Passenger Rolling Stock Door Locking – An ONRSR Case Study

ONRSR Driven Safety Improvement

All Comeng trains remaining on the Melbourne metropolitan network have been fully retrofitted with new door locking mechanisms. This has effectively eliminated the risk of “door forced” occurrences which has resulted in zero incidents reported from July 2025 to February 2026.

Background

The Comeng fleet was first introduced to the Melbourne metropolitan network between 1982 and 1989. In 2015, ONRSR approved a variation to allow the fleet to run beyond its life expiry, with conditions largely centred around improvements to the functionality of passenger doors. Of particular concern was the absence of effective door locks and the subsequent ability of passengers to force doors open while these trains were in motion.

In 2022 and 2023, an increase in reported “door forced” occurrences saw ONRSR formally request a “So Far As Is Reasonably Practicable (SFAIRP)” argument from Metro Trains Melbourne (MTM) to understand its approach, both immediate and long term, to mitigate the safety risk.

ONRSR’s Engagement

Following a fatal occurrence involving the forcing of a Comeng fleet door in June 2022, ONRSR commenced an investigation and intelligence gathering process that involved the collation of a range of information including CCTV footage and a review of data loggers. At the same time, a formal regulatory response was established that facilitated a series of engagements between ONRSR, MTM and the Victorian Department of Transport and Planning (DTP).

These initial discussions identified several proposed actions to address the risks to safety posed by the door design including the option of seeking funding approval for the design, procurement and installation of modern door locking mechanisms for the full Comeng fleet. At the same time MTM committed to exploring a series of risk controls such as audible alarms and alternative modifications to the operation of the existing doors.

In the ensuing months MTM presented to ONRSR’s technical specialists a concept installation on a static Comeng unit that included:

• Pneumatic door cylinders replaced with mechanical locking

• Handle/button activated Emergency Door Release (EDR)

• EDR speed interlocking (door release locked out above 8kph)

• Driver alerts for the EDR via Emergency Intercom

• Deferrable EDR (driver can override the release of the door locks if not safe).

While MTM continued to explore the suitability of these and a range of related safety controls, most notably audible door alarms, ONRSR continued its advocacy for the full retrofitting of the Comeng fleet with new door locking mechanisms. Chief among the regulator’s concerns was that any investment would not cover less effective risk controls at the expense of a full commitment to the procurement and installation of the door mechanisms.

By March 2023, MTM updated ONRSR on the progress of its risk control program and the related SFAIRP assessment. While progress had been made in relation to the fitting of audible alarms, ONRSR was not satisfied with the operator’s “SFAIRP” position and subsequently exercised powers under the Rail Safety National Law to further scrutinise the delivery planning in a bid to increase the pace of the program and its rollout.

A second fatal occurrence involving the forcing of a door in a Comeng train in August of 2023 further heightened the need for the issue to be fast-tracked. As it had the previous year, ONRSR conducted its own investigation and while both fatal incidents were the result of deliberate acts by passengers, subsequent regulatory enquiries with MTM culminated in ONRSR’s decision to issue two Improvement Notices to the operator for failure to review and demonstrate adequate risk controls. While this enforcement action was a significant step, ONRSR also held a series of positive and effective discussions with MTM who were soon able to demonstrate significant progress on the door mechanism replacement program.

By the end of 2023, ONRSR had conducted a site visit to Craigieburn Maintenance Depot to observe a demonstration of one of the in-service trial trainsets fitted with the door locking modification. MTM demonstrated the pneumatic door operating system which had been re-engineered to an electro-pneumatic system. This upgrade allowed for a ‘pin’ to drop into a mechanism within the door which stops the door from being forced open. A new decal was designed and attached to the doors to warn passengers of the penalty imposed if found holding or forcing the door open. In addition, MTM incorporated a new EDR function which allowed the driver to have a visual and audible alert including an override capability. The driver would be able to override the door release within 20 seconds of being alerted to an emergency.

Soon after this demonstration, and following continued engagement, updates and reporting to ONRSR, funding was approved by DTP to fit the new door locks to the entire Comeng fleet, commencing in July 2024.

With 12 full-time personnel committed to the project, it was completed in December 2025.  

Safety Improvement Outcomes

The rollout of the door locking project to the Comeng fleet coincided with a noticeable reduction in door forcing occurrences reported by MTM to ONRSR. In fact, since 1 July 2025 there has been 0 reports of such occurrences.

Despite the need for ONRSR to exercise powers under Rail Safety National Law, the management of this issue was another demonstration of how a risk-based regulator can work effectively with an operator to help advance a safety solution. ONRSR commends MTM and DTP for their willingness to work diligently and collaboratively in the interests of rail safety for the Victorian community.