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At 1209 on 24 February 2011 a suburban commuter train (215A) with 17 passengers on board was being routed from the Up South Main Line into platform 5 at the Adelaide Station. At about the same time a second commuter train (G231) with 22 passengers on board that was departing the Adelaide Station passed signal 141 located at the end of platform 3 at low speed. Shortly thereafter both drivers realised that their trains would come into conflict and applied their train brakes but it was too late to avoid a collision. There were no injuries as a result of the collision; however, both trains sustained minor damage.

The ATSB established that the driver of train G231 received a 'yellow' Right of Way flag from the Platform Coordinator, indicating that platform work was complete and that the train could advance up to signal 141 which was displaying a stop (red) indication.

It was concluded that as the train approached signal 141 the driver diverted his attention onto a lesser task of checking train notices and did not concentrate on the more important task of observing the status of signal 141. Subsequently he perceived that signal 141 had changed to a 'proceed' aspect, although the investigation subsequently established that it did not clear at any stage prior the SPAD event and continuously displayed a stop (red) indication for the passage of train G231.

In the interests of enhancing future rail safety the ATSB identified a number of safety issues which included the dispatching of trains towards starting signals, the level of protection afforded by the train's dead man's control and Automatic Warning System and a range of opportunities to reduce the risk of human performance error. The ATSB is satisfied that the actions proposed in response by Public Transport Services adequately address each of the safety issues.

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Preliminary report: 21 Aprl 2011

At 1209  on 24 February 2011 a suburban passenger train (215A) with 17 passengers on board was being routed from the Up South Main Line into number 5 platform at the Adelaide Railway Station. At about the same time a second passenger train (G231) with 22 passengers on board that was departing the Adelaide Railway Station passed signal 141 located at the end of number 3 platform at low speed. The signal was displaying a stop (red) indication.

A short time later the drivers of both trains realised that they would come into conflict and applied their train's brakes, too late to avoid a collision. There were no injuries as a result of the collision but both trains sustained minor damage.

The investigation is continuing

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Safety issues

RO-2011-002-SI-01 - RO-2011-002-SI-02 - RO-2011-002-SI-03 - RO-2011-002-SI-04 - RO-2011-002-SI-05 - RO-2011-002-SI-06 - RO-2011-002-SI-07 - RO-2011-002-SI-08 -  

Dispatching trains against starting signal

Public Transport Services procedures permit trains to be dispatched from Adelaide Station towards starting signals that are displaying a stop (red) indication.

Safety issue details
Issue number:RO-2011-002-SI-01
Who it affects:All rail operators
Status:Adequately addressed


 

Vigilance control

As a defence against driver error Public Transport Services provide their railcars with a vigilance system comprising a deadman’s control and an Automatic Warning System. However, the current system does not protect against ‘Starting against Signal’ SPAD events as occurred at Adelaide Station.

Safety issue details
Issue number:RO-2011-002-SI-02
Who it affects:All rail operators
Status:Adequately addressed


 

SPAD Investigation Form

SPAD Investigation Form (RS-ADL-283) used by Public Transport Services does not collect data on many of the human factor issues that would facilitate a better understanding of why SPADs are occurring.

Safety issue details
Issue number:RO-2011-002-SI-03
Who it affects:All rail operators
Status:Adequately addressed


 

Human factors driver training

Public Transport Services driver training does not adequately address the risk of distraction and areas of human performance error with respect to SPAD events.

Safety issue details
Issue number:RO-2011-002-SI-04
Who it affects:All rail operators
Status:Adequately addressed


 

Interactive driver training

Public Transport Services have not implemented simulator training or a similar interactive system which would allow new drivers to practice, retain and apply what they have learned without the risks associated with driving trains in traffic.

Safety issue details
Issue number:RO-2011-002-SI-05
Who it affects:All rail operators
Status:Adequately addressed


 

Inconsistencies between RoW procedures

There are inconsistencies between Right of Way procedures used by platform coordinators and passenger service attendants.

Safety issue details
Issue number:RO-2011-002-SI-06
Who it affects:All rail operators
Status:Adequately addressed


 

Inconsistencies between Work Instructions and the Common General Operating Rules

There are inconsistencies between Right of Way Work Instructions and the Common General Operating Rules.

Safety issue details
Issue number:RO-2011-002-SI-07
Who it affects:All rail operators
Status:Adequately addressed


 

Fatigue management

Public Transport Services do not have a formal fatigue policy/procedure.

Safety issue details
Issue number:RO-2011-002-SI-08
Who it affects:All rail operators
Status:Adequately addressed

 
General details
Date: 24 February 2011 Investigation status: Completed 
Time: 1209 CDT Investigation type: Occurrence Investigation 
Location   (show map):Adelaide Railyard  
State: South Australia  
Release date: 11 October 2011 Occurrence category: Serious Incident 
Report status: Final Highest injury level: None 
 
Train 1 details
Train registration: G231 
Type of operation: Suburban passenger 
Damage to train: Minor 
Departure point:Adelaide, SA
Destination:Oaklands, SA
Train 2 details
Train registration: 215A 
Type of operation: Suburban passenger 
Damage to train: Minor 
Departure point:Belair, SA
Destination:Adelaide, SA
 
 
 
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Last update 24 January 2017