Rail safety investigations & reports

Signal ME45 passed at danger resulting in a near-miss between suburban passenger trains TP43 and TR50 at Bowen Hills, Queensland on 10 January 2018

Investigation number:
RO-2018-002
Status: Active
Investigation in progress

Interim report

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Interim report published: 27 February 2019

Sequence of events

On 10 January 2018, Queensland Rail (QR) suburban passenger train TP43, was en route from Varsity Lakes to Brisbane Airport (Domestic Airport station), Queensland. At 1036:51, it arrived on time at No.2 platform, Bowen Hills station in Brisbane.

The departure signal (ME25) at the end of the platform was displaying a yellow aspect. To a driver, a yellow aspect is an indication to proceed with caution and expect the next signal to be displaying a red aspect (or stop indication). In this case, the next signal was ME45, located 390 m beyond the platform.

After the train stopped at the Bowen Hills platform, there was a scheduled changeover of the driver and guard.

At 1037:33, the train departed the platform with the new crew on board. At that time, signal ME25 was still displaying a yellow aspect.

At 1037:44, a short time after leaving the platform, the driver shut off traction power to the train when it reached 29 km/h. The train coasted around a sweeping right curve, which had a 30 km/h speed limit, before entering a straight section of track. At that point, train TP43 was 165 m from signal ME45.[1] The signal, displaying a stop indication, would have been in the driver’s direct line of sight. The driver, unaware of the stop indication, applied low traction power as the train continued towards the signal.

The automatic warning system[2] (AWS) magnet for ME45 is located 79.5 m prior to the signal. As the train passed over the magnet, the in-cab AWS system generated an audible and visual alarm, warning the driver that signal ME45 was displaying a stop indication. Recorded data from the train’s event recorder showed that the driver promptly acknowledged the alarm and then increased traction power.

At 1038:14, train TP43 exceeded its limit of authority by passing signal ME45 while it displayed a stop indication (Figure 1). The driver was unaware of the signal passed at danger (SPAD) occurrence and continued to operate the train as if signal ME45 was not displaying a stop indication.

When the train passed signal ME45, the signalling system generated a SPAD alarm to the network control officer at the Rail Management Centre. At 1038:26, the network control officer issued an emergency stop command via the train radio to the driver of train TP43. At that point, the train speed was 41 km/h.[3] The driver responded and brought the train to a stop 125 m before the potential conflict point with another train, and 220 m past signal ME45.

Figure 1: Image of signal ME45 immediately prior to the SPAD

Figure 1: Image of signal ME45 immediately prior to the SPAD. The image was taken from the front of train TP43, immediately prior to it passing signal ME45 while it displayed a (red) stop indication. Source: Queensland Rail annotated by the ATSB

The image was taken from the front of train TP43, immediately prior to it passing signal ME45 while it displayed a (red) stop indication. Source: Queensland Rail annotated by the ATSB

Signal information

Signal ME45 was a controlled[4] signal, operated from the Rail Management Centre at Bowen Hills. The signal was located at the 3.877 km mark[5] on the down[6] suburban line between Bowen Hills and Albion stations (Figure 2).

On 10 January 2018, signal ME45 functioned as designed. The signal was displaying a stop indication as the crossover[7] in advance of the signal was set for an opposing QR suburban passenger train (TR50) to cross from the up suburban line to the up main line (Figure 2).

Figure 2: Map showing the location of signal ME25, ME45 and related information

Figure 2: Map showing the location of signal ME25, ME45 and related information. The image shows the route of train TP43 (in red) and the colour light aspects displayed in the signals on the day of the SPAD occurrence – ME25 (yellow) and ME45 (red). The sweeping right curve is located just passed ME25, about where the 30 km/h speed board is indicated (in yellow). Source: Queensland Rail annotated by the ATSB

The image shows the route of train TP43 (in red) and the colour light aspects displayed in the signals on the day of the SPAD occurrence – ME25 (yellow) and ME45 (red). The sweeping right curve is located just passed ME25, about where the 30 km/h speed board is indicated (in yellow). Source: Queensland Rail annotated by the ATSB

The Universal Traffic Control[8] (UTC) system and closed-circuit television (CCTV) footage from the front of train TP43 showed that signal ME45 displayed a stop indication as the train approached and passed the signal.

The signal was a four-aspect colour light signal, capable of displaying green, double yellow, yellow or red aspects and was fitted with light emitting diode (LED) lenses (Figure 3). According to QR’s 2017 signalling statistics, trains that approached signal ME45 encountered a stop indication less than 1 per cent of the time.

Figure 3: Four aspect colour light signal indications

Figure 3: Four aspect colour light signal indications. The image shows a four-aspect colour light signalling sequence and what the colour aspect indications mean to a train driver. Source: Queensland Rail (QR)

The image shows a four-aspect colour light signalling sequence and what the colour aspect indications mean to a train driver. Source: Queensland Rail (QR)

There have been 10 SPAD occurrences at signal ME45 since 1996, including the SPAD on 10 January 2018. According to QR records, driver inattention/distraction was the primary contributor on each occasion. Five of the 10 SPADs occurred following a driver changeover at Bowen Hills.

In 2013, QR’s SPAD prevention working group requested the Signal Sighting Committee conduct a review of signal ME45 as a result of two recent SPAD occurrences. The review identified the potential of a ‘read through’ scenario for trains that approached signal ME45. A read through occurs when a driver views the incorrect signal (such as a signal for an adjacent track), usually when the non-applicable signal is located close to the applicable signal in the driver’s visual field. The potential only existed for a very brief time when signal ME37 lined up almost directly behind signal ME45 as trains traversed the sweeping right curve after leaving Bowen Hills (Figure 2). However, as trains exited the curve and entered the straight section of track, signal ME45 could be clearly seen without another signal in close proximity.

The Signal Sighting Committee recommended that the aspects in signal ME45 be upgraded to LED aspects to mitigate the risk of a read through at this location. In addition, it recommended that the stopping mark at Bowen Hills No.2 platform be relocated to a position where drivers had a better view of signal ME25 when stopped at the platform. These recommendations were subsequently implemented.

Signal ME37 was located on the down main line, which was parallel to the down suburban line. It was displaying a green aspect when train TP43 approached signal ME45.

Train information

Train service TP43 consisted of an Interurban Multiple Unit (IMU168) leading, and a Suburban Multiple Unit (SMU285) trailing. Both train units were fitted with operating event recorders and front of train cameras. The train units operated as designed.

Driver information

The driver of train TP43 gained a driver qualification with QR in 1985. At the time of the SPAD, he was qualified to operate the rolling stock that worked train TP43, and was route competent to travel over the down suburban line. The driver stated that he frequently traversed the down suburban line and was familiar with the location of signal ME45.

On 10 January 2018, the driver signed on for duty at 0357, and considered himself fit for work. He had a rest break from 0911 to 1036 prior to boarding train TP43. Before starting duty, he had 16 hours off duty. His recent duty periods and time off duty between shifts were consistent with the requirements of QR’s fatigue management system. QR conducted a drug and alcohol test following the SPAD, with a negative result recorded.[9]

The driver recalled that, while waiting for the arrival of train TP43 on 10 January, he noticed that the departure signal (ME25) at the northern end of No.2 platform at Bowen Hills displayed a yellow aspect. After the train arrived, he had a brief discussion with the driver being relieved. On entering the driving compartment, he sat in the driver’s seat. He recalled jarring his back and being surprised when the seat quickly declined to the bottom of its range. A short time later, the guard gave right-a-way.[10]

The driver stated that he elected not to adjust the seat at Bowen Hills, as this would delay the departure of the train. Instead, he chose to continue to the next station, where he could adjust the seat during the scheduled platform dwell time without delaying the train. Although the seat was at its lowest level, the driver’s view of the track and signals was not impeded.

The driver said that he did not check the aspect indication in signal ME25 prior to leaving the platform. He recalled that as the train traversed the right curve after leaving Bowen Hills, he saw a green aspect in a signal, which he thought was signal ME45. The driver subsequently reported that he thought he had probably ‘read through’ and viewed the green aspect in signal ME37.

The driver recalled applying low traction power to increase speed as the train exited the sweeping right curve. However, he could not recall acknowledging the AWS in-cab alarm or checking the aspect in signal ME45.

Driver competency processes and results

Maintenance of competency

One of the tools used by QR to meet legislative requirements for rail safety workers is a maintenance of competency (MOC) assessment to check the competence of its train drivers. A tutor driver normally administers the MOC process, which extends over a 2-day period and involves both theory and practical components. The theory assessment includes more than 250 questions covering a range of topics, including but not restricted to safety-critical elements relevant to train driving. QR train drivers are required to undertake a MOC assessment every 18 months.

QR advised the ATSB that the MOC is a formal assessment to check train driver competency. A driver is required to complete all questions in the MOC theory assessment without assistance. Any incorrect answers are meant to be noted, and the driver provided additional coaching as required before attempting the relevant question(s) again.

The driver involved in the SPAD occurrence on 10 January 2018 participated in five MOC assessments between November 2010 and February 2017, with multiple tutor drivers involved in conducting the assessments. On each occasion, the assessors deemed the train driver competent.

Risk triggered commentary driving

QR introduced risk triggered commentary driving (RTCD) as an additional control to assist with managing the risk of driver distraction/inattention while running on restricted signals. The associated procedure encouraged drivers to interact with restricted signals by speaking aloud both the signal aspect and their anticipated actions.

The concept was introduced as a tool that could be used as required. Subsequently, in 2011, QR mandated the use of RTCD as part of its SPAD reduction strategy.

According to QR training records, the driver of train TP43 attended RTCD training in December 2012. His MOC assessments in 2013, 2014 and 2017 included documented evidence of the driver correctly applying RTCD. However, the driver reported that he had never used RTCD, and was not using it at the time of the SPAD.

Operational improvement plan

As a result of the SPAD occurrence on 10 January 2018, the driver participated in a post-incident on-track observation, which was administered by a train operations inspector. The purpose of the observation was to assess and make recommendations towards an operational improvement plan (OIP). The assessor identified deficiencies and the driver was assigned to an OIP, which involved the driver participating in practical on-track coaching and mentoring sessions. Train operations inspectors, who are subject matter experts in train driver operations and assessment, administered the sessions.

In all, there were 11 individual practical on-track coaching and mentoring sessions undertaken by multiple inspectors. On each occasion, the inspectors identified safe driving[11] deficiencies in the driver’s performance, including the application of risk controls to minimise the risk of SPADs, such as RTCD and the start on yellow procedure.[12]

Review of other MOC assessments

The disparity between the driver’s OIP results and his previous MOC results prompted the ATSB to seek further evidence. The ATSB compared responses in the driver’s MOC assessments against answers in the MOC marking guide. The results showed that the driver’s written responses in each MOC, for questions requiring a detailed response, were identical or near identical to those in the marking guide. In addition, there were very few incorrect answers noted.

Based on these findings, the ATSB obtained a systematic sample of MOC assessments involving other drivers. Overall, more than 50 MOCs were obtained and analysed. Almost all of these MOCs showed a similar pattern to that of the driver of train TP43.

Investigation progress

  • To date the ATSB has interviewed a broad sample of tutor drivers and management personnel, and obtained a significant amount of documentation. Most of the relevant evidence has been collected, and the investigation is now focussed on analysing the evidence collected to date.

The ATSB investigation is continuing and will include an examination of:

  • potential factors associated with the driver not identifying that signal ME45 was displaying a stop indication
  • policies, procedures and guidance related to the adminstration of train driver MOC assessments
  • the processes used by QR to monitor the administration and effectiveness of the train driver MOC process
  • the effectiveness of RTCD and the processes used by QR to implement RTCD and monitor its effectiveness.

Findings

The ATSB informed QR management of its concerns with the MOC process during meetings in June and August of 2018. On 19 September 2018, the ATSB formally advised QR that it had identified the following safety issue:

  • Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain Rail Traffic Drivers meet relevant competency requirements. [Safety issue]

It should be noted that the ATSB is not stating that QR’s Citytrain drivers are not competent; rather, the application of the process for assessing competency has significant limitations.

This finding should not be read as apportioning blame or liability.

The ATSB’s final report will include additional findings.

Safety issues and actions

The safety issues identified during this investigation are listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

Depending on the level of risk of the safety issue, the extent of corrective action taken by the relevant organisation, or the desirability of directing a broad safety message to the rail industry, the ATSB may issue safety recommendations or safety advisory notices as part of the final report.

The initial public version of these safety issues and actions are provided separately on the ATSB website to facilitate monitoring by interested parties. Where relevant the safety issues and actions will be updated on the ATSB website as information comes to hand.

Train driver maintenance of competency assurance

Safety issue numberRO-2018-002-SI-01

Safety issue description

Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain rail traffic drivers meet relevant competency requirements.

Safety action taken:

On 19 October 2018, QR responded to the safety issue by stating it was currently undertaking a multidisciplinary review of its train driver MOC assessment process. It stated that the review would include the ‘content, assessment methods, trainer/assessors and security of training materials’.

On 11 February 2019, QR advised that it had completed a multidisciplinary review of driver training (including the MOC). A working party was convened on 7 January 2019 to identify key initiatives to improve current rail traffic crew training practices, and these new initiatives commenced introduction from late January 2019.

ATSB comment:

The ATSB will continue to monitor the progress of this and any other safety action taken in respect to whether QR can provide assurance that its Citytrain Rail traffic drivers meet relevant competency requirements now and into the future.

Additional safety action

On 11 February 2019, QR advised ATSB of the following additional safety action:

An engineering solution has been identified for ME45 to significantly reduce the possibility of collision risk due to [a] SPAD at ME45. ME45 will be “led by” preceding signals ME23 and ME25. This upgrade has been planned and is scheduled for completion by the end of February 2019.

A proactive review program is in place that analyses the train event recorders of key SPAD avoidance driving methodologies:

- Lead indicator that provides visibility of driving behaviours across the organisation;

- Enables direct and timely feedback to drivers on driving behaviour/technique.

 

______________

The information contained in this interim report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence may become available as the investigation progresses that will enhance the ATSB's understanding of the incident as outlined in this interim report.

 

__________

  1. The signal can be first sighted about 230 m prior to the signal.
  2. Automatic warning system: a supervisory system that provides an in-cab alarm when the train passes over a magnet prior to a signal displaying a restricted indication. The driver is required to acknowledge the alarm, by pressing and releasing the AWS button. The same aural and visual alarm is provided for each type of restricted indication (that is, double yellow aspects, single yellow aspect and red aspect).
  3. The designated track speed at this location is 60 km/h.
  4. Controlled and operated by a network control officer at the Rail Management Centre.
  5. Kilometres from Roma Street station.
  6. Travelling north, away from Brisbane City.
  7. Crossover: a track section used to divert rail traffic from one line to another.
  8. UTC: QR system that facilitates the movement of trains.
  9. A negative result means that no problems were detected.
  10. Right-a-way: a signal from the guard to the driver communicating platform duties were completed.
  11. Safe driving: a method of driving to suit operational conditions and reduce the risk of driver error.
  12. A risk control measure applied by train drivers at station platforms to mitigate the risk of SPAD.
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Safety issues and actions

Safety Issue

Go to RO-2018-002-SI-01 -

Train driver maintenance of competency assurance

Queensland Rail’s administration of the Maintenance of Competency assessment process provided limited assurance that its Citytrain rail traffic drivers meet relevant competency requirements.

Safety issue details
Issue number: RO-2018-002-SI-01
Who it affects: Queensland Rail Citytrain rail traffic drivers
Status: Safety action pending
General details
Date: 10 January 2018   Investigation status: Active  
Time: 1038 AEST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Bowen Hills   Investigation phase: Examination and analysis  
State: Queensland    
Release date: 27 February 2019   Occurrence category: Incident  
Report status: Interim   Highest injury level: None  
Anticipated completion: 4th Quarter 2019    

Train 1 details

Train 1 details
Line operator Queensland Rail  
Train operator Queensland Rail  
Train registration TP43  
Type of operation Suburban passenger service  
Sector Passenger - metropolitan  
Damage to train Nil  
Departure point Varsity Lakes Station, Qld  
Destination Brisbane Airport, Qld  

Train 2 details

Train 2 details
Line operator Queensland Rail  
Train operator Queensland Rail  
Train registration TR50  
Type of operation Suburban passenger service  
Sector Passenger - metropolitan  
Damage to train Nil  
Departure point Domestic Airport, Qld  
Destination Roma Street Station, Qld  
Last update 20 March 2019