Investigation - Fatal Collision 8 July 2010 - Final Report - TMR3584, September 20111414 14

At a height of 25 cm from the ground (approximate height of the braking system), the EMI readings were consistently zero. Additional measurements were taken at different heights, at 180 cm from the ground the first reading of 2 V/m was established, and it was not until 3 m from the ground and near the overhead power lines that the readings were 50 V/m. Testing included times when trains were approaching, this still did not elevate the EMI levels. The captured images of the scooter operator clearly show that she was not operating a mobile telephone at the time of the collision, nor was there any other person within close proximity.

EMI is not considered to be a contributing factor to this incident. A copy of the expert report can be found attached at attachment A.

2.5 Scooter operator behaviourThe scooter operator was observed driving the mobility scooter through the Keperra station car park at approximately ten km/h, which is the maximum permitted speed in Queensland for mobility scooters.

She kept her hands on the handlebars and, without any apparent braking, drove over the edge of the platform in the path of train 1732. The CCTV images show that the scooter operator places her right foot on the ground at the ABP, presumably in an attempt to slow, however the scooter continued over the edge of the platform.

The scooter operator routinely caught the train from Keperra station. Station staff indicated that she would routinely notify them of her arrival. They would exit the office and escort her to the ABP. Discussions with station staff also revealed that the scooter operator had been asked in the past to slow down on the platform.

The scooter operator had a degenerative spinal condition. Symptoms of this illness included weakness in her leg reflexes and occasional blackouts. She also had diabetes which the next of kin indicated resulted in her having no feeling in her feet. There were other medical conditions however they were not considered directly relevant to this investigation.

Due to her illness her doctor had prescribed at least seven different types of medication. The general side effects may include confusion, dizziness, disrupted coordination, blurred vision, tingling/numbness of extremities, and muscle weakness. This does not include any potential interactions between the drugs.

The next of kin indicated that the night before the incident the scooter operator seemed fine, and that if she felt her medication was affecting her she would not go out.

The next of kin also advised that the scooter operator had stopped driving a motor vehicle, as her doctor believed that her reflexes were not sufficient to stop a car in time. However she was reported to have had sufficient feeling in her hands to control the scooter.

Two weeks prior to the accident the scooter operator had driven her motorised scooter into a vehicle in a shopping centre car park. No damage was caused to the vehicle or scooter. The investigation was unable to gather data on this event as no investigation was undertaken at the time. Family members were told by her that the brakes hadn’t worked. The braking system was not checked prior to this fatal collision. Post collision assessment of the scooter found no issue with the brakes.

The combination of illness symptoms and medication effects is likely to have reduced her ability to effectively manipulate the motorised scooter. The previous car park incident also raised questions regarding her ability to manipulate the scooter effectively.



The scooter operator was running late for the train. The pedestrian gates closed behind her as she swiped her go card indicating that the train’s arrival was imminent. It is therefore possible that she may have been rushing to catch the train.

It is not known whether the scooter operator inadvertently accelerated the scooter by incorrectly applying the throttle rather than the brake. However, CCTV footage analysis indicated little to no change in scooter speed during her passage across the platform.

Assessment of CCTV footage indicates that the scooter driver did not slow down prior to driving over the edge of the platform. Based on estimates of when she swiped her go card and the distance travelled it is estimated that she was travelling at close to maximum speed (10 km/h) towards the ABP. Road user research estimates that drivers take approximately 2.0 to 2.5 seconds to react to a stimulus. At 10 km/h the scooter operator could potentially travel a distance between 5.6 and 6.9 m. Given the direction the scooter was pointing (towards the track) and its speed, the scooter had insufficient distance to stop prior to leaving the platform.

It is most likely that a combination of scooter speed; potential medication effects of confusion, dizziness and disrupted coordination; and her reduced mobility issues may have reduced her ability to recognise a developing situation, develop a plan, and perform the behaviours necessary to ensure her safety in the presence of an oncoming train.

Transport and Main Roads Moranbah Investigation - Fatal Collision 8 July 2010 - Final Report - TMR3584, September 201116

3 Findings

The Transport and Main Roads investigation determined the immediate cause of the incident was that the scooter operator lost control of the scooter and failed to stop prior to the edge of the platform.

4 Recommended safety actions

4.1 Rail infrastructure manager1. Queensland Rail as the responsible rail transport operator to consider a continuing education program on

the responsible use of mobility scooters on station platforms.

2. Queensland Rail as the responsible rail transport operator to consider imposing a speed limit on the use of mobility scooters on station platforms. The speed limitation should be clearly displayed at relevant entry points and other suitable locations. The displayed speed limit should be easily interpreted by users, for example ‘walking pace’.



Notes: