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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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