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At about 1411 on Wednesday 9 September 2009, scheduled XPT passenger train ST24, en route from Melbourne to Sydney, passed signal JE02 at Junee by about 33 m while that signal was displaying a Stop (red) indication. No injuries or damage resulted from the occurrence.

The driver of ST24 said that signal JE26, the signal before JE02, was displaying a Medium Turnout indication and this meant that signal JE02 would be showing a Proceed aspect. Several other rail employees also said that signal JE26 was displaying a Medium Turnout indication. However, the investigation concluded that it was almost certain that signal JE26 was displaying a Caution Turnout indication rather than a Medium Turnout indication, which would have resulted in signal JE02 displaying a Stop indication. The investigation concluded that the driver's perception of signal JE26 was influenced by expectation, distraction and possibly fatigue, and that the employee witnesses' perception of the signal was influenced by expectation, 'confirmation bias' and 'group think'.

The report identifies three safety issues in relation to prioritisation of operational tasks, signal lamp voltage and signalling design standards.

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Safety issues

RO-2009-008-SI-01 - RO-2009-008-SI-02 - RO-2009-008-SI-03 -  

Prioritisation of tasks when departing a station yard

There was no RailCorp instruction that specifically referred to the need for train crew to prioritise tasks at safety critical locations or at times when workload is high.

 

Safety issue details
Issue number:RO-2009-008-SI-01
Who it affects:All rail operators
Status:Safety action pending


 

Salience of signal JE02

The voltage of signal JE02 was below the ARTC standard for the type of globe installed.

Safety issue details
Issue number:RO-2009-008-SI-02
Who it affects:Rail infrastructure managers and signal maintenance staff
Status:Adequately addressed


 

Microlok signalling logging capabilities

The Microlok signalling program design does not meet the requirements of ARTC signalling standard SCP23 ‘Design of Microlok Interlockings’ in regard to the logging of internal bits that initiate flashing, pulsing or toggled outputs.

Safety issue details
Issue number:RO-2009-008-SI-03
Who it affects:Rail infrastructure managers and signal system designers
Status:Adequately addressed

 
General details
Date: 09 September 2009 Investigation status: Completed 
Time: 1411 EST Investigation type: Occurrence Investigation 
Location   (show map):Junee  
State: New South Wales  
Release date: 11 February 2011 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Train details
Train registration: Train ST24 
Type of operation: Passenger Train 
Damage to train: Nil 
Departure point:Melbourne, Vic
Destination:Sydney, NSW
 
 
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Last update 25 January 2017